Every finding on record at Jewish Home of Central New York

Based on record review and interviews (iQIES #3004417), the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (1) of three (3) residents (Resident #1). Specifically, Resident #1 had a physician order for pudding thick liquids, was care planned to receive pudding thick liquids and was served thin liquids for dinner on 05/01/2026. Staff did not follow the facility process for checking meal trays against the meal ticket prior to serving and the certified nurse aide provided thin liquids instead of pudding thick liquids to the resident without verification. This resulted in no actual harm with potential for more than minimal harm past non-compliance for Resident #1. Findings include: The facility policy Meal Ticket and Dining Room Service, revised 03/2026 documented the licensed practical nurse was responsible for checking each tray prior to passing to the residents. The tray would be checked for accuracy including correct consistency, presence of all items stated on the meal ticket including adaptive devices, aspiration precautions, and allergies. The facility policy Feeding and Thickened Liquids Competency, revised 08/2024 documented food service provided pre thickened fluids (nectar and honey thickened) in the correct consistency on the meal tray. For fluids that did not come pre thickened, food service provided thickening packets, in the ordered consistency, for clinical staff to prepare before serving. Resident #1 had diagnoses including dementia and difficulty swallowing. There was no documented Minimum Data Set assessment in the record as the resident was newly admitted to the facility. The 04/30/2026 Registered Nurse Manager #3's admission Assessment documented the resident was alert to person only and they were on a pureed food, pudding thick liquid diet. The 04/30/2026 Hospital Discharge Summary documented the resident had a large, infected pressure ulcer that could not be surgically debrided (removal of dead tissue) as the resident was not stable to go to the operating room. The resident had a palliative consultation and started end of life care. The resident was to continue pureed and pudding thick liquids. The 04/30/2026 Comprehensive Care Plan documented the resident was care planned for end-of-life care and pureed/pudding thickened liquids. On 05/04/2026, the facility initiated an investigation after the resident's family member reported the resident had thin liquids on their dinner tray on 05/01/2026. The family member reported they notified Licensed Practical Nurse #2 on 05/01/2026 at the time. The family reported this to the facility on [DATE], following the resident's death. The 05/04/2026 Incident Report documented Certified Nurse Aide #1 gave the resident thin liquids through a straw without checking consistency with the nurse on duty. The meal tray was served without being checked by Licensed Practical Nurse #2 and Licensed Practical Nurse #2 did not notify the Supervisor of the break in the care plan. Staff statements obtained on 05/04/2026 documented: -Licensed Practical Nurse #2, they did not check the resident's tray prior to serving as they were passing out meal trays to other residents. Certified Nurse Aide #1 passed the resident their tray. The resident's family member informed them the resident had thin liquids on the tray, they did not notify a supervisor, and the resident was not assessed. They checked the resident through the overnight shift and noted no concerns. -Certified Nurse Aide #1, the resident's meal ticket did not identify the resident needed thickened liquids. Thin liquids were present on the tray. Licensed Practical Nurse #2 did not check the ticket prior to serving the tray. Certified Nurse Aide #1 poured cranberry juice into a cup and placed a straw in it. They brought the cup to the resident's mouth, and the resident drank the liquid quickly and wanted more. Certified Nurse Aide #1 provided thin water through a straw prior to the dinner meal and stated they did not check consistency with the nurse and did not check the Task Sheet (care instructions). Three of the resident's meal tickets dated 05/01/2026 were observed in the Investigative Packet for breakfast, lunch and dinner meals and documented Regular diet, texture: pureed/pudding liquids. On 05/12/2026 at 12:04 PM and again on 05/20/2026 at 12:19 PM, Certified Nurse Aide #1 was not reached in an interview. On 05/12/2026 at 12:54 PM, Licensed Practical Nurse #2 stated in an interview they knew what diet a resident was prescribed by looking at the physician order or by looking at the meal ticket. They were supposed to check the meal tickets though that was not written in stone. If they passed a meal tray, they checked the ticket, however, the aide could also check the ticket. Trays came up from kitchen with thickened liquids. When there was an incident, they were to report to the supervisor. On 05/01/2026, they were passing trays when the resident's family member told them the resident had thin liquids on their tray. They spoke with Certified Nurse Aide #1 who reported they gave thin liquids to the resident. They did not know the resident's tray had thin liquids on it or they would have done something about it sooner. They did not look at the meal ticket after the incident, however it was their understanding from Certified Nurse Aide #1 that the meal ticket did not indicate thickened liquids. They were educated by the facility prior to the incident to check the trays for correct diet, however it was impossible to do that as sometimes, they were still passing medications at the time meal trays were being delivered. During an interview on 05/19/2026 at 9:42 AM, the Director of Nursing stated resident diets were physician prescribed, documented on the Task Sheet and documented on the meal ticket. The licensed practical nurse was expected to review the meal ticket against the meal tray before the tray could be handed to the certified nurse aide. Any incident should be reported to the registered nurse for assessment, notification to the provider and family and an investigation started. Licensed Practical Nurse #2 should have notified the registered nurse supervisor when the family reported there were thin liquids on their meal tray. They determined Certified Nurse Aide #1 did not check and verify fluids consistency before giving them to the resident. Licensed Practical Nurse #2 did not check the meal tray prior to the meal tray being served and when the resident's family notified them of thin liquids on the meal tray, Licensed Practical Nurse #2 did not notify the supervisor for assessment. The facility terminated the two staff, re-educated all nursing staff on the facility processes for dining and thickened liquids. As of 05/19/2026, all nursing staff had been trained and the three remaining untrained per diem staff would be trained prior to their next scheduled shifts. During an interview on 05/20/2026 at 11:30 AM, the Medical Director stated they were familiar with the incident. They expected staff to follow dietary physician orders for resident safety. The resident came to the facility for comfort care. The certified nurse aide gave the resident thin fluids without verifying they could have them first. The resident drank thin fluids through a straw and the certified nurse aide reported they had no distress noted at that time. They did not believe the consumption of thin liquids contributed directly to their death. 10 New York Codes, Rules and Regulations 415.12(h)(1)____________________________________________________________________________ No Actual Harm with Potential for More than Minimal Harm Past Non-Compliance was identified. The facility provided verification the following corrective actions were completed by 05/11/2026: -An investigation was started immediately on 05/04/2026 after family reported thin liquids were found on the resident's meal tray on 05/01/2026-Licensed Practical Nurse #2 and Certified Nurse Aide #1 were terminated.-Education was provided to all nursing staff on the Dining policy and updated Meal Ticket Policy.- Any remaining nursing staff who were not scheduled were educated upon return to work, prior to the start of their shift. -A facility wide audit was conducted 05/05-05/06/2026 of Dietary Care Plans and Task Sheets to verify all matched and included diet and any consistencies of food/fluid. -Altered diet consistencies were added to the Protected Health Information window in the Electronic Medical Record. -Managers were educated on tracker sheets that will be completed and handed in weekly for compilation by the nursing Quality Assurance representative. -Audit Sheet for nursing to track and report on completion of altered diets/fluid consistency, Task Sheet, Protected Health Information window and care plans.-Quality Assurance and Performance Improvement to monitor monthly for 3 months until 100% achieved.

Based on observations and interviews, the facility failed to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illness in one (1) of one (1) main kitchen. Specifically, the main kitchen had unlabeled/undated prepared and leftover food; dishes and utensils were not sanitized appropriately; and refrigerators were unclean and in poor repair.Findings include:The facility policy Guidelines for Receiving and Stock Rotation, revised 05/2024, documented food outside its original package would be labeled so staff knew what to use first; and coolers and freezers were checked to ensure all items were dated, labeled, rotated and not expired.The undated facility procedure Sanitizing Food Contact Surfaces documented the sanitizer concentration of the 3-bay sink would be tested at least twice a day for the required concentration.Food Storage During an observation and interview on 03/04/2026 at 10:04 AM, the following was observed in the main kitchen:-two pans of cooked meat in the walk-in cooler were partially covered with plastic wrap and were not labeled or dated. -several prepared food items in the walk-in dairy cooler were not labeled or dated. Food Service Director #40 stated they thought the meat was beef from the day before, the prepared food in the dairy cooler was tuna and egg salad, and the items in the milk cooler might have been ranch dressing. They all should be labeled and dated, and they did not know why they were not. During an observation and interview on 03/06/2026 at 10:30 AM, there were two dented cans on the shelves in dry storage. Food Service Director #40 moved dented cans to an unlabeled shelf in the middle of the room and stated the shelf used to be labeled and they did not know where the sign went. They usually do not have issues with dented cans and kept them on a labeled dented can shelf to return because they could be compromised. Dinnerware Sanitization and Storage During an observation and interview on 03/06/2026 at 10:30 AM, Food Service Worker #41 was washing dishes at the 3-bay sink and demonstrated how they tested the sanitizer strength. They pulled the test strip from the dispenser and placed it in the sanitizer bay, but the strip did not change color to register any sanitizer in the water. They stated there should be a number on the test strip. Food Service Director #40 then tested the sanitizer strength and found the strip did not change color to register any sanitizer in the water. Food Service Worker #41 emptied the sink and refilled the sanitizer bay with hot water instead of the sanitizer solution. Food Service Worker #41 stated this was how they filled the prior sanitizer bay as well. They filled the sink a couple hours prior and washed all the breakfast dishes in the sink. Other food service workers approached the area and removed pans and utensils from the rack of un-sanitized dishes. Food Service Director #40 retrieved the un-sanitized pan and utensils so they could be rewashed. Food Service Director #40 educated Food Service Worker #41 on how to properly fill the sanitizer portion on the sink and instructed them to rewash and sanitize all the dishes again. During an observation and interview on 03/06/2026 at 10:55 AM, Food Service Worker #42 and Food Service Worker #43 were in the dish room running the dish machine. The machine temperature read 158 degrees Fahrenheit for cleaning and 167 degrees Fahrenheit for sanitizing. The dish machine temperatures needed to be greater than 150 degrees Fahrenheit and the sanitizer greater than 180 degrees Fahrenheit. The Food Service Workers kept washing dishes and storing them to dry. Food Service Worker #42 and Food Service Worker #43 stated they did not know what the temperatures on the dish machine meant and they were not trained on that information. They stated they sanitized dishes to kill germs. Food Service Worker #42 removed a rack of bowls that were not sanitized at the proper temperature and started to carry them out of the dish room to put them in general circulation. Food Service Director #40 did not intervene until the Department of Health Surveyor stopped the staff member and asked if they should be using items from the rack. During an observation and interview on 03/06/2026 at 11:17 AM, Food Service Worker #41 refilled the 3-bay sink, and the sanitizer bay was rechecked and again tested zero. The water felt ice cold to touch. Food Service Director #40 turned on the dispenser that mixed sanitizer and water, and the water was warm and steamy. The sanitizer tested within appropriate range. The sanitizer sink was refilled, and dishes were re-sanitized. Food Service Worker #41's training records documented they were trained on washing pots and pans. Training included filling the sanitizer bay, testing the sanitizer concentration to make sure it was correct, and making sure the water temperature was at least 110 degrees Fahrenheit. Equipment Safe/Clean During an observation on 03/04/2026 at 10:04 AM, the meat walk-in cooler, dairy walk-in cooler, and milk walk-in cooler had dried food in the gaskets and on the floor. During an observation 03/05/2026 at 9:27 AM, the dairy cooler in the pantry on the first floor was very grimy with dried food debris in unit and the gaskets in poor repair. During an observation and interview on 03/06/2026 at 11:15 AM, the two reach-in refrigerators near the meat cook area had dried food in the gaskets and on the floor in the cooler. Food Service Director #40 stated they usually cleaned them every few weeks. During an interview on 03/09/2026 at 9:33 AM, Food Service Worker #41 stated they worked at the facility for two years and used the 3-bay sink on Fridays. They were trained on its use and usually filled the first bay with the soap and water dispenser, the second bay with warm water, and the third bay with the sanitizer and water dispenser. The water in all three bays should be warm. They were not retrained and got confused because they had not used the 3-bay sink in a couple weeks.During an interview on 03/09/2026 at 9:46 AM, Food Service Director #40 stated all staff were trained when hired, including sanitation and dish machine procedures. The 3-bay sink procedure was to fill the first bay with the soap and water from the pre-mixed dispenser, the second bay with warm water, and the third bay with sanitizer from the pre-mixed dispenser. The staff at the 3-bay sink were responsible for testing the sanitizer strength three times a day using the test strips that hung above the sink and recording the data on a form in the kitchen. Food Service Worker #41 only used the 3-bay sink on Fridays when they were not receiving deliveries and was confused on how to test the concentration of sanitizer because the sanitizing bay sink was not sealing correctly. The Food Service Director was responsible for documenting dish machine temperatures three times a day and they watched to let the staff know if the machine was not reaching proper temperatures. All staff were trained in how to use the dish machine but not reading or recording the machine temperatures. They stated staff should be trained in what the temperatures meant. Staff should not use dishes that were not properly sanitized. They sanitized dishes to kill germs. Cooked meat should be securely covered once cooled, and all food should be labeled and dated. Dented cans should not be used because bacteria could get in the can. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations, record review, and interviews the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional standards for two (2) of three (3) medication carts (Terrace Lane and Terrace Ridge); one (1) of two (2) medication rooms (Second floor); and one (1) of two (2) narcotic count sheets (used to reconcile controlled medications). Specifically, the Terrace Lane Medication cart had one (1) unlabeled insulin pen and two (2) bottles of vitamins without expiration dates; the Terrace Ridge Medication cart had had three (3) tubes of unlabeled cream and was unlocked and unsupervised; and the narcotic count sheet for Second floor medication room was illegible. Findings included: The facility policy Drugs and Biological Storage, revised 07/2024, documented all medications and biologicals should be stored securely and properly in accordance with regulatory requirements, manufacturers recommendations, or those of the supplier. Medication carts should be locked when the licensed nurse was away from it or stored in a non-resident area when not being utilized for medication pass.During an observation on [DATE] at 10:09 AM, the Terrace Ridge medication cart was unlocked parked at the nurses' station, with residents walking in and out of the nurses' station. During the Terrace Lane medication cart storage review on [DATE] at 2:04 PM with Licensed Practical Nurse #17, the following was observed in the top drawer of the medication cart:- one (1) opened Lispro (insulin) pen stored in a plastic bag with no opened date and an illegible handwritten name of resident.- two (2) bottles of Prevagen Vitamins with no opened date and no expiration date.Licensed Practical Nurse #17 stated the insulin belonged to Resident #65 and was used. They stated they were able to read the writing, but during observation had placed a printed label on the bag. The Prevagen Vitamins were brought in by families but should have an open and expiration date.The Terrace Lane and Terrace Ridge medication carts were both located within the same nursing station during the observation on [DATE] at 2:04 PM. The Terrace Ridge medication cart was observed to be unlocked and not in use. Licensed Practical Nurse #17 stated this was not their medication cart and the carts should always be locked when not in use, especially on the dementia unit. They stated residents wandered into the nursing station a lot and could get into the medication cart.During the Terrace Ridge medication cart storage review on [DATE] at 2:23 PM, Licensed Practical Nurse #16 stated the medication cart was their responsibility and the cart should not be unlocked, even if the nursing station door was closed. They were not sure why they left the cart unlocked. The unit had a lot of residents who wandered, and they could access the medications in the cart if it was unlocked. There were unlabeled tubes of barrier cream in the drawer. They stated this was used for most residents but not all and should be kept in the treatment cart.During an observation of the Second floor medication room on [DATE] at 3:03 PM, Licensed Practical Nurse #15 confirmed the box of six (6) tubes of barrier cream was a treatment and the cream should be stored in the treatment cart labeled with the resident's name. The narcotic count sheets for each shift medication reconciliation were not legible with medication name and prescription number. Licensed Practical Nurse #15 stated the count sheet was difficult to read.During an interview on [DATE] at 12:20 PM, the Director of Nursing stated they conducted medication cart and medication room audits. The nurses should audit their carts daily. All medications should have a label with the date opened and date expired. The nurses should lock their medication cart when they walked away. The cart should be locked for safety reasons. Narcotic reconciliation sheets should be legible. All staff should be able to clearly read the name and the prescription number to ensure the correct count and to prevent errors.10 New York Codes, Rules and Regulations 415.18(d)

Based on observations and interviews the facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for three (3) of three (3) test trays (one lunch tray on 03/06/2026 and two breakfast trays on 03/10/2026). Specifically, the lunch tray and breakfast trays included hot foods served below 110 degrees Fahrenheit and cold foods served above 60 degrees Fahrenheit and were not palatable. Findings include:The facility policy Food Palatability, revised 05/2024, documented hot food would be served at no less than 135 degrees Fahrenheit and cold food would be served no higher than 40 degrees Fahrenheit. Meals would be delivered to the units in heated/cooled food transport carts and plugged in on the floors to maintain a meal temperature palatable to most residents. During an observation on 03/06/2026 at 1:15 PM, Resident #9's lunch meal was tested, and a replacement meal was ordered. Food temperatures were measured and verified by Licensed Practical Nurse #7 and were as follows: fried chicken was 107 degrees Fahrenheit, matzo ball soup was 131 degrees Fahrenheit, diet cola was 63 degrees Fahrenheit, ginger ale was 63 degrees Fahrenheit, and water was 63 degrees Fahrenheit. The fried chicken tasted bland, and the beverages all tasted lukewarm. During an interview on 03/06/2026 at 1:15 PM, Licensed Practical Nurse Manger #7 stated the carts were meant to keep the cold items cold and warm items hot. The unit staff should serve the trays table by table and that was not how the carts were set up. Staff had to go from cart to cart looking for the correct resident and then a nurse had to verify the tray accuracy before it could go to the resident. During an observation on 03/10/2026 at 8:50 AM, a blue meal transport cart was delivered to the unit and plugged in. There was a sign posted on the side of the cart that read, Please do not plug in or turn on, repair company has been notified. A second delivery cart was delivered and plugged in. During an observation on 03/10/2026 at 9:02 AM, a hospitalized resident's breakfast tray was tested from the broken food cart. Food temperatures were measured and verified by Licensed Practical Nurse #44 and were as follows: egg and cheese croissant was 95 degrees Fahrenheit, cottage cheese was 68.2 degrees Fahrenheit, and whole milk was 55.4 degrees Fahrenheit. The egg and cheese croissant tasted cold, and the cottage cheese and milk tasted warm. During an observation on 03/10/2026 at 9:08 AM, a second hospitalized resident's breakfast tray was tested from the functioning meal cart. The food temperatures were measured and verified by Licensed Practical Nurse #44 as follows: egg and cheese croissant was 101.8 degrees Fahrenheit, skim milk was 58.1 degrees Fahrenheit, cottage cheese was 68.7 degrees Fahrenheit, and oatmeal was 128 degrees Fahrenheit. Two pancakes were provided, although the tray ticket documented waffles. The egg and cheese croissant tasted cold, the pancakes were cold (butter would not melt on them), and the milk and cottage cheese tasted warm. During an interview on 03/10/2026 at 9:13 AM, Certified Nurse Aide #45 stated they got complaints about the food sometimes and usually had to reheat food for the residents because they noticed it was cold. During an interview on 03/10/2026 at 9:29 AM, Food Service Worker #46 stated they worked at the facility for eighteen years and started using the current meal delivery carts about three to five years ago. If a cart had a sign on it not to plug it in or turn it on it should not have been plugged in or even been in service. Hot food should be served at least 140 degrees Fahrenheit and cold food below 40 degrees Fahrenheit. Cottage cheese served at 68 degrees Fahrenheit was a concern. During an interview on 03/10/2026 at 9:55 AM, Food Service Director #40 stated the current delivery carts held one side cold and one side hot. When the carts were working correctly the temperatures were good, but they had two carts currently not working. The carts were always loaded correctly, with the hot food on the hot side and their most experienced staff checked the trays. A cart with a sign saying not to plug it in or turn it on should not have been plugged in. They stated the cold side would heat up if it was plugged in even if it was not turned on. If nursing left the cart doors open the temperatures would not be maintained. Hot food should be served at least 140 degrees Fahrenheit and cold food below 40 degrees Fahrenheit. Cottage cheese served at 68 degrees Fahrenheit, milk at 58 degrees Fahrenheit, and egg and cheese croissants at 95 degrees Fahrenheit were concerns and not acceptable. 10 New York Codes, Rules, and Regulations 415.14(d)(1)(2)

Based on observations, record review, and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for two (2) of four (4) residents (Residents #6 and #66) reviewed. Specifically, Resident #6 did not have person-centered interventions in their dementia care plan, and the care plan was not updated to reflect current behavioral symptoms; and Resident #66 did not have interventions included in their dementia care plan regarding their cognitive decline and psychotropic (antipsychotics) medication usage.Findings include: The facility policy Comprehensive Care Plan, revised 05/2024, documented care plans were tailored to the individual needs and preferences of the resident and outlined specific, measurable goals and interventions. Care plans were updated quarterly, annually, and with any change in condition or plan of care. The facility policy Dementia Care, revised 09/17/2025, documented residents were provided with individualized care and services for those with a diagnosis of dementia. Resident behaviors represented an attempt by the person to communicate unmet needs, discomfort, or thoughts that they could not articulate. Care plans consisted of baseline and ongoing details such as frequency, intensity, and duration of common behaviors and specific goals for monitoring interventions for effectiveness. Care plans addressed non-pharmacological approaches for staff to use, which are consistent and focused on the residents' needs. 1) Resident #6 had diagnoses including Alzheimer's Disease and post-traumatic stress disorder. The 01/18/2026 Minimum Data Set admission assessment documented the resident had severe cognitive impairment; had no physical or verbal behaviors; did not reject care; did not wander; felt down, depressed, or hopeless over the last several days; required moderate to maximum assistance with most activities of daily living; and used a walker and wheelchair for mobility. The 01/06/2026 baseline care plan documented the resident had dementia with impaired decision making. Interventions included using simple language, brief statements and offering simple choices. The resident had behavior symptoms and was at risk for aggressive behaviors toward/from staff/others. Interventions included ensure safety and allow time to deescalate when agitated, notify the physician and report behavioral changes, and administer medications as ordered by the physician. There was no documented evidence the care plan was updated or person centered to maximize the residents' dignity and independence. The undated care instructions documented the resident had no behaviors. There were no documented instructions or interventions for staff to use to manage the resident's behaviors related to dementia. The 01/05/2026 at 9:17 AM, Registered Nurse Unit Manager #14 admission progress note documented the resident was admitted from a memory care facility and was oriented to self only. The resident was hearing impaired and had Alzheimer's Disease. The 01/07/2026 at 2:51 PM, Licensed Practical Nurse #16 progress note documented the resident was following other residents in the hallway and into their rooms yelling at them. The resident was redirected. The 01/09/2026 at 8:54 AM, Registered Nurse Unit Manager #14 progress note documented the resident was resistive to care, refused to use the walker, refused nighttime medications, and refused care during the night shift. The 01/09/2026 at 10:03 PM, Registered Nurse Supervisor #39 progress note documented the resident had undressed themself and was naked in the sitting room. The resident would not let staff get them dressed, was yelling out at staff, and was very agitated and aggressive towards staff when approached. The resident continued to yell at staff, ball their fists up at staff, and remained naked. The resident stood up on their own and walked while the staff pulled up the residents' clothing as the resident continued to yell at the staff. The resident was paranoid and convinced staff were poisoning them. The resident did not sleep at all. The 01/29/2026 at 10:31 PM, Licensed Practical Nurse #38 progress note documented the resident was approached for their nighttime medication and spit them out. The resident was approached several times with nursing supervisor assistance and then took medications with ice-cream. The resident continued to walk the unit yelling out can you help? when asked what they needed and continued to yell. The resident refused their night care. The 01/7/2026 Nurse Practitioner #37 progress note documented the resident was seen at request of nursing for follow up on their dementia. They were just admitted from another facility and had a history of dementia with behaviors. The 01/15/2026 Physician #36 progress note documented the resident was seen at request of nursing for concerns of increased agitation, paranoia, and resistance to care. The 01/23/2026 Nurse Practitioner #35 psychiatric evaluation documented the resident was seen for mood changes. The resident had diagnoses of depression, anxiety, post-traumatic stress disorder, and dementia. Staff requested the resident be seen due to concerns of aggression and mood changes. The resident should continue the Valium for anxiety, Lamictal for mood, and Seroquel for agitation and mood lability from dementia, and reinforce coping skills and non-pharmacologic interventions. There were no documented non-pharmacologic interventions or coping skills documented on the care plan. The following observations of Resident #6 were made: -On 03/04/2026 at 11:09 AM, standing near the utility room stating they needed help and was cold, while rubbing their abdomen. An unidentified staff member exited room T19, and the resident reached for their shirt tied around their waist and walked down the hallway toward the nursing station. -On 03/04/2026 from 11:10 AM until 11:36 AM, walking without a walker; telling staff and visitors they were cold, and needed help; trying to take another residents sweater; wandering into the nurses' station and refusing to leave the nurses' station; walking up and down the hallway with a walker, yelling at staff; intruding upon visitors personal space during a musical activity; and telling staff they were cold, and wanted a jacket. Resident #68 appeared to be visibly upset with tears and was difficult for staff to redirect. -On 03/04/2026 at 11:20 AM, an unknown visitor approached the surveyor and stated Resident #6 kept approaching them and saying they were not feeling well. Registered Nurse Unit Manager #14 approached the resident and the resident yelled go away!. Registered Nurse Unit Manager #14 stated let's get some cranberry juice and tried to redirect the resident from the nurses' station with a walker, while the resident shouted, I am freezing!. -On 03/05/2026 at 12:57 PM, seated at a round table alone in front of a television with a plate of food and beverage in front of them. The resident was saying I can't. I need him. and told the surveyor they were having trouble. -On 03/05/2026 at 1:08 PM, the resident approached the surveyor and said they did not know what to do. The resident said their father and mother died and they were afraid. -On 03/06/2026 at 10:36 AM, in a wheelchair wheeling toward the surveyor asking for help and raised their voice and shouted, Could you stop and talk to me?. Certified Nurse Aide #34 encouraged the resident to take deep breaths and offered a drink of soda. During an interview on 03/09/2026 at 1:45 PM, Certified Nurse Aide #11 stated they were not assigned to the resident routinely. They knew the resident required maximal assistance with their personal care, and the resident ambulated independently. They stated they were supposed to look at each resident's care plan prior to the start of their shift. They were told to redirect the resident and just allow the resident to do whatever they wanted. If there were activities, they should try to encourage them to join, and they tried to sit the resident in their recliner. The resident would reach a point when it was difficult to redirect them. They stated they would let the nurse know if the behaviors became too difficult to manage. During an interview on 03/10/2026 at 10:00 AM, Activity Aide #24 stated the activities sometimes got overwhelming because of residents with difficult behaviors, including Resident #6. During an interview on 03/10/2029 at 10:43 AM, Registered Nurse Unit Manager #14 stated that they were responsible for the initial care plan when the resident was admitted . During the interview they reviewed the electronic record and stated they thought Resident #6 had Alzheimer's disease and dementia. They stated the resident was not a regular dementia, they needed a lot of one-to-one interaction and was a very active resident. The resident had episodes of aggressive behavior, and they were afraid the resident would hurt other residents. Resident #6 liked snacks, non-alcoholic beer, and cranberry juice. They agreed the resident care plan was not personalized for their dementia care and they were in the process of updating the comprehensive care plan to be more person centered. They were not aware the comprehensive care plan should be updated with details of the care interventions to manage the residents' dementia. 2) Resident #66 had diagnoses including dementia and major depression disorder with severe psychiatric features. The 01/07/2026 Minimum Data Set assessment documented the resident had severely impaired cognition; did not have behaviors; required maximal assistance/dependent for most activities of daily living and partial/moderate assistance for most transfers; and received antipsychotics, antianxiety, antidepressant, and anticonvulsant medications. The 01/09/2026 Comprehensive Care Plan documented a focus area of cognitive deficits, and the resident exhibited impaired long-term and short-term memory, limited judgement and safety awareness related to dementia. There were no documented interventions. A focus area of psychotropic drug use. The resident would maintain the highest level of function while receiving the lowest possible dose. There were no interventions documented. The 01/08/2026 Registered Nurse Unit Manager #14 progress note documented the resident was noted to be crying and was observed with negative behaviors, including physical aggression toward nursing staff. The resident was not easily redirected. The 01/14/2026 Licensed Practical Nurse #29 progress note, documented the resident had to be monitored by staff all shift. They were getting up from their wheelchair unassisted and pulling things from tables. Staff attempted to redirect the resident by coloring or reading with no effect. The 02/04/2026 Licensed Practical Nurse #30 progress note documented the resident was unable to be left alone and required constant redirection. Alprazolam (antianxiety) was given at ordered times, but the resident was still restless. The following observations of Resident #66 were made: -On 03/05/2026 at 2:10 PM, in the lounge across from the nurses' station standing between their locked wheelchair and the table, gripping on to the opposite side of the table. -On 03/05/2026 at 2:14 PM, an activities aide brought the resident a puppy activity doll and was actively attempting to interact with the resident and showed them different parts of the doll. The resident took the puppy doll and threw it away from them and sat back down in their wheelchair. -On 03/05/2026 at 2:33 PM, the resident was brought into their room for a nap and was placed in their bed with the blanket pulled up to their chin. A fall mattress was placed beside the bed, and the call bell was clipped to the bed near the right side of the resident's pillow. During an interview on 03/06/2026 at 10:19 AM, Certified Nurse Aide #28 stated care plans were in residents' closets so staff could reference them when needed. Unit managers were responsible for creating and updating care plans. Resident #66 had dementia and at times displayed behaviors. They were unsure if there were interventions in their care plan. There should have been interventions as all residents with dementia should have individualized ways to care for them. During an interview on 03/06/2026 at 10:26 AM, Licensed Practical Nurse #15 stated the nurse manager was responsible for updating care plans. Care plans were supposed to tell staff how to take care of residents and keep them safe. Resident #66 had dementia and was on antipsychotics. Antipsychotic medication was not in the care plan as that was a Health Insurance Portability and Accountability Act violation. They had never seen the resident have behaviors before, so it was not that bad if there were not specific interventions in their care plan. They did not remember if they had seen a dementia care plan for the resident. During an interview on 03/06/2026 at 10:40 AM, Registered Nurse Unit Manager #14 stated residents with dementia or were on antipsychotics should have a care plan. There were psychotropic and dementia care plans, although interventions for dementia care could also be under behaviors. Resident #66 had Alzheimer's dementia with anxiety and depression and was also on antipsychotics. After verification in the resident's electronic medical record, they confirmed there were no interventions documented under psychotropic medication or cognitive impairment and there should be. They stated it was imperative to have a comprehensive care plan for each resident as there were specific ways to care for the residents to keep them safe. During an interview on 03/10/2026 at 12:20 PM, the Director of Nursing stated residents with dementia should have care plans specifically tailored to their needs; what triggered them, what made them happy and any other interventions that provided them with the best care. 10 New York Codes, Rules and Regulations 415.12

Based on observations, record review, and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for three (3) of eight (8) residents (Residents #79, #68, and #32) reviewed. Specifically, Resident #79 had unclean and untrimmed fingernails and was not assisted with removing unwanted facial hair; Resident #68 was not provided with assistance during meals as planned; and Resident #32 had soiled clothing with food debris. Findings include:The facility policy ADL Care, revised 06/2025, documented each morning and evening, care would be provided according to the resident's level of assistance to include elimination and peri care, partial bathing, mouth care, hair combing, and dressing. Fingernails and toenails were kept clean and at the appropriate length, females would be free from facial hair unless they choose not to have the hair removed, meal set up would be provided by staff and residents would receive assistance with meals as needed, and residents would be provided the opportunity to choose their clothing and if unable, staff would provide choices. 1) Resident #79 had diagnoses including kidney failure and atrial fibrillation (irregular heartbeat). The 02/13/2026 Minimum Data Set (assessment tool) documented the resident was cognitively intact, required partial/moderate assistance with personal hygiene, was dependent for showers and bathing, and did not reject care. The Comprehensive Care Plan initiated 01/29/2026 documented the resident had a focus area in all activities of daily living. Interventions included providing morning and nighttime care and providing grooming and hygiene needs. The undated care instructions documented the resident required partial/moderate assistance with personal hygiene. Resident #79 was observed at the following times: -on 03/04/2026 at 11:48 AM, with multiple patches of white and gray hair on their upper lip, chin, and the top of their neck. Their fingernails were long and had dark brown debris under all five nails on their right hand. The resident stated they did not want hair on their face. -on 03/05/2026 at 3:28 PM, with multiple patches of white and gray hair on their upper lip, chin, and the top of their neck. -on 03/06/2026 at 9:46 AM, with multiple patches of white and gray hair on their upper lip, chin, and the top of their neck. Their fingernails were long and had dark brown debris under all five nails on their right hand. At 10:00 AM, the resident stated they were already cleaned up that morning and staff did not offer to shave them so the hair would just stay on their face. -on 03/09/2026 at 1:49 PM, with multiple patches of white and gray hair on their upper lip, chin, and top of their neck. During an interview on 03/10/2026 at 9:53 AM, Certified Nurse Aide #32 stated they were familiar with Resident #79, and cared for them on 03/04/2026, 03/05/2026, 03/06/2026, 03/09/2026 and 03/10/2026. Resident #32 required total care assistance and never refused care. They noticed the resident's facial hair, but they were very busy during their shifts, so they did not have time to shave the resident. They planned to do it before the end of their shift because it was very noticeable. They were unsure if they were allowed to trim fingernails, but they could clean them. They stated they were not aware the residents had long nails with dark debris underneath. During an interview on 03/10/2026 at 10:54 AM, Licensed Practical Nurse #33 stated personal hygiene consisted of shaving and nail care and was completed daily during every shift by the certified nurse aides. They did not notice Resident #79's facial hair. They thought the resident was diabetic so they were responsible to trim their nails, but the certified nurse aides should keep them clean. During an interview on 03/10/2026 at 11:06 AM, the Assistant Director of Nursing stated personal hygiene consisted of shaving and nail care and was completed daily for every resident by the certified nurse aides. The nurses were responsible for trimming the nails of residents who were diabetic, but nails should always be clean. They were familiar with Resident #79, and they noticed their facial hair a week ago. They spoke with staff at that time and thought they had removed the facial hair. They were not aware the resident had long and dirty fingernails. 2) Resident #68 had diagnoses including dementia and depression. The 01/14/2026 Minimum Data Set (assessment tool) documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, did not reject care, and required substantial to maximum assistance with eating. The Comprehensive Care Plan updated on 02/18/2026 documented the resident had a focus area in all activities of daily living. Interventions included maximum assistance with eating a mechanically soft diet. The undated care instructions documented the resident required substantial/maximal assistance with eating and was upgraded to a mechanical soft consistency diet on 02/11/2026. During observations on 03/04/2026 Resident #68 was observed sitting at the end of a large oval table, asleep in their chair waiting for lunch on 03/04/2026 at 12:08 PM. At 12:18 PM, they were provided with their meal. No one assisted the resident with their meal, and they remained asleep. At 12:30 PM, Certified Nurse Aide #11 sat down to assist the resident, and at 12:31 PM, they stood up and left the resident. At 12:33 PM, Licensed Practical Nurse #16 sat down to assist the resident. At 12:36 PM, Licensed Practical Nurse #16 stopped assisting Resident #68 and began assisting another resident at the table. At 12:51 PM, Licensed Practical Nurse #16 assisted the resident with their meal again and at 12:58 PM, the resident finished their meal and was removed from the table. During an observation on 03/06/2026 at 12:44 PM, Certified Nurse Aide #31 assisted Resident #68 with their meal and stopped to assist Resident #108. At 12:57 PM, Certified Nurse Aide #31, was not assisting Resident #68 with their meal while sitting next to the resident discussing with other nursing staff who would need to be toileted after lunch. At 1:06 PM, Resident #68 fell asleep and Certified Nurse Aide #31 did not attempt to wake the resident or encourage them to eat and removed the resident from the table. The resident had 50% of their food remaining on their plate, their juice was not opened, and the pureed cherry pie was not touched. During an interview on 03/09/2026 at 8:30 AM, Licensed Practical Nurse #16 stated Resident #68 needed to be assisted with their meal. The resident would say no sometimes, but staff should keep trying. During an interview on 03/10/2026 at 10:08 AM, Certified Nurse Aide #11 stated the resident needed assistance with their meals. There were no assignments for feeding assistance. Staff should sit down and assist a resident. They were not sure if the resident had finger foods and that was why they did not assist them on 03/04/2026 and 03/06/2026 during the noon meal. They stated it was not uncommon to start assisting other residents if the resident said they did not want to eat, but they should continue to encourage them to eat. During an interview on 03/10/2026 at 10:43 AM, Registered Nurse Unit Manager #14 stated if a resident needed assistance any staff in the dining room should assist. Some residents required encouragement and others needed physical assistance. Resident #68 required substantial assistance and needed to be fed. 3) Resident #32 had diagnoses including dementia, depression, and anxiety. The 12/19/2025 Minimum Data Set (assessment tool) documented the resident had severe cognitive impairment, increased in verbal behavioral symptoms directed toward others, did not reject care, and was dependent on staff for most activities of daily living. The Comprehensive Care Plan initiated 11/24/2025, documented the resident had a focus area on activities of daily living and required assistance by staff. Interventions included anticipating the residents' needs for morning and night care. The undated care instructions documented the resident was dependent on staff for dressing the upper and lower body. Resident #32 was observed with soiled clothing, and white and brown substances on the front of their pants and shirt on 03/04/2026 at 10:15 AM and 10:40 AM; and 03/09/2026 at 10:35 AM, and 12:45 PM. During an interview on 03/09/2026 at 1:30 PM, Certified Nurse Aide #11 stated Resident #32 was dependent on staff for care and that included changing their clothing if they were soiled. They were responsible for Resident #32's care and included ensuring the resident's clothing was clean. During an interview on 03/10/2026 at 11:15 AM, Registered Nurse Unit Manager #14 stated Resident #32 was dependent on staff for all personal care. They expected staff assigned to the resident to change their clothing if they were visibly soiled. During an interview on 03/10/2026 at 12:20 PM, the Director of Nursing stated residents should not wear soiled clothing. They expected staff to change the resident's clothing if soiled. 10 New York Codes, Rules and Regulations 415.12(a)(3)

Based on observations and interviews the facility failed to ensure a clean, comfortable, and homelike environment for one (1) of three (3) resident units (Terrace, Memory care unit). Specifically, the Terrace unit had a strong urine odor, unclean surfaces including stained and sticky floors, and unclean chairs. Findings include:The facility policy Environmental Service, created 09/2024, documented the facility would follow standard cleaning protocols and daily cleaning included: resident rooms, bathrooms, dining areas, nursing stations, common areas, and therapy spaces. Floors were maintained to reduce fall risk and maintain sanitation. Maintenance may include routine mopping, periodic stripping and waxing, carpet vacuuming and shampooing as needed. The facility policy Safe, Clean, Comfortable Homelike Environment, revised 08/2024, documented all staff were responsible for the creation and maintenance of a clean, safe, homelike environment. Regular cleaning and sanitizing of personal and communal living space and equipment was part of a clean environment. The undated facility Daily Room Checklist documented the dining room should be cleaned after lunch, the floors should be swept and mopped in the living areas, and the hallways and quads should be vacuumed as necessary. The following observations were made on the Terrace unit:-on 03/04/2026 at 10:05 AM, there was strong, foul urine odor.-on 03/05/2026 at 9:56 and 1:53 PM, there was strong, foul urine odor.-on 03/06/2026 at 11:18 AM, the dining room area on the Ridge side of the unit smelled of urine.-on 03/09/2026 at 8:14 AM, there was a strong foul urine odor. At 8:59 AM, room T-22, right side, had brown/orange streaks and sticky black spots on the floor, and the entire room smelled of urine. At 10:33 AM and 12:42 PM, two dining room chairs had a red, sticky substance on the side. At 12:44 PM, on Ridge side, a chair in the sitting area was dirty with a brown sticky substance on the back and on the arms. During an interview on 03/04/2026 at 3:25 PM, a family member of a resident stated when they visited their parent the facility had foul odors, and the unit had a strong odor. They stated their parent's room was filthy at times. During an observation and interview on 03/09/2026 at 12:45 PM, Housekeeper #10 stated they were responsible for cleaning the Terrace unit. Cleaning included sweeping, mopping, dusting, and vacuuming the sitting rooms. They were responsible for cleaning the dining room floors and chairs. The dining room chairs and sitting room chairs were cleaned twice a week and as needed. They were not aware of any chairs with sticky red or brown substances. During the interview, Housekeeper #10 observed the chairs with sticky substances and stated they cleaned the chairs, and they would get dirty right away with the residents spilling food. Housekeeper #10 observed room T-22 and stated the floors were stained, they mopped them, but the floors needed to be stripped. They stated they were the only housekeeper on the day shift, and the evening housekeeper was responsible for the dining room floor after dinner, the trash, and the linen. They stated the foul odor of urine was because there were residents that would urinate on the carpeted floor, the carpet was cleaned but it was an old carpet. They were not sure when the carpet was last cleaned. During an interview on 03/09/2026 at 1:51 PM, Certified Nurse Aide #11 stated the unit often smelled of urine, or old food. They stated the resident sitting room chairs may be the source of the odor. They stated if they saw something that required cleaning, they would do what they could and let housekeeping know if a mop was needed to disinfect the area. During an interview on 03/10/2026 at 10:09 AM, Housekeeping Supervisor #12 stated Housekeeper #10 was the full-time housekeeper on the Terrace Unit. There was a housekeeper every day of the week from 7:00 AM- 3:00 PM. The housekeeper had a daily worksheet that was required to be completed during those hours. The resident room floors should be free of stains, and there should not be any dried sticky substances. They were aware of the odors on the unit and stated the Terrace Unit was the only floor that smelled that way. They stated if they shampooed the carpet a resident could urinate on the carpet 20 minutes later. During an interview on 03/10/2026 at 10:43 AM, the Director of Environmental Services stated they had one staff on the Terrace unit on day shift. After 3:00 PM, there was one person for the entire building and one person on the night shift. The day shift housekeeping responsibilities included cleaning/sanitizing bathrooms, shared spaces, resident bathrooms, and the dining rooms. They stated in a perfect world the floors should be free of stains. In February 2026 during the night shift, they shampooed the carpet floor on Terrace. They stated the unit should not have odors and there were things that could be done to rectify the issue. During an interview on 03/10/2026 at 10:43 AM, Registered Nurse Unit Manager #14 stated they were responsible for making notes on environmental issues and reporting these issues to housekeeping and maintenance staff. They stated the unit had an odor, but it was improved. They stated residents urinated on the carpet. They did room audits for cleanliness and let housekeeping know when something did not look clean. They stated they left a voicemail about the floor in room T-22, because it did not look good. New York Codes, Rules, and Regulations Title 10 S415.5(h)(4)

Based on observations and interviews the facility failed to ensure garbage and refuse was disposed of properly for one (1) of one (1) trash compactor. Specifically, there was food debris, food wrappers, milk cartons, used gloves, and dirty utensils, strewn about on the ground surrounding the trash compactor. Findings include: The facility policy Garbage Removal Plan, dated 09/2025, documented garbage bags would be removed to the facility dumpster area from the kitchen when full and at the end of the day and bags would not be overfilled to prevent tearing or spills. Dietary staff would clean garbage containers and surrounding areas, and dietary managers would monitor compliance with garbage disposal procedures. During an observation on 03/06/2026 at 08:14 AM, there was food debris, food wrappers, milk cartons, used gloves, and dirty utensils strewn about on the ground near the food compacter area. During an interview on 03/06/2026 at 11:45 PM, Food Service Director #40 stated the area near the trash compacter had food and debris because of all the snow and from plowing. They stated there should not be debris on the ground because it attracted pests. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on record reviews and interviews during the recertification survey, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (1) of one (1) resident (Resident #120) reviewed. Specifically, Resident #120 was admitted with wounds and did not have admission orders for wound care, a timely assessment by a wound care provider, and their outside wound care clinic appointment was canceled by the facility. Findings included: The facility policy admission Process, last reviewed 09/2025, documented the facility ensured all residents were admitted in a manner that promoted safety, continuity of care, and respect for resident rights. On admission, a licensed nurse completed an initial nursing assessment, assessed skin condition, and reviewed medications and treatment. Required orders on admission included treatments for wound care, rehabilitation services if indicated, and infection control precautions.The facility policy Wound Care and Wound Rounds Protocol, created 03/2024, documented all new admissions had a complete skin assessment to identify any open areas. New admissions with open areas of skin required a registered nurse to document the admission skin assessment, with size, appearance, and stage if appropriate. The physician was notified, and treatment orders were obtained. A wound consultant was notified, and the resident was added to the wound roster. Residents were seen weekly for wound rounds.Resident #120 had diagnoses including gangrene in their right leg (dead tissue) and peripheral vascular disease (poor circulation). The 01/28/2026 Minimum Data Set assessment documented the resident had intact cognition, was dependent for most activities of daily living, frequently incontinent, and at risk of pressure ulcers. The 01/16/2026 Hospital Discharge Summary documented the resident had an admission diagnosis of right foot pain and gangrenous changes to the right foot. The magnetic resonance imaging (a test that produces 3D images) noted possible osteomyelitis (bone infection). The resident was to follow-up with the wound clinic for hyperbaric oxygen therapy (medical treatment where patients breathe 100% oxygen in a pressurized chamber to enhance tissue oxygenation and promote healing). Treatment included an iodine skin-prep and dry dressing to the gangrenous wound, change daily, keep the area dry and prevent secondary soft tissue infection, and offloading as tolerated in a [NAME] shoe (a specialized orthopedic device designed to shift weight off the wound).The 01/16/2026 admission Assessment completed by Registered Nurse #18 documented the resident had a warm and swollen right fourth and fifth toe with a betadine dressing that was clean, dry, and intact. There was no documented evidence of the type and characteristics of wound the dressing was used for.There was no documented evidence of wound care orders for the right foot upon admission to the facility.The Comprehensive Care Plan initiated 01/16/2026 documented the resident was at risk for skin breakdown. Interventions included encouraging adequate dietary intake, occupational/physical therapy as necessary, and weekly comprehensive skin assessments. On 01/20/2026 the care plan documented the resident had a wound infection and interventions were to monitor discomfort related to wound and medicate as necessary, monitor vital signs, and perform treatment and change dressings as ordered. The resident was at risk for skin breakdown with interventions including certified nurse aide report of skin condition daily, complete pressure ulcer risk assessment, encourage adequate nutrition, maintain turning and positioning schedule every two to four hours with staff assist, and skin check/care every shift and with showers. The 02/09/2026 Registered Nurse Unit Manager #19 progress note documented the resident's family made an appointment with a specialized wound clinic that was recommended by the hospital and would pick up the resident and bring them to the appointment. The facility was to gather required paperwork for the appointment.The 02/10/2026 Registered Nurse Unit Manager #19 progress note documented they were made aware by the Chief Nursing Officer the resident needed to be evaluated by the in-house wound care team and could not make the outside appointment for a specialist. Staff were told not to let the resident leave for the appointment.The 02/10/2026 revised Comprehensive Care Plan for skin breakdown documented the resident had actual skin breakdown with interventions including assessing pain and medicating before wound treatment, protecting and off-loading heels, weekly comprehensive skin assessment and documentation, weekly wound measurement and documentation, and perform wound treatment as ordered.The 02/12/2026 Nurse Practitioner #20 wound care note documented it was their first evaluation of Resident #120 who presented to the facility for management of worsening arterial ulceration to their right toes. They had pre-existing ulcers of the right toes and right heel. The resident would have benefited from hyperbaric oxygen therapy. The 02/12/2026 provider orders documented the following wound care for the toes on the right foot. Wash area with normal saline; pat dry; soak the gauze in betadine; cover the toes with the betadine-soaked gauze; cover the area with an abdominal pad; and secure the dressing with woven gauze roll bandage.The 02/13/2026 provider orders documented the following wound care for the right heel arterial ulcer. Clean the area with wound cleanser; apply betadine to the base of the wound; leave open to air twice a day. The resident did not have wound care orders for 27 days.During an interview on 03/06/2026 at 1:39 PM, Assistant Director of Nursing #21 stated wound care orders were placed on admission when residents had wounds on admission, and the wound care provider saw residents within a week from admission. Residents were not required to be seen by the facility wound provider prior to going to specialized appointments recommended by the hospital.During an interview on 03/06/2026 at 3:20 PM, the Director of Nursing stated when a resident was admitted from the hospital with wounds, wound orders were placed within 48 hours from admission and were received from the hospital discharge summary or the after-visit summary. If there were no wound orders in the hospital paperwork a phone call was made to the provider for wound care orders. The wound care team saw the residents the next Thursday after admission. Resident #120 was admitted to the facility on [DATE] with wounds on their toes and heel of the right foot. There were no wound care orders placed on that day or within 48 hours of admission. There were orders for wound care in the hospital discharge summary, the registered nurse who oversaw placing orders must not have seen the orders and stated they were missed as they were on the bottom of the page and betadine was not on the after-visit summary. The admission assessment by Registered Nurse #18 documented the resident had wounds on their right foot. They expected the admission nurse or the unit manager to note the betadine dressing on their foot and ensure orders were in place on admission. The wound care provider did not assess the resident in a timely manner; since there were no wound care orders placed on admission it did not trigger the wound care team to see the resident. Wound care orders should be placed on admission, and the wound care team should have assessed the resident prior to 02/12/2026. Residents were not required to see the facility wound care team prior to going to an out of facility wound center. They were not sure why the appointment was canceled as it came from the Chief Nursing Officer.During an interview on 03/09/2026 at 10:30 AM, Licensed Practical Nurse #22 stated wound care for residents was found under treatment orders. If orders were not there, they called the supervisor to obtain orders. Supervisors or the unit manager was responsible for placing orders. Resident #120 was admitted with wounds on their right foot. They were unable to remember if there were wound treatments on admission.During an interview on 03/09/2026 at 10:46 AM, Registered Nurse #18 stated they were not responsible for placing orders on admission as they were not taught how to do so. They did the admission assessment for Resident #120 but did not remember if there were wounds. The unit manager, Registered Nurse Unit Manager #19, was responsible for placing orders.During an interview on 03/09/2026 at 3:45 PM Registered Nurse Unit Manager #19 stated on admission, wound care orders were found in the hospital discharge summary or the after-visit summary. If there were no orders, they called a provider to obtain them. The admission assessment for Resident #120 was conducted by Registered Nurse #18. Since they did the admission and was a registered nurse, they were responsible for placing the wound care orders. They were unsure why the orders were missed. They were not responsible for checking orders during the resident's stay at the facility. The resident should have had wound care orders. They were told to cancel the resident's specialized wound care appointment by the Chief Nursing Officer because the facility was not going to incur the costs unless the facility wound care team said they needed it. The Chief Nursing Officer then had the wound care provider assess the resident. 10 New York Codes, Rules and Regulations 415.1

Based on observations, record review, and interviews during the recertification survey, the facility failed to provide ongoing programs to support each resident in their choice of activities, for one (1) of one (1) Resident (Resident #20) reviewed. Specifically, Resident #20 was not provided with activities, or invited to activities that were of interest and preference.Findings include:The facility policy Activity Policy, last revised 10/2025, documented the activity department would meet the interests and the physical, mental and psychosocial well-being of each resident. All residents shall be encouraged, reminded and assisted to be involved no matter what their level of ability, to all groups centered on their personal preferences, interest and needs based on their comprehensive assessments, care plan and interviews. Resident #20 had diagnoses including dementia, Alzheimer's disease and major depressive disorder. The 06/17/2025 Minimum Data Set (assessment tool) documented the resident had severely impaired cognition, was dependent for all activities of daily living, and activity preferences included listening to music and being around animals such as pets. The Comprehensive Care Plan initiated on 12/13/2021 and updated on 09/13/2024 documented the resident was a long-term care resident and participated in music, enjoyed holding baby dolls or stuffed animals, and liked animal visits. Interventions included the resident would be provided a program calendar to help identify activities of interest. The 02/20/2026, Activities Quarterly Progress note documented the resident was alert and oriented to self only. The resident was pleasant, communicated nonsensical verbally, used body language and facial expression, and was in a wheelchair. They were passive participant in activities. At times they held stuffed animals and baby dolls. Accommodation required for activity would be transportation and cuing/redirecting. They preferred television shows, entertainment/music, social hours and animals.The resident's preferred activity participations documented:-On 12/09/2025 the resident participated in exercise and music.-On 12/17/2025, the resident participated in entertainment.-On 01/23/2026, the resident participated in move to music and an animal visit.-On 02/09/2026, the resident participated in a pet visit.The following observations of Resident #20 were made:-On 03/04/2026 at 2:24 PM, they were seated in a wheelchair around a round table outside of their room. There was another resident seated next to her. There were no activities or interactions being offered. The resident was reaching for their wheelchair breaks, and reaching at the resident seated next to them. There were no staff observed nearby. -On 03/05/2026 at 1:21 PM, they were seated in their chair and reaching for the lift pad underneath them.-On 03/06/2026 at 1:22 PM, they were brought back to the sitting area on the Terrace Ridge side after lunch and there was a music activity starting, music was playing, and other residents began to sit in circle in the area outside of the nursing station. -On 03/09/2026 at 8:20 AM, they were seated in their wheelchair, at the round table outside of their room, pulling at the lift pad underneath them. There were no activities in this area. At 10:36 AM, the resident had fallen asleep in their chair, the television was on across the sitting room, but there was no other activity.During an interview on 03/04/2026 at 3:25 PM, the resident family member stated they did not think the resident participated in any activities at the facility. They stated Resident #20 enjoyed being outside, if the weather was nice; they wished they had pet visits for the resident. During an interview on 03/10/2026 at 9:18 AM, the Director of Activities stated the Terrace unit was a dementia unit, they had musical entertainment, and they had a juke box for playing music. They reviewed the electronic record during the interview and stated the resident enjoyed hand massages, listening to music, pet visits and holding baby dolls. They were not sure how often they involved Resident #20 in the music activities. Any staff person can invite or bring a resident to an activity; it was a team effort but should primarily be activity staff. During an interview on 03/10/2026 at 9:45 AM, activity aide #24 stated Resident #20 liked music activities, and hand massages. They would try to invite them and take them to the music activities. They were not sure why the residents were not invited to the music activities but stated that sometimes the dementia unit residents' behaviors interfered with activities, and this would get overwhelming. If they were short staffed, they couldn't have a large group of residents for activity, because it would agitate some residents. The resident should have been provided with a busy board or a baby doll if not invited to the music activity.During an interview on 03/10/2026 at 10:00 AM, Certified Nurse Aide #25 stated Resident #20 enjoyed music activities. Any nursing staff member can bring a resident to activities. The resident never refused to go to activities. They have given the resident a baby doll to hold in the past, but it would usually end up on the floor. 10 New York Codes, Rules and Regulations 415.5(f)(1)

Based on record review and interview during the abbreviated survey (iQIES #734057), the facility did not ensure residents received proper foot care and treatment in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for one (1) of three (3) residents (Resident #3). Specifically, Resident #3 was recommended for routine podiatry care by a wound care provider and there was no documented evidence of podiatry care in the resident's record for eight (8) months. Findings include: The facility did not have a documented policy/procedure that addressed how podiatry consults were obtained or who was responsible to schedule them. Resident #3 had diagnoses including Alzheimer's Disease, diabetes and peripheral vascular disease (reduced blood flow to the limbs). The 02/04/2024 Minimum Data Set assessment documented the resident's cognition was moderately impaired; they were at risk of pressure ulcers, and they had no unhealed pressure ulcers or venous or arterial ulcers. The 08/06/2024 renewal physician order, (first became a standing order on 07/28/2023), documented podiatry consultation. The 08/12/2024 podiatry note documented the resident's toenails were debrided (removal of significantly thickened, diseased or damaged nails using specialized tools). They recommended continued wound care for superficial ulceration to tip of right toe until resolved. The 09/05/2024 Wound Nurse Practitioner #9 note documented the resident had an ulcer in the presence of diabetes. The ulcer on their right great toe was 0.5 centimeters wide x 0.5 centimeters long with 100% eschar (non-viable tissue). The plan was to continue Betadine (wound treatment) to the toe twice daily and continue routine podiatry visits. From 09/2024 through 04/2025, Wound Nurse Practitioner #9 continued to assess the resident's right foot weekly and recommended routine podiatry visits. There was no documented evidence the resident was seen by podiatry from 08/12/2024 through 04/29/2025. The 03/25/2025 Comprehensive Care Plan documented the resident had impaired skin integrity, diabetes and needed assistance with activities of daily living. Interventions included wound care and assistance with grooming and hygiene needs. The plan did not address nailcare or need for podiatry. The 04/14/2025 Physician #10's vascular consult documented the resident developed a wound on the top of the right second toe and the tip of the fourth toe of the left foot. A follow up with the podiatrist was necessary for nail care. The 04/30/2025 podiatry note documented the resident had a diabetic ulcer on the right second toe, they had dry skin and no signs of infection. Plan: lotion to both feet every other day and Iodine dressing to right foot second toe every other day. During an interview on 11/13/2025, Registered Nurse Manager #7 stated the facility had a podiatrist who came to the facility every three (3) months. If a resident needed to be seen sooner, they could be sent to an outside podiatrist. When a recommendation was made to see podiatry, the nurse was responsible to let the medical receptionist know to schedule the appointment. They stated they started working for the facility in April of 2025 and they had no knowledge of concerns with obtaining podiatry appointments prior to their start date. However, because the resident had diabetes, only a podiatrist was allowed to cut the resident's nails. They expected the resident's nails to be trimmed by podiatry every three (3) months and were not sure why they went eight (8) months with no documented nail care. During an interview on 11/14/2025 at 10:30 AM, Wound Nurse Practitioner #9 stated they saw the resident weekly since 2024 for wounds on their feet. They recommended podiatry in their consults because podiatry helped with nail care. They stated from what they recalled, it was difficult to tell where the resident's toenails were due to eschar that was present. They believed residents should be seen by podiatry every three (3) months and although Nurse Practitioner #9 and a vascular physician cared for the resident's feet, neither of them provided routine nail care. During an interview on 11/18/2025 at 10:16 AM, Chief Nursing Officer #3 stated there was no documented process for how podiatry consults got scheduled or who was responsible to ensure scheduling. They had spoken with their Director of Nursing and the unit secretary who verbally told them the process and they would be updating their policy to include this information. Staff were aware of the process even though it was not documented. Diabetic residents had toenail care provided by a podiatrist only. If a provider recommended routine podiatry, it was the responsibility of the unit manager to arrange the consult. The resident should have been seen for toenail care between 08/2025 and 04/2025. 10 NYCRR 415.12(k)(7)

Based on observation and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 3 medication carts (second floor Ridge cart), and 1 of 2 medication rooms (first floor) reviewed. Specifically, the second floor Ridge medication cart was unlocked and unattended; and the first floor medication room had 3 bottles of alcoholic beverages stored in a brown paper box on the floor. Findings include: The facility policy, Medication Storage Policy last revised 4/2024, documented all drugs would be stored in locked compartments. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. The facility policy, Medication Administration last revised 10/11/2023 documented the medication carts were to always be locked when not in use for medication administration; and locked and stored in a non-resident area on the unit when not in use for medication administration passes. The facility policy Resident Use of Alcoholic Beverages created 4/2011 documented residents who wished to consume alcoholic beverages on premises would have an order for use of alcoholic beverages by the attending physician or nurse practitioner. Medication Carts: During an observation on 5/17/2024 at 8:38 AM, a medication cart located on the second floor Ridge hallway was left unlocked and unattended for two minutes. There was no nurse in sight. During an observation on 5/17/2024 at 2:48 PM, an unattended, unlocked medication cart was in the hallway of second floor Ridge unit. There were no nurses in sight. During observation on 5/20/2024 at 8:35 AM, an unattended, unlocked medication cart was in the hallway outside the dining room of the second floor Ridge unit. Licensed Practical Nurse #3 returned to medication cart briefly, then left the cart unlocked to administer medications to a resident who was in the dining room. During an interview on 5/20/2024 at 9:12 AM, Licensed Practical Nurse #3 stated medication carts should be locked, and the computer screens should be closed anytime they walked away from the cart or turned their back to the cart. It was important to do this as staff, residents, or visitors could get into their cart and take something. If someone were to take a medication it could cause harm or illness. They were aware they had left the cart unattended and unlocked. They were pulled away from what they were doing by staff and residents. During an observation and interview on 5/20/2024 at 11:13 AM, Licensed Practical Nurse #8 unlocked the medication cart that was located outside of room [ROOM NUMBER] on the second floor Ridge unit, walked away, entered the dirty utility room, and then returned to the medication cart. Licensed Practical Nurse #8 stated the medication cart was supposed to be locked when not in their vision. The medication cart should be always locked when not in use to keep the medications safe and ensure the residents did not take any medicine they should not have. During an interview on 5/22/2024 at 8:55 AM, Licensed Practical Nurse Manager #1 stated all medication carts should be locked and tethered when the nurse was not physically going through the cart. It was important medication carts were locked so others did not remove and take any medications. This could cause harm or illness to someone. Medication room with Alcoholic Beverages: During an observation of the unit one medication storage room on 5/20/2024 at 3:38 PM with Licensed Practical Nurse #24, there was a cardboard box on the floor with a half empty 750 milliliter bottle of chardonnay wine labeled with Resident #75's name; an unopened, unlabeled 750 milliliter bottle of cabernet wine; and an unlabeled half empty 1750 milliliter bottle of brandy. Licensed Practical Nurse #24 stated they did not think the alcohol should be stored on the floor, but it had been stored there for the year that they had been employed at the facility. All alcohol should be labeled with the resident's name. During an interview on 5/22/2024 at 10:07 AM, Licensed Practical Nurse Unit Manager #17 stated residents could have alcohol if they had an order for it. All alcohol bottles should be labeled just like a medication. Resident #75 had a labeled bottle of wine in the medication room, and they did not have an order for it, but should have. Resident #28 did have an order for brandy. It was important that alcohol was labeled and verified the same way as medications were, the right resident and the right drink order. During an interview on 5/22/2024 at 10:42 AM, the Assistant Director of Nursing stated alcohol was locked in the medication room and required an order just like any medication. It was supposed to be labeled with the resident's name. 10NYCRR 483.45 (g)(h) 49448 50561

Based on observation, record review, and interview during the recertification and abbreviated (NY00311928 and NY00320383) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 3 of 8 residents (Residents #31, #95 #103) reviewed. Specifically, Resident #31 was not assisted with showering, washing their hair, and removing facial hair; Resident #95 was not assisted with nail care; and Resident #103 was not assisted with toileting. Findings include: The facility policy, Physical Care/ADLs (activities of daily living) dated 11/2014, documented each morning and evening, the resident had attention to elimination, partial bathing, mouth care, hair combing, and dressing in clean clothing. Each resident had a minimum of one shower or tub bath per week and one bed bath per week. Nursing provided some choices in the bathing schedule. Each resident had an individualized plan for their hair care based on their wishes, and fingernails and toenails were kept clean and at the appropriate length. Male residents were shaved as often as necessary to keep them comfortable and neat, and females were free from facial hair unless they choose not to have the hair removed. The facility policy, Toileting Residents dated 8/2015 documented the registered nurse indicated time frames the resident should be toileted on the resident personal care sheet, and the time selected reflected the individual needs of the resident on a 2-4 hour basis and as needed during the night. This was recorded under the toileting section on the personal care record. After toileting, the certified nurse aide initialed in the correct space and indicated the time the resident was toileted. The certified nurse aide assignment sheet, resident care plan, and person care record reflected the resident's toileting approaches. 1) Resident #31 had diagnoses including dementia and cellulitis (skin infection) of the buttock. The 3/28/2024 Minimum Data Set assessment (health assessment tool) documented the resident had severe cognitive impairment, required substantial to maximal assistance with showering, and was dependent for personal hygiene. The comprehensive care plan last reviewed 12/27/2023 documented the resident required assistance with activities of daily living. Goals included the resident would be neat, clean, and well-groomed daily. Interventions included assistance of one staff for personal hygiene and toileting tasks, provide grooming needs, shower weekly per schedule, and shampoo hair with showers. The care instructions (Kardex) last updated on 3/28/2024 documented the resident was dependent on staff for care and would have their shower on Mondays during the day shift. The resident was observed: - on 5/16/2024 at 10:38 AM, seated outside of their room in a reclining position chair. Their shoulder length hair appeared wet and greasy on the top and the back of their head. There were white flakes on their scalp. The resident had multiple 1/2 inch white gray hairs on their chin. The resident asked how many whiskers they had while trying to pull them out and stated, I have cat whiskers. - on 5/17/2024 at 9:36 AM, sitting in their reclining position chair. Their hair was greasy with white flakes on the scalp. The resident had multiple 1/2 inch white gray hairs on their chin. - on 5/20/2024 at 9:09 AM, lying in bed, dressed in grey pants and a long blue sleeve floral print shirt. Their hair appeared wet and greasy. The resident had multiple 1/2 inch white gray hairs on their chin. The certified nurse aide documentation for Resident #31 from 5/1/2024-5/20/2024 included: - on Monday 5/6/2024 there was no documentation care was provided. - on Monday 5/13/2024 a shower was documented as self-care. - on Monday 5/20/2024 there was no documentation a shower was provided. - on Tuesday 5/21/2024 and there was no care documented. During an interview on 5/21/2024 at 1:54 PM, Registered Nurse Unit Manager #14 stated staff reviewed the resident care plan for assistance level, shower days, and specifics for the resident. They had a shower schedule which matched the care plan and the tasks sheets. All resident care should be documented in the electronic medical record. If the care section was left blank, they could not determine that care was completed. If a resident refused care the aide should let the nurse know and then reapproach the resident. If the resident had refused showers they should have been notified. Personal hygiene included shaving of both men and women if they wished and should be done daily. Resident #31 had a history of refusals, but they were not made aware of any shower refusals. It was not dignified for women to have facial hair or greasy hair. They did notice the facial hair on Resident #31's chin. Every resident should be provided a shower and if they did not want one a note should have been written in the record why they did not receive a shower. If a shower was not provided a bath should be given instead so the resident felt clean. During an interview on 5/22/2024 at 9:50 AM, Licensed Practical Nurse Unit Manager #6 stated Resident #31 should have received daily care and that should have included removal of facial hair, washing their hair, and receiving their weekly showers. If a resident had dirty greasy hair, it was dignity issue and good hygiene was important for resident care. During an interview on 5/22/2024 at 10:12 AM, Certified Nurse Aide #7 stated they reviewed the care plan to find specifics for the resident's care including personal care needs and shower days. Personal hygiene consisted of oral care, facial care, cleaning, shaving men and women, and nail care. They stated they were responsible for Resident #31's care last week and the resident did not refuse care. They did not always have time to document the care they provided. They stated they did not give the resident a shower, wash the resident's hair, or remove the facial hair. They were aware of the resident's chin hair and should have shaved or trimmed it and completed the resident's shower. They stated the resident's hair was greasy and they should have washed the resident's hair even if it was not their shower day. They reviewed the documented care and stated it appeared the resident only received one shower in a month. 2) Resident #95 had diagnoses including Alzheimer's disease (a type of dementia) and hypertension (high blood pressure). The 3/2/2024 Minimum Data Set assessment (a health assessment tool) documented the resident had severe cognitive impairment and required substantial to maximal assistance for personal hygiene. The 3/14/24 care instructions documented the resident required maximal assistance with bathing which included nail care, and their shower was scheduled on Thursday during the day shift. The certified nurse aide documentation documented the resident received a bath during the day shift on 5/16/24 but did not receive personal hygiene care on 5/2/24, 5/4/24, 5/7/24, 5/8/204, 5/9/2024, 5/10/24, and 5/12/24. During an observation on 5/16/2024 at 10:18 AM, the resident's fingernails were approximately 1/4 inch long and jagged, with a dark brown substance under all 5 nails on the right hand and under the left thumb nail. During an observation on 5/20/2024 at 10:41 AM, the resident's fingernails were long and jagged with dark brown debris under all 10 fingernails. During an interview on 5/21/2024 t 9:20 AM, Licensed Practical Nurse Unit Manager # 26 stated the resident's shower was scheduled for Thursdays during the day shift. During an observation on 5/21/2024 at 11:34 AM, the resident's fingernails were long with dark brown debris under all 10 fingernails. During an interview on 5/21/2024 at 1:54 PM, Registered Nurse Unit Manager #14 stated staff reviewed the resident care plan for assistance level, shower days, and specifics for the resident. All resident care should be documented in the electronic medical record. If the care section was left blank, they could not determine that care was completed. Personal hygiene included ensuring nails were clean, trimmed and filed. During an interview on 5/22/2024 at 9:50 AM, Licensed Practical Nurse Unit Manager #6 stated staff should review the care task sheet (care instructions) that was generated from the care plan for the resident's activity daily living care. This included shower day and any specific cares for the resident. Personal hygiene consisted of nail care (clean and trimmed). Resident #95 was not diabetic, and the aides should have completed the residents nail care. They stated it was important to keep nails clean and short as it was a dignity issue and infection control issue as bacteria could pool under the nail beds. During an interview on 5/22/2024 at 10:08 AM, Certified Nurse Aide #7 stated the resident did not refuse care and they had not noticed the resident's nails were dirty or they would have cleaned them. They stated the resident's nails should be clean and kept short to prevent them from scratching themselves and to keep bacteria from underneath the nails. They stated the certified nurse aide documentation indicated the resident received one shower in May. They stated based on the lack of documentation it appeared the resident did not receive showers on their shower days. It was important to document care otherwise it looked like the care was not complete. 3) Resident #103 had diagnoses including dementia, urge incontinence (an urgent and uncontrollable need to urinate), and a history of urinary tract infections. The 2/18/2024 Minimum Data Set assessment (a health assessment tool) documented the resident had severely impaired cognition, did not reject care, was dependent for toileting, was frequently incontinent of urine and always incontinent of bowel. The comprehensive care plan reviewed 11/16/2023 documented the resident had an activity of daily living deficit. Interventions included assistance with toileting, brief/pad changes, and toilet before all meals. The resident was incontinent of bladder and would be maintained on a toileting program that promoted dignity and prevented skin breakdown. Interventions included redness and skin breakdown were monitored during toileting/ brief changed every 2-4 hours and as needed, and maintain toileting schedule every 2-4 hours and as needed. The May 2024 certified nurse aide documentation for Resident #103 did not document toileting was completed: - on 5/16/2024-5/17/2024 on the day, evening, or night shifts. - on 5/18/2024 and 5/19/2024 on the evening shift. - on 5/20/2024 on the day, evening, or night shifts. The following continuous observation of Resident #103 was made on 5/21/2024 from 8:49 AM to 2:22 PM: - at 8:49 AM sitting in their reclining position chair being assisted with breakfast. - at 9:39 AM, being wheeled to the common pod area in reclining position chair. - at 11:37 AM, being wheeled into the dining room. - at 12:33 PM being wheeled to the common area. - at 1:36 PM being wheeled to the music activity by the nursing station. - at 2:22 PM at the music activity sitting in their reclining position chair. Resident #103 was not provided with toileting/ incontinence care during this time. During an interview on 5/21/2024 at 1:47 PM Certified Nurse Aide #22 stated all residents were toileted every 2-4 hours whether they were continent or incontinent. Toileting was important for urinary tract prevention, and it prevented skin breakdown. Resident #103 was incontinent. They thought they toileted the resident around 9:00 AM but had not toileted them since 9:00 AM because they were busy. They stated the resident should be toileted frequently because they could not speak for themselves. During an interview on 5/22/2024 at 9:46 AM Licensed Practical Nurse #19 stated residents were toileted every 2-4 hours and as needed. Incontinence care was important for dignity, illness and infection prevention and good hygiene. It was not appropriate for anyone to be in the same incontinence brief for 6-7 hours as it promoted skin breakdown. Resident #103 sometimes verbalized they needed to use the bathroom but should still be toileted regularly. During an interview on 5/22/2024 at 10:07 AM Licensed Practical Nurse Unit Manager #17 stated all residents were toileted or provided with incontinence care every 2-4 hours for urinary tract infection prevention and wound prevention. It was not appropriate for any resident to be in the same incontinence brief for 6-7 hours and Resident #103 should have been offered to be toileted. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interview during the recertification and abbreviated (NY00311928) surveys conducted 5/16/2024-5/23/24, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 8 staff (Certified Nurse Aides #10, #11, #13, #20 and #21; Licensed Practical Nurses #8 and #18, and the Assistant Director of Nursing) observed; and for 1 of 2 residents (Resident #4) reviewed. Specifically, - Licensed Practical Nurse #8 did not perform hand hygiene or wear gloves when administering medication via a gastrostomy tube (feeding tube) to Resident #44 who was on enhanced barrier precautions. - Resident #25 was on contact precautions and Licensed Practical Nurse #8 did not put on the required personal protective equipment prior to entering the resident room and administering insulin; Certified Nurse Aides #10 and #11 entered Resident #25's room and did not put on personal protective equipment prior to providing care; and Certified Nurse Aide #13 entered the resident's room to remove the breakfast food items and did not wear personal protective equipment. - Resident #48 was on enhanced barrier precautions and personal protective equipment was not worn by Certified Nurse Aides #20 and #21, Licensed Practical Nurse #18, and the Assistant Director of Nursing during wound care or incontinence care. - Resident #4's urinary catheter drainage collection bag was lying directly on the floor without a barrier. Findings include: The facility policy, Infection Prevention and Control Program revised 1/2024, documented the Infection Control Program was designed to prevent, identify, report, investigate, and control the spread of infections and communicable diseases for all residents, staff, volunteers, visitors and other individuals providing services under a contractual arrangement; and to provide a safe, sanitary and comfortable environment; and to help prevent the development and transmission of disease and infection, in accordance with State and Federal Regulations. The facility policy, Enhanced Barrier Precautions revised 3/2024, documented enhanced barrier precautions was an infection control intervention designed to reduce transmission of multidrug-resistant organisms. Enhanced barrier precautions involved gown and glove use during high-contact resident care activities for residents known to be colonized or infected with multidrug-resistant organisms as well as those at increased risk of multidrug-resistant organism acquisition (e.g., residents with wounds or indwelling medical devices). The facility policy, Tube Feedings dated 3/2017, did not address the required personal protective equipment to be used for medication administration. The undated facility policy, Contact Precautions documented a precaution sign would be placed on the outside of a resident's room door, the isolation cart (contains personal protective equipment) would be placed outside of the resident's door. Gloves would be worn by all staff who entered a resident's room and removed, and hands washed before leaving the area. Gowns would be worn by all staff providing care if their clothes could become soiled with infectious material. 1) Resident #44 had diagnoses including gastrostomy (surgically made opening into the stomach for food). The 3/2/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required maximum assistance with activities of daily living, and had a feeding tube. The comprehensive care plan initiated on 2/14/2018 documented the resident required a tube feeding as an alternative means of nutritional support for their nutrition and hydration. The 4/23/2024 physician order documented enhanced barrier precautions were to be maintained every shift. During an observation on 5/20/2024 at 10:33 AM, Licensed Practical Nurse #8 prepared medications for Resident #44. They stated the resident received all their medications through the gastrostomy tube. The nurse gathered the required medications and supplies and entered the resident's room. They did not perform hand hygiene or apply gloves. Licensed Practical Nurse #8 reached under the resident's blankets and gown for the gastrostomy tube with ungloved hands and began to prepare for medication administration by administering a water flush. Licensed Practical Nurse #8 stated, Are you marking me down for not wearing gloves? and continued to give the resident medications without wearing gloves. After attempting to give the medications through the gastrostomy tube they stated the tube seemed to be plugged and they were going to get the Unit Manager. They washed their hands in the sink prior to leaving the room. During an interview on 5/20/2024 at 11:11 AM, Licensed Practical Nurse #8 stated they should have worn gloves during the medication administration for Resident #44 to prevent the spread of germs. They thought they washed their hands prior to touching the resident's gastrostomy tube and washed their hands after completing the medication administration and that should have been good enough. During an interview on 5/21/2024 at 8:51 AM, Licensed Practical Nurse Unit Manager #1 stated staff were supposed to wear gloves any time they touched a gastrostomy tube. This was an infection control standard. The staff should have worn gloves upon entering the room. Licensed Practical Nurse #8 should have worn gloves knowing they were going to administer medications and a water flush through a gastrostomy tube. During an interview on 5/22/2024 at 11:30 AM, the Assistant Director of Nursing stated staff should wear gloves when they provided medications through a feeding tube. This was the standard of care. It was important to wear gloves to prevent the spread of pathogens from one resident to another resident. Gloves and hand hygiene were major keys to the prevention of infection in the residents. 2) Resident #25 had diagnoses including asthma, chronic respiratory failure, and diabetes. The 3/13/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required maximum assistance with activities of daily living, and had received insulin in the last 7 days. The 5/16/2024 Nurse Practitioner #44 progress note documented the resident's urinalysis (a urine test that checks for infection) and culture (a lab test that checks for bacteria in the urine) was positive for a urinary tract infection. The urine was positive for greater than 100,000 pseudomonades (a type of bacteria). The May 2024 physician orders did not document the resident was to be on contact or enhanced barrier precautions. During an observation on 5/17/2024 at 1:56 PM room had a contact precautions sign on the door. The resident's call light was alarming. Certified Nurse Aide #10 entered the room and did not apply personal protective equipment. They exited the room and stated the resident wanted their juice opened. The resident had stated to them they thought they had the flu. Certified Nurse Aide #10 did not perform hand hygiene. During an observation on 5/17/2024 at 2:13 PM, Resident #25's room had a contact precautions sign posted on the outside of the door. Certified Nurse Aides #10 and #11 started to enter the room not wearing any personal protective equipment or performing hand hygiene. The certified nurse aides paused and read the sign outside the resident's room and continued to walk into the room. There was no personal protective equipment outside of the room. At 2:21 PM, both certified nurse aides exited the room and did not perform hand hygiene. There was a small bottle of hand sanitizer observed outside the door on the railing. The current comprehensive care plan and resident care instructions did not document the resident was to be on contact precautions or enhanced barrier precautions. During an observation and interview on 5/20/2024 at 12:03 PM, there was a contact precautions sign on the resident's door. Licensed Practical Nurse #8 stated they were not sure what the sign was for and thought it was an old sign and proceeded to enter the resident's room to complete a blood sugar via fingerstick. They did not perform hand hygiene and applied gloves. Prior to exiting the room, they entered the bathroom, removed their gloves, and washed their hands. At 12:18 PM, Licensed Practical Nurse #8 prepared the resident's insulin pen, they did not use hand sanitizer or wash their hands, they put on gloves, entered the resident's contact precautions room without all the required personal protective equipment on, and administered the insulin. During an interview on 5/21/2024 at 8:58 AM, Licensed Practical Nurse Unit Manager #1 stated the contact precautions sign was for Resident #25. The resident had a recent urinary tract infection and a fall requiring staples to the forehead. For those two reasons the resident was required to be on contact precautions. Resident #25 had bacteria in their urine and all staff should have known this information. The contact precautions required staff to have full personal protective equipment on when entering the resident's room. Staff were educated on personal protective equipment on 5/17/2024 and the signs on the door instructed the staff on what personal protective equipment to wear. It was important to wear the required personal protective equipment to prevent the spread of germs and to keep the infection confined. Staff should participate in morning report to get updated information on residents and if they had questions, they should be reaching out to them. During an interview on 5/22/2024 at 9:50 AM, Certified Nurse Aide #12 and Certified Nurse Aide #13 stated they were regular staff on Unit 2. Both certified nurse aides stated they were unsure what enhanced precautions meant. Certified Nurse Aide #13 stated Resident #25 was on contact precautions last week. When they entered the room last week not wearing personal protective equipment it was okay because they were just picking up the resident's meal tray. Contact precautions was only needed when providing the resident's personal care. It was important to practice the proper infection control precautions to protect themselves and the residents from germs. During an interview on 5/22/2024 at 11:30 AM, the Assistant Director of Nursing stated if a nurse was performing a fingerstick for a blood glucose check they should be wearing gloves. If Resident #25 was on contact precautions staff should be wearing a gown to protect the resident. When staff did not wear the appropriate personal protective equipment, this was an infection control issue. 3) Resident #48 had diagnoses including urinary incontinence, diabetic foot ulcers, and unspecified skin changes. The 4/28/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for toileting, bathing, dressing, was always incontinent of bowel and bladder, had diabetic foot ulcers, and had applications of dressings to the feet. The comprehensive care plan initiated 6/12/2023 and revised 4/18/2024 documented the resident had skin breakdown to the left and right heels and open areas to the bilateral buttocks. Interventions included the resident was to be followed by the wound team on weekly rounds, signs and symptoms of infection were to be monitored, and enhanced barrier precautions were to be maintained. Resident #48's physician orders documented: - 12/29/2023 hydrophilic dressing paste that adhered to wet, eroded skin topically, once daily, in a circular motion to open areas on the left and right buttocks. - 4/15/2024 left medial heel diabetic foot ulcer, skin prep to wound base, leave open to air daily. - 4/22/2024 maintain enhanced barrier precautions every shift. - 5/17/2024 zinc cream to coccyx (lower tailbone) twice daily and as needed for prevention of skin alterations. During an observation of Resident #48's incontinence care and wound care on 5/20/2024 at 11:49 AM, Certified Nurse Aide #21 entered the resident's room with a mechanical lift machine (used to transfer residents). Certified Nurse Aide #21 put on gloves and did not perform hand hygiene and did not put on a gown. At 11:55 AM, Certified Nurse Aide #20 entered the resident's room, put on gloves, and did not perform hand hygiene, or put on a gown. They attached the mechanical lift pad to the mechanical lift and transferred the resident from their chair to their bed to perform incontinence care. At 11:59 AM, Licensed Practical Nurse #18 entered the resident's room, put on gloves, did not put on a gown, and did not perform hand hygiene. At 12:01 PM, Licensed Practical Nurse #18 removed their gloves, did not perform hand hygiene, stated they were going to get the Assistant Director of Nursing, and exited the room. At 12:02 PM Licensed Practical Nurse #18 and the Assistant Director of Nursing both entered the room, applied gloves, and did not perform hand hygiene, and did not put on a gown. At 12:06 PM Licensed Practical Nurse #18 applied zinc cream to the resident's buttocks wound wearing gloves. They removed the gloves, washed their hands, and applied new gloves and performed the wound treatment. Hand hygiene was performed by both upon exiting the room. At 12:18 PM, Certified Nurse Aides #20 and #21 transferred the resident back to their medical recliner chair after dressing the resident. Certified Nurse Aides #20 and #21 removed their gloves and exited the room without performing hand hygiene. There was no visible signage near the resident's room that documented the resident was on enhanced barrier precautions. During an interview on 5/20/2024 at 1:07 PM Licensed Practical Nurse #18 stated enhanced barrier precautions were for any resident with a wound, catheter, tube feeding, or history of a super bug (drug resistant bacteria). It was important to protect susceptible residents by wearing a gown and gloves and eye protection if there was a chance of bodily fluid splashes. They should have worn a gown when providing wound care because Resident #48 was on enhanced barrier precautions. There should have been a sign on the door that informed staff of the precautions and what personal protective equipment was needed but it must have fallen off. During an interview on 5/22/2024 at 10:42 AM the Assistant Director of Nursing stated residents who had urinary catheters or wounds were on enhanced barrier precautions. Personal protective equipment was worn with treatment or care such as incontinence care, bathing, or emptying a urinary drainage bag. Resident #48 was on enhanced barrier precautions and they and the other staff members who performed wound care and incontinence care during the observation on 5/20/2024 should have all had at least gowns on. This was important to prevent the spread of infection from one person to another. During an interview on 5/22/2024 at 10:55 AM, the Infection Preventionist stated contact precautions were for residents with infections like clostridium-difficile (an intestinal bacteria), stomach bugs, or urinary tract infections with multiple drug resistant organisms. Staff were required to wear gowns, gloves, masks, and shields when performing care. If a resident had a laceration, abrasion, or a gastrostomy tube feeding they should be on enhanced barrier precautions. Gloves should be worn when performing gastrostomy tube feedings, flushes, or administration of medications for infection prevention control purposes. It was the standard of care to wear gloves for gastrostomy tube feedings, medication administration and flushes. Gloves kept the resident safe. All staff should wear gloves and gowns for enhanced barrier precautions. Whenever a resident was put on precautions, they went to the unit to verify that it was needed. They put an orange dot on the resident's name outside the door and put signage on the back of the door for enhanced precautions. The signs on the front of the door were for contact precautions. During a follow-up interview on 5/22/2024 at 11:30 AM, they stated enhanced barrier precautions were a step above standard precautions to stop the transmission of infections between residents and staff. Gown and gloves were required, and masks were optional and should be used if there was a risk of bodily fluid spray. Residents on enhanced barrier precautions were those that had multi-drug resistant organisms, catheters, gastrostomy tube feedings, open wounds, surgical wounds, or central line devices. Resident #48 was on enhanced barrier precautions for their wounds. Gowns and gloves were required for all the resident's wound care, incontinence care, or any other hands-on care. It was not appropriate that gowns were not worn during wound and incontinence care of Resident #48 because staff could spread infections or give the resident an infection. 10 NYCRR 415.19(a)(b) 48675 49448

Based on record review, observation, and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not maintain an effective pest control program so that the facility was free of pests for 2 of 3 nursing floors (first and second floors). Specifically, there was evidence of drain flies and fruit flies on the first and second floors. Findings include: The Pest Sighting Service Report Log, located in the mail room, documented that no pests were observed by staff from 2/28/2024 to 4/24/2024. The Pest Control Vendor Invoice documented that no pests were observed from 2/28/2024 to 4/24/2024. The Pest Siting Service Report and the Pest Control Vendor Invoice forms did not document the facility areas checked by the vendor. The following observations were made: - on 5/16/2024 at 11:40 AM in the second floor Ridge side spa room, there were 4 live drain flies and multiple dead drain flies. - on 5/17/2024 at 12:15 PM in the second floor kitchenette, there was 1 live fruit fly. - on 5/17/2024 at 12:30 PM in the first floor kitchenette, there were 2 live fruit flies. - on 5/20/2024 at 9:45 AM in the first floor kitchenette, there were 2 live fruit flies. - on 5/20/2024 at 9:59 AM in the second floor kitchenette, there were 2 live fruit flies. During an interview on 5/21/2024 at 11:55 AM, the Director of Environmental Services stated if staff saw pests, they should report it to the housekeeping team lead or a supervisor. They stated the pest control vendor had been doing monthly inspections of the facility for the last three months and no pests had been identified. There were nine drains that were treated to prevent pests and they were not sure if the second floor Ridge spa room drain was included on this list. They stated work orders were entered when staff emailed or called the maintenance department, and all staff should be documenting pests in the mail room pest sighting log. The Director of Environmental Services stated it was important that all areas of facility were checked for pests. During an interview on 5/22/2024 at 9:38 AM, the Food Service Director stated they were not aware of any fruit flies in the first and second floor kitchenettes. They stated the main kitchen utilized a separate pest control vendor from the rest of the facility, and they came monthly. The Food Service Director stated the other vendor checked the rest of the facility for pests. The Food Service Director stated the drains in the facility kitchenettes had a monthly drain treatment done by a vendor, and this treatment could also be completed as needed. 10NYCRR 415.29(j)(5)

Based on observation, record review, and interview during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure residents were assessed for risk of entrapment from bed rails prior to installation, did not review the risks and benefits of bed rails with the resident or resident representative, and did not obtain informed consent prior to the installation of bed rails for 4 of 4 residents (Resident #48, #59, #109, and #119) reviewed. Specifically: - Resident #109 had no documented evidence of a bed rail assessment prior to bed rail installation, explanation of the risks and benefits of bed rails to the resident or their representative, or consent prior to bed rail installation. Additionally, the resident's enabler bar was not removed timely, and the resident was found with their arm between the enabler bar and the mattress. - Residents #48, #59 and #119 had no documented evidence of a bed rail assessment prior to bed rail installation, explanation of the risks and benefits of bed rails to the resident or their representative, or consent prior to bed rail installation. Findings include: The undated facility policy, Use of Bed Enablers documented the use of bed enablers would be carefully considered and justified based on individual resident needs. Therapy would complete an assessment on admission and upon receiving a therapy evaluation from nursing. Careful attention for risk factors such as fall risk, mobility, cognitive status, and individual preferences would be taken into consideration before implementing. Therapy would send a work order to maintenance for the application of the bed enabler(s) per manufacturer instructions. Nursing staff would be responsible for documentation and care planning the use of the enabler device(s) and adding the information to the certified nurse aide care assignment sheet. 1) Resident #59 had diagnoses including spinal stenosis (spaces between the bones of the spine are narrowed) of the thoracic (mid back) region and chronic pain. The 4/26/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, functional limitation in both legs, required substantial/maximal assistance with rolling left to right, and was dependent for sit to lying and chair to bed transfers. The resident had falls prior to admission. The 3/20/2024 comprehensive care plan documented the resident was at risk for falls. Interventions included answer call bell promptly, keep call bell within reach, and mattress next to bed. On 5/8/2024 the resident was at risk for skin breakdown and interventions included to provide left and right bed enabler bars to assist with positioning and comfort. The 4/7/2024 Fall Risk Assessment documented the resident was at high risk for falls. On 4/8/2024 at 9:44 AM, the Director of Therapy sent an electronic mail to the Director of Nursing regarding the residents who needed or had bed enabler devices and were safe/ appropriate for use and Resident #59 was not included. During observations on 5/16/24 at 12:18 PM and 5/17/24 at 8:44 AM there were 1/4 bed rails on both sides of the resident's bed. There was no documented evidence of a bed rail assessment prior to bed rail installation, that the risks and benefits of bed rails were explained to the resident or their representative, or that consent was obtained prior to bed rail installation. During an interview on 5/21/2024 at 11:01 AM Certified Nurse Aide #32 stated that Resident #59 had bed enabler bars on both sides of their bed, and they used them for positioning. The resident had a safety mat on the floor and had falls in the past. The bed enabler bars were not listed on the certified nurse aide assignment sheet. During an interview on 5/21/2024 at 12:35 PM the Director of Therapy stated the resident was able to use the bed enabler devices for positioning and was care planned for their use. The enabler bars could be a possible safety risk if the resident did not use them correctly. They did not review the risks or benefits with the resident's representative and did not obtain informed consent prior to installation of the enabler bars. 2) Resident #119 had diagnosis including Parkinson's disease (a progressive neurological disorder), neurocognitive disorder with Lewy body dementia, and repeated falls. The 1/23/2024 Minimum Data Set Assessment documented the resident had severely impaired cognition, had functional limitation of one arm, required supervision or touching assistance with rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, and chair to bed transfers. The resident had 2 falls without injury and 2 falls with injuries (expect major injuries) since admission/entry or reentry or the prior assessment and did not use any restraints or alarms. The 10/6/2023 comprehensive care plan documented the resident had cognitive deficits related to Lewy body dementia and had impaired long term and short-term memory, limited judgement, and safety awareness. The resident required assistance with all aspects with care. The resident required assistance with bed mobility and transferred with staff assistance. The resident was at risk for falls related to their cognitive deficits. Interventions included use appropriate devices and level of assistance as recommended. The resident was at risk for skin breakdown and the updated 5/8/2024 interventions included to provide a left side bed enabler device to assist with positioning and comfort. The 3/24/2024 Fall Risk Assessment documented the resident was a high risk for falls. During an observation on 5/16/24 at 10:12 AM the resident was in their room in bed. There was a 1/4 bed rail on the right side of the bed. There was bruise on the resident's right arm just above elbow. The updated 5/22/2024 certified nurse aide assignment sheet documented the resident was independent with bed mobility. It did not include the use of an enabler bar. There was no documented evidence of a bed rail assessment prior to bed rail installation, that the risks and benefits of bed rails were explained to the resident or their representative, or that consent was obtained prior to bed rail installation. During an interview on 5/21/2024 at 12:56 PM the Director of Therapy stated the resident could use the bed enabler device. The enabler bars could be a possible safety risk if the resident could not use them correctly. They did not review the risks or benefits with the resident's representative and did not obtain informed consent prior to installation. 3) Resident #109 had diagnoses including Parkinson's disease (a progressive neurological disorder), Alzheimer's disease (a type of dementia), and repeated falls. The 2/17/2024 Minimum Data Set Assessment documented the resident had severely impaired cognition, rejected care 1- 3 days, and wandered 1- 3 days. The resident had functional limitation of both legs, was dependent for rolling left to right, lying on the side of the bed, sit to stand, and chair/ bed to chair transfers, had 2 or more falls since admission/entry or reentry or prior assessment with no injury, and used both a bed and chair alarm daily. The 5/12/2023 comprehensive care plan documented the resident had impaired short and long-term memory, limited judgement and safety awareness related to Parkinson's Disease and Alzheimer's Dementia. The resident had a vision deficit related to the aging process and cognitive deficits. The resident had an activity of daily living deficit and required assistance with all aspects of care including bed mobility assistance of 2, transfer assistance of 2, and was non ambulatory. The resident was at risk for falls and interventions included the use appropriate assistive devices and level of assistance as recommended. The care plan did not include the use of a bed enabler device. The 3/29/2024 certified nurse aide assignment sheet did not include the use of enabler bars. On 4/1/24024 at 8:58 AM, the Director of Therapy sent an electronic mail to the Maintenance Director with a list of residents that needed their bed enabler bars removed, Resident #109 was on the list. There was no documented evidence in the resident's record of a bed rail assessment prior to bed rail installation, that the risks and benefits of bed rails were explained to the resident or their representative, or that consent was obtained prior to bed rail installation. The facility's 4/8/2024 Accident and Incident report documented to refer to the 4/9/2024 progress note completed by Registered Nurse Supervisor #30. Staff statements included: - Licensed Practical Nurse #31's statement documented the time of the incident was the first time they saw the resident that evening (at 11:50 PM). The care plan was followed, and the resident leaned a lot and was shaky due to Parkinson's Disease. The certified nurse aides found the resident lying half on and half off their bed with their head on the bed and feet/ legs on the mattress on the floor. The resident's right arm was pressed against the metal railing of the bed and a skin tear was found on their left arm. - Certified nurse aide #32's statement documented they did not see the resident until they found them. At the time of the incident, they were completing their rounds, the care plan was followed, the resident usually reaches for things, there was no change in their activity of daily living functions, and it looked like they were in that position for hours. - Certified nurse aide #33's statement documented they last saw the resident at the start of their shift during rounds in the resident's room. The resident was observed to be leaning off the bed with their head on the bed and their arm was wedged between the (bed) rail and the mattress. The resident's legs were on the mattress on the floor. The care plan was followed. The resident was known to get up and climb out of their bed. The resident had a cut on their left arm and their right arm was discolored from being wedged. On 4/9/2024 at 11:50 PM Registered Nurse Supervisor #30 documented on 4/8/2024 at 11:30 PM, the resident was found lying halfway out of their bed. Their upper torso was on the bed and their lower extremities were on the floor mattress. Staff reported their right arm was pressed against the bed and the enabler bar on the outside of the bed. The right arm was reported by staff as cold but at the time of the assessment the arm was warm to the touch with normal capillary refill. The care plan was followed and there were no apparent injuries noted. The provider would be notified in the morning and family was notified. A new order was obtained to initiate fall protocol and monitoring. No signs of abuse, neglect or mistreatment were identified, and nursing would continue to monitor. There was no documented evidence the enabler bar usage was reviewed after the incident despite therapy's request for removal on 4/1/2024. During an interview on 5/21/24 at 12:28 PM the Director of Therapy stated the therapy department determined if a resident needed enabler devices for positioning on their bed. The residents were evaluated for bed positioning upon admission and when they were receiving therapy services. If a resident was physically able to use the enabler device, therapy would send an electronic mail to the maintenance department who then installed the device. Therapy staff also determined if the devices were no longer needed. In the past both nursing staff and the therapy department reviewed the risks and benefits of bed rails with the resident or resident representative. They were unsure who obtained informed consent prior to the installation of the enabler devices. They thought the nursing staff added the enabler devices to the care plan. They stated on 4/1/2024 they completed a full house audit on residents who had enabler devices on their beds and requested that Resident #109's be removed as the resident was unable to follow commands and it was not safe. The resident was cognitively impaired, and it posed a possible safety risk. The Maintenance Director was notified via electronic mail of the request for removal. They were unaware the enabler device was still installed on the bed on 4/8/2024. During an interview on 5/17/2024 at 1:11 PM Registered Nurse Unit Manager #14 stated they thought nursing staff monitored the resident's ability to use the enabler devices installed on their bed. They were unsure who reviewed the risks and benefits of bed rails with the resident or resident representative. They were unsure who obtained informed consent prior to the installation of the enabler devices. They stated only residents who were able to use the enabler devices had them installed on their beds. Therapy recommended the use and discontinuation of the enabler devices and the maintenance staff installed and removed the devices. Resident #109 no longer had an enabler device installed on their bed and they were unsure if the resident was ever care planned for the use of the enabler device on their bed. They did not recall the 4/8/2024 incident when the resident was found with their arm between the enabler device and their mattress. They stated incident reports were reviewed by the interdisciplinary team during the report and the team reviewed care plan interventions. They stated enabler bed devices posed a possible safety risk for entrapment. During an interview with the Director of Maintenance on 5/21/2024 at 2:04 PM, they stated the therapy department notified them of which resident needed bed enabler devices installed or removed via electronic mail. They stated they received an electronic mail notification that documented Resident #109 needed their bed enabler devices removed on 4/1/2024 at 8:58 AM and again on 4/11/2024 at 3:10 PM. The bed enabler device should have been removed on 4/1/2024, but they did not have documented evidence the bed enabler device was removed until after the 4/11/2024 notification. Bed enabler devices posed a risk for injury, and it was important to remove the requested equipment for safety reasons. The facility checked the bed enabler devices during their monthly audits. During an interview on 5/21/2024 at 4:06 PM the Assistant Director of Nursing stated the therapy department determined if a resident could benefit from the use of a bed enabler device. Maintenance staff installed the device on the bed. They were unsure who reviewed the risks and benefits of bed rails with the resident or resident representative. They were unsure who obtained informed consent prior to the installation of the enabler devices. Nursing staff was responsible for updating the care plan if a resident used bed enabler devices and nursing or therapy could request the removal of the device. Nursing staff received notification on the installation and removal of bed enabler devices and therapy was responsible to ensure the devices were removed. They recalled the 4/8/2024 incident when Resident #109's arm was found pressed against their bed enabler device and mattress. They stated a request was made for the device to be removed and it was not done. If therapy determined the resident no longer could use the bed enabler device, it was a safety risk for the resident. During a telephone interview on 5/22/2024 at 1:22 PM Certified Nurse Aide #33 stated on 4/8/2024 they were completing their first rounds of the shift with another certified nurse aide. They observed the resident half on and half off their bed with their arm between the bed enabler device and mattress. They moved the resident's arm prior to the nursing supervisor coming to assess to the resident. They told the nursing supervisor what they saw when they found the resident and wrote a statement. They thought bed enabler devices were care planned but could not recall if Resident #109 had a bed enabler device on their care plan. 10NYCRR 415.12(h)(1)(2) 49448

Based on observation, record review, and interviews during the recertification survey conducted 5/16/2024-5/23/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 4 of 4 residents (Residents #26, #41, #109 and #119) reviewed. Specifically, Residents #26, #41, #109 and #119 were not offered meaningful activities of their choosing as care planned. Findings include: The facility policy, Activity revised 3/2024, documented the activity department would provide an organized and ongoing program for the residents. The program would meet the interests, physical, mental, and psychosocial well-being for reach resident. The activity programs would be developed in accordance to meet resident specific and individual needs/interests. All residents would be encouraged, reminded, and assisted to be involved no matter their level of ability. Each resident's monthly participation would be tracked by the activity aides. The facility policy Sensory Stimulation dated 4/2024 documented the activity department would provide group or individual sensory stimulation for those residents who may exhibit cognitive deficits, confusion, or disorientation. Sensory stimulation was the activation of one or more of the senses such as taste, sight, hearing, smell, and touch. Sensory stimulation was a key component for improving the quality of life for those living with dementia. Types of visits/ programs may include, but were not limited to music appreciation group, programs, or individual listening, and walking or wheeling outside. The May 2024 Terrace Recreation Calendar documented on 5/16/2024 at 2:00 PM there was a live Elvis concert outside under the tent. During an observation on 5/16/24 at 10:37 AM, a sign posted in the elevator documented there was an outdoor Elvis concert under the tent out front of the facility at 2:00 PM and popcorn and cotton candy would be served. 1)Resident #41 had diagnoses including Alzheimer's disease (a type of dementia), major depressive disorder, and generalized anxiety disorder. The 7/6/2023 Minimum Data Set Assessment (a health status assessment tool) documented the resident had severely impaired cognition, it was very important to the resident to listen to music they liked, to be around other people, to do their favorite activities, and go outside to get fresh air when the weather was good. The 6/29/2023 comprehensive care plan documented the resident was admitted to the facility for long term care. Interventions included to encourage the resident to participate in activities of choice. The resident required assistance of 1 with all aspects of care including transfers and ambulation. The resident ambulated with a rolling walker and staff assistance or wheelchair with staff assistance. The 7/10/2023 activities comprehensive care plan documented to provide and review the program calendar to help identify activities of interest, respect refusal, and re-approach. The resident liked music. A 1/4/2024 Director of Activities progress note documented the resident was able to voice their leisure interests to staff when asked or promoted. The resident needed staff to encourage them and bring them to groups. They liked to be around others, would attend live music, singalongs, and socials. Recreation staff would continue to invite them to attend groups. The 4/3/2024 activities quarterly assessment completed by activity aide #39 documented the resident's hearing was adequate and they participated in group activities both large and small. The resident needed reminders, encouragement, and cuing/redirection. Their activity preferences included entertainment/music, social hours, and outdoors. The resident needed staff to encourage them and bring them to groups. The resident enjoyed being around others, and attending live music and singalongs. Recreation staff was to continue to invite them to attend groups. During an observation on 5/16/24 at 2:20 PM, Resident #41 was inside on the unit and asked, What do we do now?. The resident stated they would love to go outside. Resident #41's May 2024 activity log did not document they had gone outside or attended live music entertainment on 5/16/2024. 2) Resident #109 had diagnosis including Parkinson's disease (a progressive neurological disorder) and Alzheimer's disease (a form of dementia). The 5/19/2023 Minimum Data Set Assessment documented the resident had severely impaired cognition, the resident felt it was very important for them to listen to music they liked, somewhat important to do things with groups of people, very important to attend favorite activities, and to go outside to get fresh air when the weather was good. The 5/13/2023 comprehensive care plan documented the resident had cognitive deficits and staff would anticipate and meet the resident's needs and speak slowly and clearly, allowing the resident adequate time to process information. The resident required assistance with all aspects of care and was non-ambulatory. The resident required assistance with wheelchair mobility. The updated 5/22/2023 activities comprehensive care plan documented to provide and review the program calendar with the resident to help identify activities of interest and respect refusal and re-approach. The resident liked music. A 5/13/2024 Director of Activities progress note documented the resident could answer simple questions. They joined groups but required redirection and cueing. The resident enjoyed attending live music. The resident also would people watch. Recreation staff was to continue to invite and encourage them to attend groups of interest. The 5/13/2024 activities annual assessment completed by the Director of Activities documented the resident had normal hearing, semi-actively participated in activities, needed encouragement, cueing, and transportation. The resident enjoyed entertainment/music and social hours. On 5/16/2024 at 2:39 PM, the resident was observed seated in their chair in the television lounge on the unit. At 2:43 PM, the television signal went out. Resident #109's May 2024 activity log did not document they had gone outside or attended live music entertainment on 5/16/2024. 3) Resident #119 had diagnoses including Parkinson's disease (a progressive neurologial disorder) and neurocognitive disorder with Lewy bodies (a type of dementia). The 10/13/2023 Minimum Data Set Assessment documented the resident had severely impaired cognition, enjoyed listening to music, doing things with groups of people, and participating in favorite activities. The 10/6/2023 comprehensive care plan documented the resident was admitted to the facility for long term care. Interventions included to encourage the resident to participate in activities of choice. The resident had cognitive deficits related to their diagnoses and exhibited impaired long term and short memory loss. Interventions included to speak slowly and clearly, allowing the resident adequate time to process information. The resident required assistance with all aspects of care and was independent with mobility. The revised 1/17/2024 activities care plan documented the resident participated in live music and the outdoors. Interventions included provide and review program calendar to help identify activities of interest, respect refusal and re-approach. A 1/17/2024 Director of Activities progress note documented the resident was able to voice their leisure interests when prompted and would occasionally join group activities such as live music, or sometimes would sit in the main areas of the unit and people watch. Recreation staff would continue to encourage them to join groups. The 4/22/2024 Activities quarterly assessment completed by the Director of Activities documented the resident's hearing was normal, they participated in group and individual groups, were a semi-active participant, required encouragement, liked entertainment/music, and outdoors. The resident needed staff to invite them and encourage them to attend groups. They liked attending live music and getting outside. Recreation staff was to continue to invite and encourage them to attend groups of interest. A 5/9/2024 Director of Activities progress note documented the resident had a short attention span, enjoyed musical activities, and socializing with others. During an observation on 5/16/24 at 2:40 PM, the resident was observed seated in a chair on the unit watching television. During an interview with the resident's representative on 5/16/2024 at 3:45 PM, they stated the resident loved music and was a musician. Resident #109's May 2024 activity log did not document they had gone outside or attended live music entertainment on 5/16/2024. During an interview on 5/22/2024 at 10:38 AM activity aide #39 stated the Terrace unit was a locked unit and most of the residents had dementia. The Director of Activities came up with the activity calendar along with resident unput. The facility celebrated National Nursing Home Week the prior week. They had special events planned for the week including a live Elvis concert outside under a tent in the front of the building. The activity staff collaborated and came up with a list of residents they determined who would not be appropriate to attend the day of the event. They thought the Director of Activities had a copy of the list. Resident preferences were obtained on admission, annually, and during quarterly assessments by interviewing the residents or resident representatives. It was important for the residents to attend activities of interest for stimulation, quality of life, and enjoyment. Activity staff only documented if the residents attended activities and did not document if they refused to attend events. They were unsure why Resident #119 did not attend the live music event. They stated Resident #41 was asked to attend the event but declined. Resident #109 liked music and going outside, they thought the resident was sleeping in their chair when residents were brought outside. They stated they should have woken Resident #109 up and asked them if they wanted to attend the event. During an interview on 5/22/2024 at 11:04 AM the Activities Director stated the department decided which programs to put on the calendar with the resident's input. The activity staff completed the resident's assessments and obtained their activity preferences on admission, annually, and quarterly via interviews with the resident or their representative. Activities were important for the resident's quality of life and wellbeing. The Terrace Unit was a memory care unit. The Elvis concert was opened to all residents to attend. They did not have list of residents to ask to the event and expected staff to invite all residents as this was a special event for National Nursing Home Week. They had been discussing the event in the facility's morning report for some time and the need for all hands-on deck approach to transport residents. They wanted as many residents as possible to attend the event. They were unsure why the turnout was not as large as they expected, but it was tough getting the residents out with the limited staff they had. They stated they were working with the activity staff to improve their documentation as they did not document refusals at this time. Any resident who enjoyed music and being outdoors should have been offered to attend the activity. 10NYCRR 415.5(f)(1)

Based on record review, observation, and interview during the recertification survey and abbreviated (NY00311928 and NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure a safe, clean, comfortable, and homelike environment for 3 of 3 resident floors (Terrace floor unit, first floor unit, and second floor unit) reviewed. Specifically, the Terrace floor unit had unclean resident wheelchairs, damaged and sticky flooring, and damaged countertops; the first floor unit had sticky floors in the dining room; and the second floor unit had a resident room with a damaged commode, a spa room with a water damaged cabinet, cigarettes and loose tobacco were kept in the second floor unit kitchenette, and the noise level in the dining room was loud during meal service. Additionally, the Terrace floor unit, first floor unit, and second floor unit had spa access doors that self-locked from the inside when opened too hard. Findings include: The facility policy, Safe, Clean, Homelike Environment revised 3/2024, documented all staff were responsible for the creation and maintenance of a clean, safe, homelike environment and a pleasant dining experience that promoted social interaction. 1) Unclean Resident Wheelchairs During observations on 5/16/2024 at 10:42 AM and 5/17/2024 at 1:03 PM, Resident #26 was in the Terrace unit lounge area seated in their positioning recliner chair. The chair had dried food debris on the footrest and the side of the chair. During observations on 5/16/2024 at 10:37 AM and 2:23 PM, 5/17/2024 at 8:53 AM and 1:13 PM, Resident #41 was observed seated in their wheelchair on the Terrace Unit. Their wheelchair was unclean with dried food debris on the frame. During an interview on 5/22/2024 at 10:05 AM, Licensed Practical Nurse Unit Manager #6 stated certified nurse aides on the 11:00 PM-7:00 AM shift were responsible to ensure resident wheelchairs were cleaned. If staff noticed the chairs were unclean on the resident's shower day, they should be cleaned. It was easier to clean the chairs on the night shifts as the residents were typically in bed. Unclean chairs were undignified and were a potential infection control issue. During an interview on 5/22/2024 at 10:27 AM, certified nurse aide #7 stated they were unsure if Resident #26's and Resident #41's chairs were unclean or stained because they appeared to be old. The 11:00 PM-7:00 AM shift was responsible to ensure the resident's chairs were clean. Anyone could clean a resident's chair if they noticed it was unclean. Unclean chairs were undignified and a possible infection control issue. During an interview on 5/22/2024 at 10:49 AM, the Director of Environmental Services stated nursing was responsible to ensure wheelchairs were cleaned. Wheelchairs were cleaned mostly during the third shift or during resident showers. They stated they did not notice any unclean wheelchairs during a recent walk through of the facility. 2) Loud Environment During an observation on 5/16/2024 at 2:07 PM, an unidentified dietary aide cleared trays and dishware from the tables in the second floor unit dining room. They picked up the dishware, scraped it off, and placed it in bins on a wheeled cart. This scraping and placement of the dishes in the bins caused a very loud clatter, and they continued to do this from table to table. There were seven residents in the dining room eating. At 2:13 PM, three residents remained in the dining room eating. The unidentified dietary aide began removing dishes from one of the tables a resident was eating at, and loudly scraped the food off the plates. During an observation on 5/17/2024 at 10:18 AM, the same unidentified dietary aide from the 5/16/2024 observation was in the second floor unit dining room. They moved from table to table and cleared dishes. Residents were still in the dining room eating at tables that were being cleared by the dietary aide. They scraped and then placed breakfast dishes in bins in a manner that caused loud clatter. They attempted to remove a tray of food that was in front of Resident #57 without asking if the resident was done eating. The resident leaned forward and said, no, no, no. The unidentified dietary aide then slid the tray back over to the resident. During an observation on 5/17/2024 at 1:21 PM, the second floor dining room had meal cart #2 plugged into the wall in the dining area between tables of the residents. The cart was very loud, and it was difficult to hear the residents or staff talking. At 1:23 PM, Certified Nurse Aide #12 stated this is very loud and closed the cart doors and said it was much quieter. At 1:25 PM, another unidentified staff member stated, that cart is too loud and unplugged the tray cart. During an observation and interview on 5/20/2024 at 8:55 AM, a loud beeping was heard coming from room [ROOM NUMBER]. Resident #44's tube feeding machine had completed the feeding and was beeping. The beeping continued until 9:41 AM (46 minutes later). Licensed Practical Nurse Unit Manager #1 entered the room and shut the tube feeding machine off. They stated the tube feeding ran for 12 hours and was started at 8:00 PM. They stated they should have shut off the tube feeding pump when it first started beeping but they were in the dining room assisting residents and could not be in two places at once. During an observation on 5/20/2024 at 10:22 AM, Licensed Practical Nurse #8 was assisting Resident #69 with their breakfast. An unidentified dietary aide was loudly dropping all the dishes from the table into the cart. They wiped the table down while the resident was still at the table being assisted with breakfast. During an interview on 5/22/2024 at 10:03 AM, Dietary Aide #4 stated they always tried to give the residents enough time to eat before the dining room was cleared and did not want to be in the way while the residents were eating. They stated the goal was to have the breakfast trays delivered to the unit by 9:00 AM, and the dining room was cleared no earlier than 10:00 AM, but sometimes things ran late. Dietary Aide #4 stated they sometimes had to clear trays while residents were still in the dining room because if they did not, it caused the next meal to be late. They stated if they had to clear while residents were still in the dining room, they started clearing on the side of the dining room that was served first, as those residents were typically done eating and already moved out of the dining room. They stated they would not clear from a table that a resident was still eating at as it would not be a nice or dignified experience for that resident. During an interview on 5/22/2024 at 9:49 AM, the Food Service Director stated the resident food hot boxes should be kept in the unit side hallways during use and should not be placed in the resident dining rooms. Once all residents were finished eating at a table staff cleared that table, even if residents at a table next to were still eating. They stated this had been the table clearing process for the last [AGE] years, and the Rabbi preferred a two hour window before the next meal due to kosher guidelines. The Food Service Director stated milk products and meat products could not be in the dining room at the same time, and that was why a table would be cleared immediately after all residents were done eating. During an interview on 5/22/2024 at 12:20 PM, the Administrator stated the warming units made some noise and they should be plugged in the unit 2 hall and not plugged in the dining room. 3) Unit Spa Self-Locking Doors During an observation on 5/20/2024 at 11:34 AM, Resident #56 was taken into the second floor shower room. At 12:00 PM, Certified Nurse Aide #27 exited the shower room alone. At 12:12 PM Certified Nurse Aide #27 returned to the shower room, but the door was locked, and the resident was inside. They went to get the nurse and returned to the shower room door and waited for the nurse. The nurse arrived moments later, and the key did not work. The nurse retrieved a different key and was able to unlock the door. During an observation on 5/20/2024 at 1:10 PM, the second floor spa room door locked from the inside when pushed open. If the door was pushed hard it opened into the room, and the push button door lock on doorknob inside the room was pressed, locking the door from the inside. On 5/20/2024, between 3:30 PM and 3:38 PM, the following was observed: - the first floor unit side spa door locked from the inside when pushed open. If the door was pushed hard it would open into the room, and the push button door lock on doorknob inside the room was pressed, locking the door from the inside. - the Terrace unit Lane side spa locked from the inside when pushed open. If the door was pushed hard it would open into the room, and the push button door lock on doorknob inside the room was pressed, locking the door from the inside. During an interview on 5/22/2024 at 10:54 AM, the Director of Environmental Services stated they were not aware the doors for the second floor spa, the first floor spa, and the Terrace unit lane side spa self-locked from the inside when the lock/unlock button hit the wall. They stated they had not heard of any residents being locked inside a facility spa room or staff needing to get a key to unlock the door. Those doors were original to the building. They stated maintenance of a safe environment for residents was important. 4) Unclean Floors/Ceiling Tiles/Resident care areas During observations on 5/16/2024 at 10:28 AM and 5/17/2024 at 8:36 AM, the first floor unit dining room floor was sticky. During observations on 5/16/2024 at 12:16 PM, 5/17/2024 at 8:36 AM, and 5/20/2024 at 9:31 AM, the Terrace unit dining room floor was sticky. There were several stained ceiling tiles throughout the dining room. On 5/16/2024, between 11:50 AM and 1:10 PM, the following was observed on the second floor: - resident room [ROOM NUMBER]'s bathroom had a commode with sections that were oxidized with bubbled paint. - the second floor unit lane side spa room cabinet had a section that was water damaged. - the second floor unit kitchenette had a staff food bag in the non-kosher refrigerator that contained loose tobacco and cigarettes. On 5/16/2024, between 12:41 PM and 1:00 PM, the following was observed on the Terrace floor unit: - the Terrace ridge unit side spa room had a section of floor with a missing tile, and a countertop that was chipped with exposed plywood. - resident room T17's floor was scraped with black marks. - the Terrace unit ridge side entrance to the dining room had a cabinet/sink with cracked drawers. During an interview on 5/17/2024 at 2:40 PM, the Director of Environmental Services stated all staff food bags should go in the staff break room. The second floor non-kosher refrigerator had a sign on it which read for residents only. They stated the second floor kitchenette was not where staff personal bags were stored. There should be no smoking material in the kitchenettes since family members and residents had access to these rooms. During an interview on 5/21/2024 at 1:24 PM, the Director of Environmental Services stated the dining room floors were mopped after every meal, a neutral floor cleaner was utilized, and they had never been told about sticky floors. The same floor cleaning chemical had been used for a few years. A daily task of the housekeeping staff was to clean the floors in the facility. They stated the commode in the bathroom of resident room [ROOM NUMBER] was in disrepair, and it did not look homelike and should have been replaced. Staff should have identified the commode and reported it to the maintenance department to be replaced. They were not aware of the cabinet with the damaged water section in the second floor lane side spa, or of the missing floor tile and the damaged countertop in the terrace ridge spa. These findings should have been identified by staff on the floor and reported to the maintenance department. The floor in resident room T17 floor was at the threshold to be stripped and waxed. They would usually complete this task when rooms were empty, but if a resident was living in the room they would be removed for a few hours and the room floor would be stripped and waxed. They were not aware the surface of the doors to the cabinet in the Terrace dining room were in disrepair and were not homelike. They would periodically tour the facility including sampling resident rooms and common areas. This was not documented. The Director of Environmental Services stated it was important a safe and clean environment for residents and staff was maintained. During an interview on 5/22/2024 at 11:09 AM, Housekeeper #5 stated the facility used a peroxide disinfectant on the laminated flooring for many years, and that it was a daily task for housekeeping to mop the floors in the dining room. They stated the dining room floors had been replaced a few years ago, and this new floor had a non-stick surface on it so staff and residents would not fall. Housekeeper #5 stated the dining room floors were mopped each day and certain spill spots on the floor required a more thorough mopping. They would try to buff and scrub resident room floors before they were too scraped up. They stated that if the scraping marks on a resident room floor had reached a certain threshold the floor would have to be stripped and waxed. Housekeeper #5 stated nursing staff was not unlocking the wheels on the resident beds before moving them. This created black dragging marks on the floor and was an ongoing issue. 10 NYCRR 415.29(c)(3-4)(d)(i)(3)(j)(1) 40803 50561

Based on observation, record review, and interview during the recertification and abbreviated (NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure the resident's representative was notified when there was a need to alter treatment significantly for 1 of 1 resident (Resident #48) reviewed. Specifically, Resident #48 did not have the capacity to make medical decisions and their health care proxy (person appointed to make healthcare decisions when the individual can no longer do so) was not notified when the resident developed a wound which required treatment. Findings include: The facility policy, Criteria for Assessing Changes in Resident Condition revised 10/11/2023 documented a change in condition was defined as an improvement or decline in physical, mental and/or psychosocial status. Skin breakdown and open areas were included but not limited to examples of a condition change. The licensed nurse notified the provider for further orders, management, or treatment. New orders were initiated by the licensed nurse and a change of condition progress note was documented in the electronic medical record. The resident's family was notified, and family notification was documented in the progress note. Resident #48 had diagnoses including Alzheimer's disease (a progressive disease that alters memory) and urinary incontinence. The 4/28/2024 Minimum Data Set Assessment (a health status screening and assessment tool) documented the resident had severely impaired cognition, was dependent on staff for toileting, hygiene, bed mobility and transfers with a mechanical lift, was at risk for pressure ulcers, and had applications of ointments/ medications other than to feet. The resident's admission Face sheet documented the resident had two family members who were designated as both Health Care Proxies and emergency contacts. The comprehensive care plan initiated 1/6/2021 and reviewed 12/28/2023 documented the resident was at high risk for skin breakdown related to decreased mobility and incontinence. Interventions included incontinence care, certified nurse aide was to report skin conditions daily during care and report any abnormalities to the nurse, maintain turn and position schedule every 2-4 hours, and use skin protectant/ barrier when performing perineal care (washing genital and rectal areas). The 10/18/2023 Assistant Director of Nursing wound team progress note documented the resident had a 3.5 centimeter by 2 centimeter open area to the left buttocks and a 3.5 centimeter by 2 centimeter open area to the right buttocks. The wounds were new and the Assistant Director of Nursing recommended treatment with collagenase (an ointment used to remove dead tissue) and continue current treatment for heels. The 10/18/2023 physician order documented apply collagenase topical ointment 250 unit/ gram once daily to 3.5 centimeter by 2 centimeter open areas to left and right buttocks after cleansing with normal saline and patting dry, then cover with a foam dressing. There was no documented evidence the resident's Health Care Proxies/emergency contacts were notified of the new bilateral buttock's wounds and treatment identified by the Assistant Director of Nursing. During an observation on 5/20/2024 at 11:54 AM, Certified Nurse Aides #20 and #21, and Licensed Practical Nurse #18 provided incontinence care to the resident. A reddened area approximately the size of a ping pong ball was noted to the middle right buttocks. Licensed Practical Nurse #18 said this area was reported to them this morning by an unidentified certified nurse aide and they had not seen it yet. Licensed Practical Nurse #18 left the room and returned with the Assistant Director of Nursing. The Assistant Director of Nursing stated the area to the buttocks was new and this was moisture associated skin damage. Licensed Practical Nurse #18 applied the ordered zinc ointment per the Assistant Director of Nursing's direction. There was no documented evidence through 5/21/2024 the resident's Health Care Proxies/emergency contacts were notified of the new buttocks wound identified on 5/20/2024 by the Assistant Director of Nursing. During a telephone interview on 5/22/2024 at 8:48 AM the resident's designated Health Care Proxy/emergency contact stated in 10/2023, they observed wounds on the resident's buttocks during incontinence care that they were never notified of and wondered how long they had been there. They were not aware of any current wounds to the buttocks. They visited often and stated they did not get updated on any wounds but asked to see the chronic foot wounds when they visited. They thought they should be updated on new wounds. They attended care plan meetings and was only updated on the resident's wounds during the meetings when they asked about them. During an interview on 5/22/2024 at 10:07 AM Licensed Practical Nurse Unit Manager #17 stated families were notified of any change in condition. Family should also be notified of new wounds and changing wounds. It was important for quality of life and permission for treatment. Resident #48 was not cognitively intact, and their family should be notified. The resident's family member liked to be involved and attended all outside wound appointments in the past. If the resident's family was notified for any reason, it should be documented in a progress note. During an interview on 5/22/2024 at 10:42 AM the Assistant Director of Nursing stated family representatives were updated on change of condition that included incidents, new and changing wounds, as well as medication changes and care plan changes. They did not notify Resident #48's representative of the buttocks wounds they identified on 10/18/2023 or the new buttock wound identified on 5/20/2024 and they should have. 10NYCRR 415.3(e)(2)(ii)(b,c)

Based on observation, record review, and interview during the recertification and abbreviated (NY00326481) surveys conducted 5/16/2024-5/23/2024, the facility did not ensure residents were treated with respect and dignity in a manner and environment that promoted maintenance or enhancement of quality of life for 13 of 13 residents (Residents #59 and 12 anonymous residents) reviewed. Specifically, Certified Nurse Aide #36 was observed speaking loudly near the main dining room about Resident #59's urinary drainage device; and multiple staff were observed using their personal communication devices in care areas during working hours. Findings include: The facility Employee Handbook revised 3/1/2015, documented staff were not permitted to use cell phones during work hours and individual earphones were prohibited. The facility policy, Safe, Clean, Homelike Environment revised 3/2024, documented the facility was committed to providing residents with a homelike environment that de-emphasized the institutional character of the setting. The facility policy, Resident Rights revised 6/2000, documented residents had a right to personal privacy and confidentiality of their personal and clinical records. 1) Resident #59 had diagnoses including urinary tract infection and obstructive uropathy (blocked urine flow). The 5/6/2024 Minimum Data Set assessment (a health status screening and assessment tool) documented the resident had severely impaired cognition, had an indwelling catheter (drains urine from the bladder), and was dependent for toileting. The comprehensive care plan initiated 3/20/2024, documented an alteration in elimination related to use of a urinary drainage device. Interventions included the drainage bag was kept covered for dignity. During an observation on 5/20/2024 at 12:24 PM, Certified Nurse Aide #36 brought Resident #59 into the dining room. The resident stated they needed to use the bathroom. Certified Nurse Aide #36 replied loudly to the resident that they had just gotten off the bed pan and had a catheter. There were 4 residents seated nearby. During an interview on 5/21/2024 at 1:38 PM, Registered Nurse Manager #14 stated staff should not talk about resident specific information such as catheters and bed pans when in the dining room as that was not dignified or homelike. An attempt was made on 5/22/2024 at 11:48 AM to conduct a phone interview with Certified Nurse Aide #36, however, the call was not answered. 2) During a resident meeting on 5/16/2024 at 11:11 AM, 12 of 12 anonymous residents reported staff frequently used their cell phones and earbuds in resident care areas. The residents felt staff pretended they could not hear them when they utilized their personal communication devices. During an observation on 5/20/2024 at 9:32 AM, Licensed Practical Nurse #2 was seated with residents at a dining room table during the breakfast meal and was looking at their phone. They did not interact with residents. During an interview on 5/22/2024 at 8:55 AM Licensed Practical Nurse Unit Manager #1 stated cell phones, were not allowed in resident care areas, and there were no exceptions. If staff were on their phones, they were not attending to the needs of the residents. That could result in resident injury, an elopement, or other worse case scenarios. It was also a violation of resident privacy and confidentiality to have personal cell phones in resident care areas. During an observation on 5/21/2024 at 11:01 AM, Certified Nurse Aide #32 was observed to sitting in the television lounge area on the unit using their personal cell phone. They stated they should not be using their personal cell phones in resident care areas. During an interview on 5/21/2024 at 1:38 PM, Registered Nurse Manager #14 stated staff should not be using their personal cell phones in resident care areas. 10NYCRR 415.5(a)

Based on observation, record review, and interview during the abbreviated survey (NY00322111), the facility failed to ensure each resident had the right to be free from neglect for 1 of 4 residents reviewed (Resident #4). Specifically, on [DATE], the resident was not provided with services that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Surveillance video of the nursing unit from [DATE] at approximately 7:38 PM, revealed a resident falling backwards off a partition (separating the dining room from the hallway) that was approximately 27 inches in height and hitting their upper back on the floor in the hallway. The resident remained on the floor for approximately two and a half hours while 5 certified nurse aides (CNAs #1, 16, 17, 18, and 26), 1 licensed practical nurse (LPN #5), 1 resident helper (resident helper #27), and the housekeeper (housekeeper #47) walked by the resident without attending to the resident and without notifying a registered nurse (RN Supervisor #4) to complete an assessment. After approximately 2 hours, the resident unsuccessfully attempted to get up and tipped over twice. Shortly thereafter, the resident got themselves into a kneeling position and attempted to use the handrail to stand and fell over. This occurred 3 more times until 10:20 PM when CNA #17 and resident helper #27 transferred the resident into a wheelchair (without RNS #4 present for an assessment). RNS #4 arrived on the unit several minutes after the resident was transferred to the wheelchair and shortly thereafter pronounced the resident deceased . Furthermore, the facility failed to report the incident as required. This resulted in Immediate Jeopardy to Resident #4. Findings include: The Falls policy, revised [DATE], documented a fall was defined as an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface. A fall may be witnessed, reported by the resident or an observer, or identified when a resident was found on the floor/ground. In the event a resident fell or was found on the ground, a head-to-toe evaluation must be performed. Upon arrival of the nurse, a quick head-to-toe scan was to be performed without unnecessary movement, palpating, and examining all areas for breaks in the skin and/or other abnormal findings and staff were to obtain vital signs, neurological checks for unwitnessed falls or falls with head injury, and obtain blood sugar if the resident was diabetic. If there was no obvious injury, the resident could be moved to a comfortable position. The Criteria for Assessing Changes in Resident's Condition policy, revised ,d+[DATE], documented it was the policy of the facility to evaluate sudden changes in a resident's condition and assessing. Sudden changes in condition were defined as a change in level of consciousnesses, delirium, lethargy, unresponsiveness, vomiting, elevated temperature, or a change in oxygen saturation level, blood glucose, or blood pressure. The policy listed the Medical Director as being available for communication 24 hours per day 7 days a week. The Abuse policy (undated) documented residents will be protected from neglect while at the facility. An intervention used by the facility to prevent abuse/neglect included staff will be supervised to identify inappropriate behaviors while caring for or in attendance with residents. The facility's policy addressed investigating allegations of mistreatment, neglect, and abuse promptly and thoroughly. If an investigation showed mistreatment, employees would be disciplined and reported to appropriate licensing boards. The facility policy also included reporting abuse, neglect, and mistreatment according to Federal and State laws. The Administrator or designee was responsible for the initial reporting to the New York State Department of Health (NYS DOH) The resident helper job description documented the resident helper was responsible for non-nursing tasks and listed duties the person may perform. The list of duties did not include transferring residents. Resident #4 had diagnoses including a past traumatic brain injury (TBI) following an accident. The [DATE] Minimum Data Set (MDS, an assessment tool) assessment documented the resident had severe cognitive impairment, exhibited physical behaviors on ,d+[DATE] days of the assessment period, and verbal and other behaviors on ,d+[DATE] days of the assessment period. The resident's behaviors impacted the resident, significantly interfered with care, interfered with activities and social interactions, put others at risk for significant injury, and significantly disrupted care or the living environment. The resident was independent with transfers and ambulation in their room and needed supervision with ambulation in the corridor. The resident had no falls in the month prior to admission and had a fall/falls in the ,d+[DATE] months prior to admission with no serious injuries. The [DATE] former registered nurse (RN) Manager #19's progress note documented the resident was admitted from another skilled nursing facility. The resident had a past head injury from an accident and was independent with ambulation, transfers, eating, and toileting. The comprehensive care plan (CCP), initiated on [DATE], documented the resident was at risk for falls and staff were to investigate the cause of falls immediately, evaluate patterns of falls, and request rehabilitation referrals when needed. The [DATE] certified nurse aide (CNA) Assignment Sheet (care instructions) documented the resident was independent with transfers and bed mobility and required supervision with ambulation. There was no documentation in the CCP or CNA Assignment Sheet the resident had a behavior or history of placing themselves on the floor. The [DATE] Incident Report completed by the Director of Nursing (DON) documented on [DATE] at 7:30 PM, an unidentified certified nurse aide (CNA) reported to an unidentified licensed practical nurse (LPN) the resident was on the floor near the dining room in the hallway. The resident had a history of putting themselves on the floor and getting up on their own and was noted to be without injury related to the fall. Staff education was to be done to get residents off the floor in common areas and to read the CCP on all residents. The DON documented the CCP was followed, the investigation did not support abuse, neglect, or mistreatment, and there was not a failure to provide timely, safe, consistent, and adequate care and treatment to the resident. Included with the [DATE] Incident Report were statements obtained by the facility including: - statements from CNAs #1, 16, 17, 18 and 26 who documented on [DATE], the resident was on the floor during the evening shift. - CNA #1 noted on [DATE] at around 10:00 PM, they were leaving the unit for break and saw the resident laid out on the floor in the hallway. They called the resident's name 3 times, and the resident did not respond. They told licensed practical nurse (LPN) #5 the resident was on the floor and LPN #5 said it was fine. CNA #1 left for break and when they returned, the resident was sitting up in a chair looking ghostly pale, slumped over. Registered nurse Supervisor (RNS) #4 was present. - LPN #5 documented on [DATE] at 8:30 PM, they noticed the resident was on the floor and the resident placed themselves on the floor on many occasions. They interacted with the resident at 8:50 PM. At 10:10 PM, they noted something brown around the resident's mouth and called a CNA (unidentified) to get the resident off the floor. At 10:20 PM, LPN #5 called RNS #4 and when RNS #4 responded, the resident was up in the wheelchair. They attempted to obtain vital signs and RNS #4 pronounced the resident deceased . The facility's surveillance video from the nursing unit was reviewed from [DATE] from 7:29 PM through 10:58 PM, and the following was observed: - at 7:38 PM, the resident, whose back was seen just in frame view, was sitting on a partition (separating the dining room from the hallway, approximately 27 inches in height) and fell backwards. The resident's legs went up in the air and the resident's back struck the floor. After falling, the resident moved themselves, so their head was next to the wall, propped on a door jamb, with their legs outstretched and positioned parallel with the hallway. - At 7:41 PM, CNA #26 entered a room across the hall from where the resident was and did not approach the resident and LPN #5 walked by the resident without stopping. - At 7:42 PM, the resident turned themselves, so their head was against the wall. LPN #5 and CNA #26 walked by the resident and neither stopped. - Between 7:47 PM and 7:55 PM, LPN #5 checked the resident's blood sugar as the resident was lying on the floor, went to the nursing office, and returned a few moments later to check the resident's blood sugar a second time; housekeeper #47 and CNAs #16 and 18 walked by twice; housekeeper #47 started mopping the dining room floor (the resident was on the floor right outside the entryway into the dining room), and CNA #26 went to the linen cart which was less than 2 feet from where there resident was lying in the hallway. - At 7:56 PM, the resident straightened their legs, so they were outstretched across the hallway and propped them against a door jamb. The resident was blocking most of the hallway with their legs. - Between 7:57 PM and 8:45 PM, CNA #26 walked by the resident 5 times (once walking around the resident's legs); CNA #16 walked by twice; Resident Helper #27 and CNA #26 wheeled an unidentified resident in a chair past Resident #4 while maneuvering the chair to get around Resident #4's legs; CNA #18 assisted an unidentified resident to walk by and then walked by alone, and housekeeper #47 walked by twice. None of the staff stopped. - At 8:51 PM, the resident hit their hand with a clenched fist against the floor ,d+[DATE] times. - Between 8:52 PM and 9:01 PM, CNA #17 walked by, appeared to look at the resident, and did not stop. At 8:56 PM, CNA #17 and LPN #5 walked by. The resident was sitting with their knees bent, leaned forward at the waist. - Between 9:02 PM and 9:03 PM, the resident attempted to stand twice by placing one foot flat on the floor and pressing up with their hand. The second time, the resident got themselves into a kneeling position and on their hands and knees. The resident sat back down, bent at the waist with their head down. - At 9:04 PM, LPN #5 walked by and did not stop. - At 9:05 PM, the resident pushed their right hand into floor, tried to push themselves up, and returned to sitting, bent at the waist. - At 9:06 PM, the resident placed their left foot and right hand on the ground and attempted to lift their buttocks off the floor. The resident continued this until 9:13 PM and then pounded their right hand onto the ground a few times. - At 9:28 PM, CNA #16 looked down the hallway where the resident was and entered the nurse's office. - At 9:37 PM, the resident used their right hand to push themselves up and was sitting with their right hand on the floor. The resident tipped over and their weight went from their hand to their elbow. The resident did this a second time and at this time, an unidentified person's body and hands was seen in the dining room with their hands gesturing at the resident. The resident gestured at the unidentified person in the dining room and kicked their leg in the direction of the unidentified person. The unidentified person did not step into camera view. - At 9:38 PM, the resident tried to press themselves up and at 9:40 PM the unidentified person was seen in the dining room with their hands gesturing towards the resident. The resident tipped over and fell on to their left side and laid on the floor in a curled up position. - At 9:44 PM, CNA #1 walked out of the nurse's office, towards the unit exit, and then turned around and looked in the direction of the resident. CNA #1 walked back into the nurse's office and then exited the office and the unit 1 minute later. - At 9:49 PM, the resident pushed themselves to a sitting position and was slumped over with their head down. The resident fell over to the right side and was lying down in a curled up position. CNA #17 entered the room (kitchen) next to where the resident was and did not approach the resident. The resident pushed themselves to a sitting position and to a high kneeling position. They tried to reach out for the wall/handrail, fumbled for it with their hands, used their left hand to push on their thigh, and then fell over backwards. They were now on the floor with their back and head against the wall. - At 9:50 PM, the resident pushed themselves to a sitting position with knees bent and their head against the wall, slumped down. - At 9:54 PM, the resident rolled from side to side and hit their right hand on the floor. - Between 9:55 PM and 9:56 PM, the resident pushed themselves to a sitting position and then fell backwards into a lying position twice. - At 10:01 PM, CNA #16 looked towards the resident from a distance and did not approach the resident. - At 10:06 PM, the resident pushed themselves to a sitting position, slumped forward, and then tipped over to a lying position. - At 10:07 PM, the resident pushed themselves to a sitting position, got onto their hands and knees, reached out for the handrail, and fell to the right side. The resident was lying in a curled up position. - At 10:09 PM, the resident pushed themselves to a sitting position and tipped over to a lying position and then pushed themselves to sitting, dropped to their elbows, and then tipped over to a lying position. - At 10:14 PM, the resident pushed themselves to a sitting position, tipped over again lying on their side and then repeated this again. - At 10 :17 PM, LPN #5 exited the nurse's office and entered the medication room which was in the same hallway where the resident was on the floor. - At 10:18 PM, LPN #5 walked to the resident and talked to them. At 10:19 PM, the resident pushed themselves to siting and LPN #5 walked away. - At 10:20 PM, CNA #17 exited the doorway next to the where the resident was (kitchen), looked at the resident, and the resident rolled to their left side. CNA #17 walked to the nurse's office and resident helper #17 looked in the resident's direction from a distance and entered the nurse's office. - At 10:23 PM, CNA #17 and resident helper #27 physically assisted the resident into a wheelchair and wheeled the resident down the hallway to outside of the nurse's office. LPN #5 was not present when the resident was transferred and exited the nurse's office when CNA #17 and resident helper #27 arrived. LPN #5 spoke to staff and walked away. CNA #17 and resident helper #27 walked away. Resident helper #27 entered the nurse's office and CNA #17 returned to camera view a few seconds later and applied a clothing protector to the resident. The resident was sitting in a wheelchair, slumped to the left side with their head down, and their feet under the chair. The resident had deep, rapid respirations. CNA #17 fixed the resident's feet and resident helper #27 returned with a Styrofoam cup with a straw in it that they placed on the handrail. CNA #17 rubbed the resident's head and LPN #5 exited the nurse's office at the same time RNS #4 arrived to the unit (3 minutes after the resident was assisted off the floor). LPN #5 and RNS #4 attempted to obtain a blood pressure, LPN #5 obtained a temperature (ear); RNS #4 obtained a blood sugar, and RNS #4 listened to the resident's heart and lungs with a stethoscope. At 10:35 PM, CNA #17 removed the blood pressure cuff from the resident's arm. During an interview on [DATE] at 11:42 AM, CNA #16 stated on [DATE], the resident was lying on the floor near the dining room after dinner, they did not know what time but stated dinner was around 5:30 PM, and CNA #1 let LPN #5 know. CNA #16 stated themselves and CNA #1 asked the resident to get up, but the resident looked at them and did not speak. CNA #16 stated they did not know if LPN #5 directed CNA #1 to do anything when they reported the resident was on the floor. CNA #16 left the facility at 8:00 PM or 9:00 PM and the resident was lying on the floor when they left. During an interview on [DATE] at 12:44 PM, CNA #18 stated the resident usually sat on the floor in the evening and when the resident did that, they let the nurse know and asked the resident to get up. CNA #18 stated it was up to the LPN to let an RNS know if the resident seemed hurt. CNA #18 left the facility at 9:00 PM on [DATE] and the resident was sitting on the floor in the hallway when they left. They stated they let LPN #5 know the resident was on the floor that shift. During an interview on [DATE] at 3:25 PM, CNA #17 stated the resident was typically on the floor in the hallway and when CNA #17 saw this they reported it to a nurse. On [DATE], they first saw the resident on the floor around 8:30 PM or 8:45 PM and did not think it was odd but at 9:00 PM, the resident remained on the floor and did not respond verbally to CNA #17. They thought this was unusual, so they let LPN #5 know the resident was not speaking and they saw something brown come out of the resident's mouth. CNA #17 stated LPN #5 had them get the resident up and put them in a wheelchair and they could not recall who assisted them with this. During an interview on [DATE] at 12:08 PM, CNA #1 stated on [DATE] after 9:00 PM, when they were leaving the unit for a break, they saw the resident on the floor. They went to the resident and said their name and they moved a little, but they did not talk so they said the resident's name 2 more times. The resident did not speak, move, or get up. CNA #1 reported this to LPN #5 who said it was okay and CNA #1 went to break. When they got back from break, the resident was in the wheelchair, was ghostly pale, and RNS #4 was there. During an interview on [DATE] at 1:42 PM, RNS #4 stated on [DATE] during the evening shift, they did not see the resident until LPN #5 called them and reported the resident was lying on the floor, eating feces. When RNS #4 arrived to the unit, the resident was in a wheelchair, their skin was mottled (occurs when near the end of life, red and purple spots appear on skin and spread up the arms and legs), they had no blood pressure, so they pronounced the resident deceased . RNS #4 was told by LPN #5 when they got the resident up in the chair, coffee ground emesis (indicative of a stomach bleed) came out of their mouth. RNS #5 stated eating feces was not normal behavior for the resident and with a change in condition, staff should not get a resident off the floor without an RN assessment. During an interview on [DATE] at 3:49 PM, LPN #5 stated on [DATE], they did not recall the first time they saw or interacted with the resident, but it was likely at dinner time. The resident was first noted to be on the floor after dinner probably. LPN #5 stated the resident picked at things that were not there when they sat on the floor. That evening, the resident did not respond to them when they were on the floor but that was usual as the resident responded to people they liked, and the resident did not like LPN #5. LPN #5 stated they did not see the resident in distress when they were on the floor and extended their hand and offered assistance multiple times. They stated no staff told them the resident was on the floor. They noticed it themselves and asked the CNAs why the resident was on the floor. They did not call an RNS as they did not think the resident being on the floor was a fall. They stated they did call RNS #4 when the resident had brown around their mouth and fingers, and they thought they were eating feces. During an interview on [DATE] at 5:00 PM, the DON stated: - they completed all aspects of the incident investigation process. They reviewed all incident reports, updated CCPs, and ensured investigations were complete. - The DON, former Administrator #49, the Chief Executive Officer (CEO) ruled out abuse/neglect and determined what was reportable to the NYS DOH. - The DON completed the investigation into the resident being on the floor on [DATE] when they found out about it on [DATE] in morning report. RNS #4 should have started an incident report on [DATE] and did not. During the investigation, the DON found that at least 3 staff members told LPN #5 the resident was on the floor and LPN #5 never checked on the resident. LPN #5 was re-educated as they did not have the resident assessed when they were on the floor. - The DON did not personally review the entire video from [DATE] when they completed the investigation. They could not access video footage on their own and the CEO and former Administrator #49 watched it and typically, former Administrator #49 reported to the DON what they saw or would have the DON watch certain portions of video. The DON watched about 12 minutes of the video and did not see the resident fall, nor were they told the resident fell . - If a resident fell , there should be an assessment, neurological checks, provider/family notification, 3 days of notes monitoring the resident, and the staff should have gotten the resident off the floor. - LPN #5 did not call RNS #4 as they did not think the resident fell . - When LPN #5 thought the resident had coffee ground emesis, that would be a change in condition, and they should not have moved the resident without an assessment. - Resident helper #27 should not have provided any hands on care, should not have assisted the resident off the floor, and the DON was not aware they had. Resident helper #27 was not on the assignment sheet and when the DON did the investigation, they did not know resident helper #27 was working. - The DON did not investigate the resident's death because they did not think the death was related to a fall and they could not determine if the resident fell . They stated they saw the resident on the floor, rolling and sitting. They mostly saw the portions of the video with LPN #5 as they were responsible for the re-education of LPN #5, and they were not told by former Administrator #49 that the resident fell . During an interview on [DATE] at 11:10 AM, NP #3 stated they were notified on [DATE] that the resident expired. Initially they were told the resident had an unresponsive episode but as time went by, they heard other accounts of what happened including lack of response by the LPN to reports from a CNA and also the possibility that a fall occurred. NP #3 watched the video from the nursing unit on [DATE] with former Administrator #49 and the CEO. They saw the resident fall and did not know if they struck their head. The video was long, so they fast forwarded through a lot of it. After watching the video, the NP told former Administrator #49 and the CEO their concern was the time lapse of the resident being on the floor with no one assisting them. During an interview on [DATE] at 9:00 AM, the CEO stated they did not have a hands-on role in investigations. In this case, there was a discussion on [DATE] and since they had access to the video, they pulled the video and Former Administrator #49, and the DON watched it as they were responsible for the investigation. Former Administrator #49 watched the video, and the DON was in and out of the office when it was playing. Former Administrator #49 and the DON told the CEO they were interviewing everyone involved and the CEO would not have a role in reviewing staff statements. The CEO stated they were not medical, but the resident fell and was on the floor for quite some time. Former Administrator #49 did not see the video as alarming, but the concern was that people were walking by the resident when they were on the floor. The staff stated being on the floor was the resident's typical behavior. Former Administrator #49 was called for an interview on [DATE] and did not reply to the message. Attempts were made on [DATE] and [DATE] to reach housekeeper #47 and resident helper #27 for interviews and no responses were received. 10NYCRR 415.4(b) ------------------------------------------------------------------------- Immediate Jeopardy was identified, and the facility CEO and DON were notified on [DATE] at 3:59 PM. Immediate Jeopardy was removed on [DATE] at 11:30 AM prior to survey exit based on the following corrective actions taken: - 100% of staff on duty were educated according to the approved training plan. - 17 staff from various departments were interviewed and confirmed participation and understanding of the education (dietary, housekeeping, activities, nursing). - The facility developed a plan to educate any staff not working prior to the start of their shift with education to be done by the Assistant Director of Nursing (ADON) Educator, ADON Supervisor, DON, or RN Manager #30.

Based on observation, interview, and record review during the recertification and abbreviated (NY 399 and NY 605) surveys conducted from 3/1/22-3/8/22, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents reviewed (Resident #79). Specifically, Resident #79 was admitted and assessed as mild risk for developing pressure ulcers and had a deep tissue injury (DTI, deep red, maroon, purple discoloration) to their coccyx (tailbone) that was not routinely monitored and developed into a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. This resulted in harm to Resident #79 that was not immediate jeopardy. Findings include: The facility policy Wound/Wound assessment dated ,d+[DATE] documents all admissions will have a skin assessment. Residents admitted with an injury such as hematomas (pooling of blood under the skin), rhabdomyolysis (a breakdown of muscle tissue), and all other injury diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Any wounds needing treatment the [physician] will be notified for orders. Once a week, full body surveillance may be done during bath time. Any new marks will be reported to the licensed practical nurse (LPN) for follow up and a registered nurse (RN) assessment to be done. The facility policy Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Full body surveillance will be done on shower days. Any new marks or changed areas will be reported to the LPN for follow-up and a RN assessment will be done. When the completed shower sheet had noted changes, the LPN will notify the RN and these changes may be on 24-hour reports. The National Pressure Injury Advisory Panel (NPIAP) dated 2016 documents deep tissue pressure injury as intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration. Resident #79 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/7/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance of 2 for bed mobility, transfers, and toileting, extensive assistance of 1 for locomotion, dressing, hygiene, and bathing, was at risk for the development of pressure ulcers, did not have pressure ulcers, had a non-surgical dressing, was on a turning and positioning program and had pressure reducing devices for bed and wheelchair. The 12/31/21 RN Unit Manager #2 Admission Nursing Form documented the resident had a red and bruised area on the coccyx. The Braden (measures risk of developing pressure ulcers) scale documented the resident was a mild risk for skin breakdown. The 12/31/21 comprehensive care plan documented the resident was at risk for skin breakdown and for falls. Interventions included utilize pressure reducing devices, provide assist with bed mobility, transfer with staff assist, complete pressure ulcer risk assessment (Braden Scale) quarterly and as needed, certified nurse aide (CNA) report on skin condition daily during care and report any skin abnormalities to nurse, provide pressure reducing mattress, use pressure reducing cushion in wheelchair, maintain turning and positioning schedule every 2-4 hours and as needed with staff assist, prevent friction during transfers, use skin protectant/skin barrier when performing perineal care, off load heels while in bed, anticipate needs, use proper footwear, ensure call bell in reach at all times, and maintain safe environment. The 1/18/22 at 2:37 PM RN Unit Manager #2 progress note documented the family wanted the resident sent to the hospital for dehydration. The physician was made aware and ordered the resident be sent to the hospital. The resident was hospitalized from 1/18/22-1/24/22. The 1/19/22 updated comprehensive care plan (CCP) documented the resident as at risk for skin breakdown. Interventions did not include goals, interventions, or notes for skin breakdown. The 1/24/22 hospital discharge summary documented the resident was to be discharged back to the facility. The resident was admitted to the hospital for bladder distention. An indwelling urinary catheter was inserted. The discharge summary did not document a dressing or treatment to the coccyx area. The untimed Nursing Admission Assessment form created by RN Unit Manager #2 on 1/24/22 and completed 2/8/22 documented the resident's general skin condition was pale and dry with no [CONDITION(S)] (swelling). The resident had a bruise on the coccyx/sacral area, was chair fast, had very poor nutrition, and was a moderate risk for skin breakdown. The resident's skin was clean, dry, and intact. The 1/24/22 at 5:32 PM RN Supervisor (RNS) #9 progress note documented the resident had a new dressing to the coccyx that was undated upon return from the hospital at 4:06 PM. The surrounding skin was intact and blanchable. The resident had bruising to several areas including the left hip, lower back, left hand, and right wrist which were apparent IV sites. The resident also had bruising to the right ankle and right small toe. There was no further documentation describing if the coccyx dressing was removed or an assessment of the underlying area. The 1/24/22 re-admission Braden scale completed by RN Unit Manager #2 documented the resident was at mild risk of developing a pressure ulcer. The 1/24/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/24/22 updated CCP documented the resident had a sacral fracture and was at risk for skin breakdown. Interventions included comfort measures, provide pain medications as ordered, utilize pain scale, reposition every 2 hours and as needed, adaptive devices as directed, assist with transfers, and utilize pressure relieving devices. The CCP documented staff were to complete Braden scale quarterly and as needed, CNA report of skin condition daily during care and report any skin abnormalities to a nurse. Additionally, staff were to provide pressure reducing mattress, pressure reducing device in wheelchair, turn and position every 2-4 hours with staff assistance, use skin protectant/skin barrier during perineal care, document any pain, and their fracture was to be followed by the orthopedic physician. The treatment administration record (TAR) documented ice to sacrum prn was not administered in 1/2022 or 2/2022. There was no documentation between 1/24/22-2/15/22 the resident's coccyx was monitored or assessed. The 2/15/22 at 6:36 AM RNS #8 progress note documented the resident had a dirty dressing covering the sacral area. The LPN removed the dressing and underneath was a large, reddened area that looked like it was filled with grayish silly putty in the shape of a hook. The LPN cleaned it and put a covering on it. The area would be seen by the skin team and the resident was not complaining of pain. The 2/16/22 at 11:33 AM Wound RN #7 progress note documented the resident had an unstageable (full thickness tissue loss in which the base of the ulcer was covered by dead tissue) area on the coccyx measuring 4.5 centimeters (cm) x 3.0 cm, was to have no brief on in bed, had an alternating air mattress and a ROHO cushion (both pressure relieving devices). The treatment was Santyl (used to remove dead tissue) and back to bed after meals. The note documented the resident had a noticeable decline. The 2/16/22 updated CCP documented the resident had an unstageable pressure ulcer on the coccyx. Interventions included treatments as ordered, assess during treatments and document weekly. Staff were to put the resident back to bed after meals, consult with the dietitian as needed, and turn and reposition every 2 hours as recommended. The CCP documented to monitor for infection, perform wound care rounds weekly, provide ROHO, alternating air mattress, and weekly wound measurements. The 2/2022 TAR documented on 2/16/22 at 12:11 PM, a new order to cleanse open area (did not specify location) with normal saline (NS), pat dry, apply Santyl to wound bed, cover with border foam dressing daily and as needed. The 2/18/22 at 3:38 PM registered dietitian (RD) #25 progress note documented the resident had a new unstageable pressure ulcer to the coccyx and refer to the weekly wound RN note on 2/16 for details. The 2/21/22 Wound RN #7 initial skin assessment of new area documented the resident had an unstageable pressure ulcer on the coccyx measuring 4.3 centimeters (cm) x 3.0 cm. The TAR documented on 2/18/22 at 11:37 AM, cleanse open area with NS, pat dry, apply Santyl to wound bed then crushed [MEDICATION(S)] tab (antibiotic), cover with border foam dressing daily and prn. The 2/22/22 at 1:51 PM Support RN #3 progress note documented family was made aware of the area on the coccyx when the resident returned from the hospital and had become a wound. The facility was treating the wound and the wound care team was following. The 2/23/22 at 11:57 AM RN Unit Manager #2 note documented skin rounds were done and the deep tissue injury (DTI) to the sacrum had now opened and measured 4.0 cm x 4.0 cm with a 2.0 cm tunnel at 12 o'clock with clear view of the sacral bone. The family was made aware, and the resident was to be sent to the wound clinic for evaluation. The 2/23/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/23/22 at 1:01 PM Wound RN #7 progress note documented the resident now had a Stage IV pressure ulcer on the coccyx measuring 4.0 cm x 4.0 cm with a 2.0 cm tunneling at noon position. On re-admission a RN noted a deep tissue injury in the area. Treatment was NS gentle packing and cover. The facility was to set up a wound clinic appointment. The 2/24/22 at 3:28 PM Wound RN #7 progress note documented the resident had an unstageable pressure ulcer on the coccyx measuring 4.5 cm x 3.0 cm. The resident was to have no brief in bed, and an alternating air mattress and ROHO cushion. The treatment was Santyl and back to bed after meals. The 2/28/22 physician note documented the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When coming to the facility for the first time, the resident had a sizable bruise over the sacrum that later opened and basically exposed a sacral Stage IV decubitus (pressure ulcer) which could be very difficult to heal since there was not much viable tissue over the large area and a very deep space. During an observation of a treatment with LPN #6, RN Unit Manager #2, and Wound RN #7 on 3/3/22 at 2:24 PM, RN Unit Manager #2 and Wound RN #7 rolled the resident to the left side. Wound RN #7 removed the old coccyx dressing. LPN #6 cleansed the wound with NS. The wound was about 4 cm x 4 cm x 2 cm with tunneling at 12 o'clock and the wound was pink with granulation. The wound was packed as ordered, covered with a border dressing, and the dressing was dated. When interviewed on 3/4/22 at 4:17 PM, RN Unit Manager #2 stated the 1/24/22 admission skin assessment documented the deep tissue injury as a bruise. The area was unstageable, and staff could not see below the intact outer skin. RN Unit Manager #2 stated the resident was initially admitted with the same area due to a fall prior to admission. The bruise was later classified as a deep tissue injury. The RN expected CNAs to observe the area during care and report any changes or abnormalities to the nurse. The 3/7/22 at 3:21 PM Support RN #3 progress note documented a 2/16/22 follow up report from the 11-7 nurse who worked 2/15/22 into 2/16/22. The resident had a pressure ulcer to the coccyx and was added to wound rounds. Staff were to continue to monitor. When interviewed on 3/7/22 at 11:23 AM, CNA #5 stated the resident could not reposition themself in bed since returning from the hospital, so staff were repositioning the resident every couple of hours. The CNA stated CNAs were not able to make notes in the electronic record, only document that care was done or not done, and were to report any abnormal findings to the nurse for documentation. The CNA remembered a sacral dressing prior to mid 2/2022 and that it had never been observed to be dirty. When interviewed on 3/7/22 at 11:51, RNS #9 stated they did not remember working the day their note was written on 1/24/22 and did not remember assessing the resident upon return from the hospital. When interviewed on 3/7/22 at 12:26 PM, LPN #6 stated only the RNs were allowed to complete assessments. LPN #6 stated they did not remember the resident having a coccyx dressing and would have noted it if they did. Upon return from the hospital, the resident had a reddened area that staff were putting barrier cream on to prevent further breakdown. The LPN stated no CNA asked the LPN to look at the coccyx area prior to the resident's coccyx area opening to a Stage IV pressure ulcer. When interviewed on 3/7/22 at 12:28 PM, RN Unit Manager #2 stated the resident continued to have the coccyx bruise upon return from the hospital. The facility did not track bruises on pressure areas, was not aware the resident returned from the hospital with a dressing to that area, and staff were applying barrier cream to prevent the bruise from deteriorating. When interviewed on 3/7/22 at 12:30 PM, Wound RN #7 stated the facility did weekly wound rounds and did not observe bruises. Wound RN #7 stated a DTI looked like a bruise and the extent of injury was unknown until the area opened. The resident had the coccyx bruise upon initial admission and was not identified as a DTI until the area opened on 2/16/22. A resident with a bruise was looked at daily by unit staff during care but would not be formally tracked. Unit staff should alert the nurse with any changes in the bruise. The CNAs should have alerted a nurse for assessment if the resident had a coccyx dressing. The RN was expected to write a progress note regarding the area with the dressing. The wound nurse would be made aware if the area under the dressing was open. Wound nurse #7 stated RN Unit Manager #2 was aware of the resident's comorbidities and coccyx bruise. The resident's comorbidities contributed to the bruise developing into a Stage IV pressure ulcer and the facility should have tracked the bruise closer in hindsight. When interviewed on 3/7/22 at 12:54 PM, physician #32 stated they were made aware of the Stage IV coccyx area after it opened. The area manifested as a closed bruise, staff were unable to assess what was under the closed skin, and the facility did not track bruises. The physician stated a different treatment would have been ordered if they knew the area would open to a Stage IV wound. When interviewed on 3/8/22 at 10:43 AM, the agency physician assistant (PA) stated the resident was not under their care. The PA had not seen the resident's coccyx wound, but due to the resident's multiple comorbidities and the area being on a pressure area, they would have monitored it more closely. When interviewed on 3/8/22 at 11:24 AM, the Director of Nursing (DON) stated bruises on pressure areas were not tracked by the facility. A skin assessment was to be done by a RN on the day of admission/readmission and all dressings should be removed to assess the area underneath unless there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated nurses do not assess a resident's skin weekly unless asked to by a CNA. The DON expected the CNA to notify the RN if there was a new or dirty dressing on a resident. It was expected that the RN remove the dressing, assess the area, and document it in a progress note. The DON stated RN Unit Manager #2 informed her there was no dressing and a bruise on the resident's coccyx on admission. The resident did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON expected CNAs to perform daily skin checks during care and report abnormal findings to the nurse. The DON stated staff were unsure if the dressing from re-admission on 1/24/22 was the same as the dirty dressing found on 2/15/22 as there was no documentation of a coccyx dressing between those dates. There was no investigation done on the dirty dressing found on 2/15/22 as staff were not aware of the reported 1/24/22 coccyx dressing. The DON stated there should have been follow up to the 1/24/22 dressing and why it was in place on readmission. When interviewed on 3/8/22 at 1:09 PM, Wound RN #7 stated they were unsure how long the dressing found on 2/15/22 was on the resident. The resident should have had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] When interviewed on 3/8/22 at 02:34 PM, physician #32 stated the resident was assessed by them on 1/25/22 and the bruise was not looked at. The bruise was not checked by the physician with subsequent visits as they did not assess bruises unless asked by staff. The resident was placed on wound rounds once the bruise opened. 10NYCRR 415.12(c)(2)

Based on observation, record review, and interview conducted during the standard survey and abbreviated surveys (NY 259), it was determined for 1 of 5 residents (Resident #9) reviewed for pain, the facility did not ensure residents received the necessary care and services to attain or maintain the highest practicable physical well-being. Specifically, Resident #9 expressed increased pain and difficulty transferring with no timely assessment and treatment completed by a qualified professional. Findings include: Resident #9 had [DIAGNOSES REDACTED]. The resident's 2/27/2015 Minimum Data Set (MDS) assessment documented she was severely cognitively impaired, required limited to extensive assistance for most activities of daily living (ADLs), was on a scheduled pain medication, and had not expressed any pain during the assessment period. The resident's 3/17/2015 comprehensive care plan (CCP) documented she had impaired mobility related to a history of a [MEDICAL CONDITION], was to be ambulated with a rolling walker and assist of 1 to and from the bathroom and to meals as tolerated. The resident had minimal complaints of pain, and staff were to monitor for pain or changes in range in motion, and report pain for evaluation. The May 2015 Medication Administration Record [REDACTED]. On May 13, 2015, physical therapy (PT) conducted an evaluation and noted the resident was a significant fall risk due to decreased safety awareness. The PT note documented the resident exhibits good rehab. potential. On May 19, 2015, the Medication Administration Record [REDACTED]. The pain scale assessment, dated 5/19/2015 at 6 AM documented the resident's pain was rated as 4 out of 10 for pain in legs (no specific leg documented). There was no documented effect after the PRN Tylenol was administered. The pain scale assessment on 5/19/2015 at 10 PM documented the resident had a 4 out of 10 level for knee pain with effect documented as pending. Nursing notes on 5/19/2015 documented the resident complained of knee pain (specific knee not documented). The notes documented PRN Tylenol was given with pending results. On 5/20/2015 for 3 PM - 9 PM, the licensed practical nurse (LPN) progress note documented during a transfer from wheel chair to bed, the resident grimaced with right leg pain and her routine Tylenol had just been administered. The LPN note documented the resident moaned in pain while laying in bed and when the LPN tried to adjust the resident's position. The note documented the LPN notified the nursing supervisor and the resident was transferred back out of bed, into her wheel chair. There was no documentation in the resident's record the registered nurse (RN) Supervisor assessed the resident after being notified by the LPN. The pain scale assessment, dated 5/20/15 at 7 PM, documented the resident expressed a 5 out of 10 for leg pain and received Tylenol with effect The 24 hour nursing report dated 5/20/2015 for the 3 PM to 11 PM shift documented the resident complained 10/10 pain during a transfer from the wheel chair to the bed. The resident complained of right sided thigh, leg, and groin pain. The report documented, Supervisor eval, routine Tylenol was given with some relief and the resident was assisted out of bed. There was no documented evidence the physician was notified of the resident's increased pain at that time. When interviewed via phone on 8/20/2015 at 10:28 AM, certified nurse aide (CNA) #19 stated the resident complained of pain when standing on 5/20/2015; stated pain was not normal for the resident; and said she reported this to LPN #18. CNA #19 stated the resident normally required 1 staff to assist during transfers, and required the assistance of 2 staff on the evening of 5/20/2015. When interviewed on 8/20/2015 at 3:40 PM, LPN #18 stated CNA #19 notified her the resident seemed to have pain during transferring. She stated she contacted RN Supervisor #20 to come and assess the resident. LPN #18 stated RN Supervisor #20 came to the unit, but she was unsure if RN Supervisor #20 assessed the resident. LPN #18 stated RN Supervisor #20 suggested the resident be transferred out of bed back to her wheel chair. When interviewed via phone on 8/21/ at 8:43 AM, RN Supervisor #20 stated she remembered LPN #18 contacting her to come to the unit as the resident had expressed pain while in bed. She stated she assessed the resident; did not document her assessment in the resident's record, and said she should have. On 5/27/2015 at 1 PM, the LPN progress notes documented the resident complained of severe pain in right leg and lower back down to her foot. The nurse practitioner (NP) progress note, dated 5/27/2015, documented the resident complained to staff of back, hip, and knee pain and was unable to tolerate a leg lift, knee bending, and any type of manipulation. The note documented the resident was to be evaluated by physical therapy to help the resident work through this sciatica situation of pain. The note documented if the resident did not show improvement, we may consider an X-ray in the future.an X-ray would be ordered in the future. On 5/27/2015 at 1 PM, the NP ordered the resident to receive [MEDICATION NAME] (Tylenol and an opioid pain medication) at that time and then every 6 hours PRN for 3 days. The NP also order a PT evaluation and warm packs to the right buttocks twice a day for 5 days. When the NP was interviewed on 8/20/2015 at 2:20 PM she stated after she saw the resident (on 5/27/2015), she was not sure if the resident had hip or back pain. She said PT evaluated the next day and reported the resident could not even stand, so they would not evaluate the resident until after X-rays were taken. The pain scale assessment, dated 5/27/2015, documented the resident's pain was 7 out of 10 at 6 PM. Tylenol was administered with the documented effect of the pain level being 4 out of 10, one hour after the medication was given. At 7:45 PM, the resident's pain was documented at 6 out of 10. The medication [MEDICATION NAME] was given with the documented effect of 3 out of 10, one hour after the medication was given. The pain scale assessment dated [DATE] at 1:45 AM documented the resident's pain level was 8 out of 10 in her right hip and leg; [MEDICATION NAME] was documented as administered; the effect on the resident's pain level was not documented. The pain scale assessment dated [DATE] at 7:30 AM documented the resident was given [MEDICATION NAME] for right hip and leg pain. The resident's pain level was not documented and there was no documentation regarding its effect. The untimed NP note dated 5/28/2015 documented the resident still complains of leg pain today and continues to take the [MEDICATION NAME]. The NP documented she had a discussion with PT who stated she could not proceed with PT unless they did an X-ray. The PT assessment dated [DATE] documented to change the resident to a Hoyer lift transfer; was to be non-ambulatory; changed to a 2 person assist for bed mobility; and staff were to ice the right hip as needed. On 5/28/2015 (untimed order), the NP ordered X-rays to the resident's hip and pelvis area. Nursing notes, dated 5/28/2015 at 6 PM, documented the results of the resident's X-ray showed an acute right [MEDICAL CONDITION]. Nursing notes at 6:30 PM documented the resident was given Tylenol with results pending, and was transferred to the hospital. 10NYCRR 415.12