Every finding on record at Loretto Health and Rehabilitation Center

Based on observation, interview, and record review during the abbreviated survey (2711290) conducted on 03/10/2026, the facility did not 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 one (1) of four (4) residents reviewed (Resident #2). Specifically, for Resident #2:- The 11/28/2025 Hospital Discharge Summary documented several pressure ulcers and recommended treatments. There was no documented evidence that the resident's skin was assessed upon admission and treatment orders were not obtained timely. - On 12/05/2025, nursing noted eight unstageable pressure ulcers (base of wound obscured by non-viable tissue; true depth could not be determined until tissue removed), and there was no documented evidence that physician ordered treatments were obtained for three of the pressure ulcers. - On 12/16/2025, nursing noted 10 pressure ulcers and there was no documented evidence that physician ordered treatments were obtained for five of the pressure ulcers. Findings include: The facility policy, Nursing Charting and Documentation, dated 10/21/2025 upon admission/readmission the following evaluations and assessments would trigger once automatically, unless otherwise noted, in the electronic record for nursing to complete: Nursing Admission/readmission Evaluation/Baseline Care Plan; Nursing Admit/Readmit every shift note; Pain Assessment; Fall Risk Evaluation; Self Administration of Medications; Braden Scale for Predicting Pressure Sore Risk; Elopement Evaluation, Tuberculosis Questionnaire; Functional Abilities; AIMS Evaluation; and Daily Skilled Observation/Assessment. The policy did not include a skin assessment. The facility policy, Skin and Wound-Pressure Injury Mitigation of Risk, Identification, Treatment and Documentation of Pressure Injury, dated 12/01/2025, documented Standards of Practice Pressure Injury Risk Mitigation Principles of Practice would be assessed and implemented upon admission/readmission, then weekly for the next 3 weeks, then quarterly or when there is a change in condition or return from the Emergency Room. This would be documented in the resident's record using the Braden Scale Assessment Tool and care plans would be placed in the chart with interventions based on the Braden Score. All residents with pressure injury on admission must be documented within the Skin and Wound module in the electronic record and reported to the provider and/or the Wound Care Nurse/designee and this information flowed to the 24-hour Report & Shift Report within the electronic record. When a resident develops a pressure injury during their stay, this must be reported to the provider or Wound Care Nurse/designee. Pressure injury must be placed in the electronic record within the Skin & Wound module and evaluated every seven days. Resident #2 had diagnoses including kidney cancer with metastasis (spread to other parts of the body), heart failure, and malnutrition. The 10/17/2025 Minimum Data Set assessment documented the resident's cognition was intact, they required partial/moderate assistance with rolling left and right and partial/moderate assistance with chair/bed-to-chair transfers. The resident had three unstageable pressure ulcers, one Deep Tissue Injury (pressure ulcer; purple/maroon discolored area or blood-filled blister due to damaged soft tissue) and Moisture Associated Skin Damage (erosion of skin from prolonged moisture from urine, feces, sweat or wound drainage). The 11/28/2025 Hospital Discharge Summary documented the resident had a wound on the sacrum (triangle-shaped bone in lower spine) and underwent surgical debridement (medical procedure that removes dead, damaged, or infected tissue) in the operating room on 11/21/2025. The resident had a wound vacuum assisted closure device (battery powered device used to accelerate healing) placed to the sacrum and they also had multiple other wounds. Wound care orders included:-to sacrum, cleanse with normal saline moistened gauze, pack cavity with a 4 x 4 gauze soaked in Vashe (antimicrobial treatment), cover with an abdominal pad and secure with tape daily and as needed. -to the buttock wound (report did not document which side), cleanse with normal saline moistened gauze, apply Aquacel AG (antimicrobial treatment), cover with dry gauze and an abdominal pad and secure with tape daily and as needed.-to both foot wounds, cleanse with normal saline moistened gauze, apply Aquacel AG, cover with dry gauze and an abdominal pad, and secure with gauze wrap daily and as needed. -leg wounds (location was not specified in the report), cleanse with normal saline, apply Mepilex (absorbent foam dressing), change every 2 days and as needed. The 11/28/2055 readmission Packet (facility document containing hospital record review for resident medical information prior to admission) documented the resident's pressure ulcers included: left lateral (to the side) heel, right heel, right lateral foot, left ankle, sacrum, coccyx (tail bone), left buttocks and the resident had a wound vacuum assisted device. The 11/28/2025 admission Assessment completed by Registered Nurse #7 documented the resident had impaired skin and to see Skin and Wound for updates. There was no documented evidence that the resident's skin was assessed upon admission in the Skin and Wound section of the resident's record. The 11/28/2025 physician orders documented:- a wound treatment, a wound vacuum assisted closure device to the sacrum and a dressing to be changed three times weekly.-offloading heel boots in bed at all times. There was no documented evidence of physician ordered treatments for the resident's other pressure ulcers documented in the hospital discharge summary and the facility's readmission Packet. The 11/28/2025 Comprehensive Care Plan documented the resident had potential for alteration in skin integrity. Interventions included turning and repositioning every 2-4 hours and as needed. There was no documented evidence in the Comprehensive Care Plan that the resident had an actual skin impairment. The 11/29/2025 at 3:14 AM, 7:17 AM and 10:35 AM Registered Nurse #8's Skin Issue notes documented 25 skin issues were not evaluated. The 11/30/2025 at 10:25 PM Registered Nurse #9's Skin Issue note documented 25 skin issues were not evaluated. The 12/01/2025 Nurse Practitioner #5 note documented the resident had multiple pressure ulcers and they continued with ordered preventative and treatment measures in place. The 12/01/2025 at 9:35 PM Registered Nurse #9's Skin Issue note documented the resident's right heel was unstageable and measured 4.6 centimeters wide x 3.7 centimeters long x 0 centimeters deep. Registered Nurse #9 documented:- on 12/02/2025 at 11:44 AM, 25 skin issues were not evaluated.- on 12/02/2025 at 3:21 PM, 25 skin issues were not evaluated. The 12/02/2025 physician orders documented:-to right and left heel pressure ulcers, apply Mesalt (highly absorbent dressing used for heavily draining or infected, moist, necrotic (non-viable tissue) wounds), cover with a gauze pad and wrap with gauze wrap daily. There was no documented evidence that the resident's left heel had been assessed prior to implementing a treatment order. The 12/05/2025 at 3:39 PM Registered Nurse #7's Skin Issue note documented:- the right rear hip blister measured 2.6 centimeters wide x 1.7 centimeters long x 0 centimeters deep.- the right gluteus (previously documented as the sacrum/coccyx) measured 7.5 centimeters wide x 9.6 centimeters long x 0 centimeters deep. - the left gluteus was unstageable and measured 16.9 centimeters wide x 11.2 centimeters long x 0 centimeters deep.- the buttocks had Moisture Associated Skin Damage and measured 9 centimeters wide x 9.3 centimeters long x 0 centimeters deep. -the left heel was unstageable and measured 9.2 centimeters wide x 6.4 centimeters long x 0 centimeters deep and had 100% eschar (black/brown, non-viable tissue).-the right 5th toe was unstageable, measured 2 centimeters wide x 2.9 centimeters long x 0 centimeters deep and had 100% eschar.-the right rear ankle was unstageable, measured 1-centimeter-wide x 1-centimeter-long x 0 centimeters deep and 100% eschar.-the right heel was unstageable, measured 6.6 centimeters wide x 7.7 centimeters long x 0 centimeters deep and had 100% eschar.-the right lateral ankle was unstageable, measured 7.9 centimeters wide x 2.7 centimeters long x 0 centimeters deep and had 100% eschar. The 12/05/2025 physician orders documented:-to left buttock, cleanse, apply skin prep daily and offload when possible.-to non-intact blister right rear hip, monitor daily for dislodgement of scab, and for signs of infection. There was no documented evidence a physician ordered treatment was obtained for the resident's right lateral ankle, right rear ankle, and the right 5th toe. The 12/06/2025 at 6:48 PM Registered Nurse #8 documented the resident was sent to the hospital for conditions unrelated to their wounds. The 12/16/2025 Hospital Discharge Summary documented the resident's principal diagnosis during admission was fluid overload. The resident's wound vacuum assisted closure device was discontinued to their sacrum and new recommendations included to apply Santyl (wound treatment, removes dead tissue) to wound base, gently pack wound with lightly moistened gauze, and cover with dry gauze and an abdominal pad and secure with tape twice daily. There were no other documented wounds or recommended treatments on the Hospital Discharge Summary. The 12/16/2025 Skin Issues note completed by Registered Nurse #3 documented: -the left 5th toe was unstageable and measured 1-centimeter-wide x 3.5 centimeters long x 0 centimeters deep.-the left heel was unstageable and measured 9.9 centimeters wide x 6.1 centimeters long x 0 centimeters deep.-the left rear ankle was unstageable, measured 8 centimeters wide x 1.7 centimeters long x 0 centimeters deep and had 100% eschar.-the right 5th toe was unstageable, measured 1.5 centimeters wide x 3.3 centimeters long x 0 centimeters deep and had 100% eschar.-the right heel was unstageable, measured 5.5 centimeters wide x 5.6 centimeters long x 0 centimeters deep and had 60% eschar. -the right ankle amputation site was unstageable, measured 0.5 centimeters wide x 0.4 centimeters long x 0 centimeters deep and had 90% eschar. -the right buttock was a Stage 4 (full thickness wound with extensive tissue loss, exposed muscle, tendon, ligament or bone), measured 7.7 centimeters wide x 6.4 centimeters long x 0 centimeters deep and had 30% slough (non-viable tissue).-the right rear thigh had a blister measured 3.8 centimeters wide x 1.7 centimeters long x 0 centimeters deep.-the sacrum was a Stage 4, measured 3.1 centimeters wide x 2.3 centimeters long x 0 centimeters deep and had 30% slough.-the left buttock fold was unstageable, measured 4.4 centimeters wide x 4 centimeters long x 0 centimeters deep and had 90% eschar. The 12/17/2025 physician order documented treatments were implemented for the resident's heels, the left and right buttock and the sacrum. There was no documented evidence of a physician ordered treatment for the resident's right rear thigh blister, unstageable right ankle amputation site, unstageable left rear ankle, unstageable right dorsum 5th toe, and unstageable left dorsum 5th toe. During an interview on 03/02/2026 at 12:15 PM, Registered Nurse Clinical Coordinator #3 stated when wounds were found on assessment, orders should be implemented the same day. If orders were not on the hospital discharge paperwork, then they spoke to the facility wound nurse for recommendations. All wounds were reported in email to the wound nurse and the wound provider. On 12/16/2025, they just followed wound orders documented in the hospital report and any remaining areas without a treatment, they covered with a dry gauze until seen by the wound provider. During an interview on 03/02/2026 at 1:21 PM, Registered Nurse #7 stated that when a resident was readmitted , the admission assessment was done by a registered nurse, and the skin assessment was required to be completed withing 24 hours. If wounds were found, treatment should be implemented during the shift. If the hospital After Visit Summary had wound treatment recommendations, they were instructed by the facility to follow those recommendations and implement them after discussion with their provider. If a skin assessment could not be done on their shift, they verbally reported to the oncoming shift to complete. They recalled doing the resident's admission Assessment on 11/28/2025. The Skin and Wound application in the electronic record was fairly new, and they thought they had issues uploading information into the record that day. They were not sure why orders were not obtained and implemented for the resident's other wounds, and they expected orders would be more timely. On 12/05/2025, they did the resident's weekly wound assessment and stated a treatment should have been ordered for the resident's right lateral ankle, right 5th toe and right rear ankle. During an interview on 03/05/2026 at 10:58 AM, Registered Nurse #8 stated when a resident was admitted the skin assessment was to be completed within 24 hours and if it could not be done on their shift, it was passed on verbally to the oncoming shift to complete. Their note on 11/29/2025 at 3:14 AM was not documented by them as they worked the day shift. On 11/29/2025 at 7:17 AM and 10:35 AM, they had never documented a note where 25 skin issues had not been evaluated and they were not sure how those notes got in the record. During an interview on 03/05/2026 at 10:32 AM, Registered Nurse #9 stated ideally, a skin assessment was done during the shift the resident was admitted however they had 24 hours to do so. For a resident that was being readmitted , if there were skin issues that were being followed from the previous admission, if not resolved in the record, there would be a pop up that said skin was overdue and show that it was still in progress and not completed. Skin issues needed to be resolved before documenting the new skin assessment. They followed hospital wound care recommendations upon admission and if no recommendations were documented, they obtained an order usually based on their previous treatment orders. Orders should be obtained on the same day. On 11/30/2025 at 10:25 PM, they were not familiar with a note that documented 25 skin areas were not assessed by them. They had never seen that note before. They stated on 12/01/2025 and 12/02/2025, they were not on duty and did not write the notes documented in the resident's record. The resident should have ordered treatments to the areas. During an interview on 03/10/2026 at 10:53 AM, the Director of Nursing stated a head-to-toe assessment was completed within 24 hours of admission and a wound treatment implemented once the skin was assessed. A Braden Scale was done as well to determine what interventions to put into place. If at risk of pressure, the facility implemented preventative interventions. If a resident had actual pressure wounds, the wound nurse would be notified, treatments put in place, the certified nurse aide Task List (direct care instructions) would be updated with turning and positioning, a pressure reducing mattress and weekly skin assessments would be implemented. If the hospital made wound recommendations, the facility tried to ensure the treatments they had closely matched, and the wound nurse and wound provider would see the resident weekly. If an admission Skin Assessment could not be done on the shift the resident was admitted on , it was not done because of resident refusal or behavior. They expected the nurse to document the reason the assessment was not done and notify the next shift to complete. A medical provider should be called to get a verbal order for a treatment. The wound nurse and wound provider were involved with every pressure ulcer that was not a Stage 1 and they needed to monitor to determine if the right treatment was in place. They monitored weekly. Registered nurses on the unit did treatments and took pictures of wounds. On 11/28/2025, they could see in the resident's record that skin issues were documented as not evaluated. They did not see any pictures taken on 11/28/2025. They expected upon admission the resident would have a pressure mattress and offloading boots which were ordered. On 12/01/2025, when an order was obtained for the resident's left heel, they expected a documented assessment of the heel in the record. On 12/05/2025 and 12/16/2025, they expected treatment orders to be obtained for all of the resident's documented pressure ulcers or a rationale documented why treatment was not needed. 10 New York Codes, Rules and Regulations 415.12(c)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00367212/446001) surveys conducted 8/25/2025-8/29/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for four (4) of fourteen (14) resident units ([NAME] Units 4, 5, 7, and 13) reviewed. Specifically, Resident #63 had dirty linens, and a soiled brief left at their bedside; Resident #187's room had a ceiling tile with a large brown stain and an unclean privacy curtain; Resident #314's room had a ceiling tile with a medium black stain; Resident #21's window shade had several brown spots; and Resident #373's wheelchair was unclean. Findings include:The 12/2018 Housekeeper job description documented job duties specific to housekeeping included cleaning walls and ceilings by washing, wiping, dusting, spot cleaning, disinfecting and deodorizing as instructed; and removing dirt, dust, grease, etc. from all surfaces using proper cleaning/disinfecting solutions.The facility policy “Cleaning and Disinfection/Non-critical care and shared equipment,” dated 7/22/2024 documented cleaning and disinfection of the facility, including resident rooms, was completed in accordance with environmental services policies and procedures. Privacy curtains were removed and laundered on a regular schedule, as needed, when soiled, and when a resident was removed from transmission-based precautions.The undated facility policy, “Safe and Homelike Environment,” documented the resident had the right to a safe, clean, and comfortable environment in which they received treatment and support for daily living. The facility policy “Wheelchair Cleaning,” dated 10/1/2024, documented housekeeping staff did regularly scheduled cleaning of wheelchairs. Certified nurse aides would do daily inspection and cleaning after meals as needed. Additionally, any staff member may place an electronic work order at any time if cleaning was needed outside of the routine wheelchair cleaning schedule. The certified nurse aide placed chairs to be cleaned in the designated area. To clean the chair, remove all equipment from chair (cushions, leg rests, drainage bags, oxygen canisters, and personal devices); and remove the wheelchair seat cushion cover. Both seat cover and cushion needed to be disinfected, cleaned and dried separately. The cushions and covers were placed on a designated rack for proper drying prior to being placed back on the chair. The Wheelchair Cleaning Log sheet was completed and provided to the Housekeeping Manager/Operations/Manager/Designee.Fourth Floor Observations:During an observation on 8/27/2025 at 1:49 PM, Resident #63 was lying in bed and soiled linens and a soiled brief in a mechanical lift pad were on the floor next to the bed.During a telephone interview on 8/29/2025 at 9:51 AM, Resident #63’s family stated the resident’s room frequently has soiled briefs on the floor. They saw soiled linens on the overbed table when visiting. During an interview on 8/29/2025 at 10:43 AM, Certified Nurse Aide #43 stated they provided care for Resident #63 on 8/27/2025. The resident was incontinent and was normally changed after meals. They would take the resident back to their room and change the brief while the resident was in bed. The dirty wash clothes were hung on the side of the cleaning basin and the brief was rolled up at the end of the bed. Once the resident was changed, they put the wash clothes in the dirty linen holder and the brief in the trash. They never left them on the floor as it was not sanitary.During an interview on 8/29/2025 at 11:50 AM, Licensed Practical Nurse #42 stated incontinence products and linens should never be on the floor, it was a contamination and infection control issue. They should be rolled up and put at the end of the bed and discarded before going to the next resident’s room. They had to pick up incontinence products and dirty linens before. During an interview on 8/29/2025 at 12:02 PM, Licensed Practical Nurse Assistant Nurse Manager #41 stated soiled linens and briefs should not be on the floor, they should be disposed of, and the linens should go to the soiled linens bin. During an interview on 8/29/2025 at 1:12 PM, Registered Nurse Unit Manager #48 stated soiled briefs and linens should not be left on the floor, it was unsanitary. Fifth and Seventh Floor Observations:The 6/1/2025 – 8/29/2025 work order log for the 5th floor documented maintenance exchanged ceiling tiles twice on 8/1/2025, on 8/5/2025, on 8/6/2025, and twice on 8/27/2025. Housekeeping provided a privacy curtain on 6/4/2025, and three times on 8/14/2025. During an observation on 8/25/2025 at 10:50 AM, Resident #187’s room had a brown water spot on the ceiling tile in a circular shape about the size of a dinner plate. The privacy curtain had a large brown stain at the bottom corner. During an observation and interview on 8/25/2025 at 1:31 PM, Resident #314’s room had a black stain on the ceiling tile in a circular shape about the size of a wiffle ball. The resident stated the facility changed the tile and the stain came back.During an observation on 8/25/2025 at 1:26 PM, the seventh-floor small resident lounge had a metal bed flipped on its side and parts of the bed were located throughout the room. There were multiple wheelchairs in the room. During an interview on 8/28/2025 at 11:08 AM, Housekeeping Crew Leader #58 stated they went around to the rooms and looked at the resident’s privacy curtains to see if they needed to be replaced. They changed the curtains when they were dirty. The 5th floor and below were done regularly. They kept a record for privacy curtain replacement, but the paperwork was misplaced. They stated they washed about 20 in the last couple of days. During an interview on 8/28/2025 at 3:08 PM, the Senior Director of Operations stated the small lounge was a resident area and the scattered electrical items were bed components on the floor. The repair should not have been made in a resident area. The bed and mattress should be removed from the floor and moved to the maintenance area until repaired.Thirteenth Floor Observations:The 8/2025 housekeeping logs for the 13th floor had a single line through room curtains. There was no documentation if the curtains were cleaned. During an interview on 8/26/2025 at 9:28 AM, Resident #21 stated there were several brown spots on both window shades. The resident stated they were embarrassed by them.During an observation on 8/26/2025 at 9:23 AM and 8/27/2025 at 12:44 PM, Resident #373’s navy blue wheelchair’s armrests were soiled with food particles. During an interview on 8/27/2025 at 12:49 PM, Housekeeper #60 stated they were responsible for cleaning resident wheelchairs in the morning, if they were in the hallway. There was no real schedule, night shift was doing it, but the Housekeeping Director waned them done in the morning. If the wheelchair appeared dirty, they knew to clean them. During an interview on 8/27/2025 at 12:59 PM, Certified Nurse Aide #61 stated if there was a dirty wheelchair they would clean it. Resident #373’s wheelchair armrests were dirty. They thought the night shift would have cleaned it before getting the resident up for the day. If the wheelchair was not on the schedule for cleaning that day, they would clean it when the resident went back to bed. All staff were responsible for cleaning resident chairs.During an interview on 8/28/2025 at 11:49 AM, Licensed Practical Nurse #47 stated staff should wipe down chairs if they notice them soiled. They had a schedule for each floor. Housekeeping typically cleaned chairs per the schedule and the certified nurse aides would put the chairs in the hall on the night shift. During an interview on 8/29/2025 at 12:02 PM, the Director of Maintenance stated they were made aware of the resident room ceiling tile on the 5th floor on a Friday about three weeks ago. They replaced it and by Monday the tile needed to be replaced again. They called the vendor for the leak and changed the tile again. There was a repair done, but it was a heating and cooling pipe, so the repair would require the system on that floor to be unable to heat or cool for approximately three hours at the minimum. The vendor had to come when the temperature was not going to be too hot outside. If housekeeping was unable to clean a window shade, they should order a new one. Once the new item came in, they notified maintenance to install the shade. They were not notified to install any window shades on the thirteenth floorDuring an interview on 8/29/2025 at 12:16 PM, the Director of Housekeeping stated staff had checklists to be completed daily for their room cleaning. Window shades were part of the deep clean, and they should be cleaned if dirty as part of the room cleaning. If the housekeeper was unable to get them clean, they should report it to the crew leader or them and they would attempt to clean it with something different. If they still were not clean, they would contact maintenance to have them replaced. They stated they were not notified of any additional cleaning needed or replacements for the thirteenth floor. The process for cleaning wheelchairs was on the 3rd shift schedule. They had a staff member that worked 4 days a week to clean chairs. Rooms assigned a deep clean got wheelchair cleaning also. If staff saw a dirty chair, they were expected to clean it when they saw it. 10 NYCRR 415.29(j)(1)

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025 - 8/29/2025, the facility did not ensure the resident environment remained free of accident hazards for three (3) of three (3) residents (Residents #5, #63, and #510) reviewed. Specifically, Residents #5, #63, and #510 were transferred via a mechanical lift with assistance of one and not assistance of two as planned.Findings includeThe facility policy Transferring Residents with Assistive Devices, dated 4/1/2024 documented Physical and Occupational Therapy were responsible for evaluating the resident and updating the activities of daily living care plan for levels of assistance and transfer status. The mechanical total lift required assist of one of two staff to operate the lift and to assist the resident, per the plan of care. Certified staff were NOT able to make a determination to use a lesser mode of transfer (ex. resident was a total mechanical lift and staff decided to use a stand/pivot transfer). Certified staff were able to make a determination to use a higher mode of transfer (ex. Resident was a sit-to-stand lift and staff decided to use a total mechanical lift). For additional information, follow the manufactures recommendations. 1) Resident #5 had diagnoses of stroke, diabetes, and surgical after care. The 7/4/2025 Minimum Data Set assessment documented the resident was severely cognitively impaired and was dependent on staff for chair to bed transfers. The Comprehensive Care Plan initiated 10/27/2023 and revised 3/12/2025 documented the resident had an activities of daily living self-care performance deficit related to generalized weakness. Interventions included chair to bed transfers with assistance of two and mechanical lift. The comprehensive care plan initiated 10/27/2023 documented the resident had risk for falls related to stroke and impaired mobility. Interventions included the use of assistive devices per physical and occupational therapy evaluations. Certified Nurse Aide #23 documented in the 8/2025 Certified Nurse Aide Activities of Daily Living Report Resident #5 was dependent, where the helper did all the effort, resident did provide the effort to complete the activity, and the assistance of two or more helpers was required for the resident to complete the activity for chair/bed-to-chair transfer on 8/28/2025. During an observation and interview on 8/28/2025 at 2:45 PM, Certified Nurse Aide #23 transferred Resident #5 back to bed from their wheelchair with a mechanical lift without additional staff assistance. Certified Nurse Aide #23 stated the mechanical lift should be used with two people, but they did not have enough staff to do that. They stated they had to do what they had to do for the residents. During an interview on 8/29/2025 at 1:23 PM, Licensed Practical Nurse #24 stated the facility policy was to use two people for a mechanical lift transfer. Resident #5 required assistance with the mechanical lift and required two people. The purpose of two people when operating the mechanical lift was for the safety of the resident. If they were moving the lift and the wheel or arm caught on the bed or anything, the resident could swing, and the lift could tip over. During an interview on 8/29/2025 at 1:37 PM, Registered Nurse Unit Manager #25 stated therapy decided whether a resident needed one or two person assistance with the mechanical lift. Resident #5 required two person assistance with the mechanical lift. Therapy decided they required two people, and they should never be assisted with only one person. Staff should read and follow the care plan for each resident. Short staffing was not an excuse for inappropriate use of the mechanical lift. The unit had appropriate staffing, and everyone was willing to help, they were not short staffed on the unit. 2) Resident #63 had diagnoses including weakness, reduced mobility, and need for assistance with personal care. The 6/26/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment and was dependent for transfers. The Comprehensive Care Plan initiated 6/15/2021 and revised 4/5/2022 documented the resident had an activity of daily living self-care deficit performance related to confusion, dementia, and impaired balance. Interventions included the resident was dependent on assistance of two with the mechanical lift for transfers. The 10/17/2024 Physical Therapist #49 evaluation documented the resident required total dependence of two for transfers with the use of a mechanical lift. During an observation on 8/28/2025 from 1:39 PM-1:42 PM, Certified Nurse Aide #43 entered the resident's room with a mechanical lift. The resident was in their high back wheelchair in the room. There were no other staff present in the room. At 1:42 PM, Certified Nurse Aide #43 came out of the room with the white mechanical lift pad, the mechanical lift was still in the room and the resident was now lying in their bed. During an interview on 8/29/2025 at 10:43 AM, Certified Nurse Aide #43 stated the resident went back to bed after meals. The resident required assistance of two with the mechanical lift. They stated they transferred the resident back to bed by themselves yesterday after lunch. They were short staffed a lot and they often transferred residents by themselves even if they were supposed to be transferred with assistance of two. The resident was dead weight and was heavier and that was why they required assistance of two. During an interview on 8/29/2025 at 11:50 AM, Licensed Practical Nurse #42 stated the Kardex (care instructions) informed the certified nurse aides the resident's transfer status. If a resident was an assist of two, it was for safety or what was assessed by therapy. Resident #63 was heavy, so they required assistance of two with the mechanical lift. It was easier to position the resident in the pad and/or the chair correctly with two people. 3) Resident #510 had diagnoses including stroke with left sided weakness, abnormalities of gait and mobility, and need for assistance with personal care. The 7/31/2025 Minimum Data Set assessment documented the resident was cognitively intact and was dependent for transfers. The Comprehensive Care Plan initiated 1/10/2025 and revised 1/22/2025 documented the resident had an activities of daily living self-care performance deficit related to generalized deconditioning, impaired mobility, and weakness. Interventions included the resident was dependent on two for transfers with the mechanical lift. The 3/28/2025 Physical Therapist #50 discharge summary documented the resident was dependent for transfers. The discharge summary did not specify the use of a mechanical lift or how many staff were required for assistance. During an observation on 8/25/2025 from 11:12 AM-11:22 AM, Certified Nurse Aide #51 entered the resident's room with a mechanical lift. There were no other staff present in the room. The resident was sitting up in their high back wheelchair in a hospital gown. At 11:22 AM, Certified Nurse Aide #51 exited the room, the mechanical lift was still in the room and the resident was lying in their bed. During an interview on 8/28/2025 at 9:36 AM, Resident #510 stated they had a stroke, and staff used a mechanical lift to transfer them. They stated it was always just one staff that performed the transfer. During an interview on 8/29/2025 at 11:05 AM, Certified Nurse Aide #51 stated the Kardex informed them if a resident required one or two staff with the use of the mechanical lift. They referenced the Kardex every morning because things changed. They were a float, so they moved units a lot and was not familiar with the residents. They stated they could not recall how they transferred Resident #510 on 8/25/2025 but they would never transfer a resident alone if they required assistance of two because that could cause an accident. During a telephone interview on 8/29/2025 at 1:12 PM, Registered Nurse Unit Manager #48 stated the resident's transfer status was on the Kardex and they expected the certified nurse aides to check this daily. It was a discussion between therapy and nursing that determined if a resident required assistance of one or two with the mechanical lift. Resident #63 required two for transfers. They did not have access to the electronic medical record but thought Resident #510 required assistance of two with the mechanical lift. During an interview on 8/29/2025 at 2:22 PM, the Director of Rehabilitation stated the expectation for mechanical lift use was staff followed the residents' care plan. The care plan documented if the resident required assistance of one or two. Therapy decided on the transfer ability and the equipment used to transfer the residents' safely. They worked with the residents and reviewed the residents' behavior, size, cognition, and diagnoses, among several additional factors that determined the residents' needs for mechanical lift transfers. If a resident was care planned for two person assist, the staff should not use just one person. The determination for the use of two was made for a reason and they needed to use two for the safety of both the residents and the employees.10NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for four (4) of thirteen (13) medication carts (4th floor cart [NAME] building, and 5th, 7th,and 6th floor [NAME] carts), two (2) of fourteen (14) treatment carts (2nd and 4th floor [NAME] carts) and one (1) of seven (7) medication storage rooms (5th floor [NAME] medication room). Specifically, the 5th and 7th floor [NAME] medication cart had undated and expired medications and biologicals; the 6th floor [NAME] medication cart was left unattended and unlocked; the 2nd and 4th floor [NAME] treatment carts were unlocked; and the 5th floor [NAME] medication room had expired medication. Findings include:The facility policy Drug and Biological Storage of Medications, dated 5/28/2024, documented medication carts and medication supplies were locked when they were not attended by persons with authorized access. All injectable drugs and biologicals delivered to the facility would have pharmacy labels on the outside container as well as the drug vial should container and vial become separated. Once an injectable drug was opened a sticker noting the date the vial was opened, and the initials of the nurse should be placed on the vial, or the information could have been written directly on the vial. Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from inventory, disposed of, and reordered from the pharmacy if a current order existed. Unsecured Treatment Cart: During an observation on 8/25/2025 from 12:26 PM to 12:36 PM, the treatment cart on 2 [NAME] located outside room [ROOM NUMBER] was unlocked and contained intravenous supplies and scissors. At 12:36 PM an unidentified staff walked by and locked the cart. During an observation on 8/27/2025 at 11:48 AM, the treatment cart on 2 [NAME] was unlocked. The top drawer contained two pairs of scissors, Aspercream (topical pain relief), bacitracin, triple antibiotic ointment, silver antimicrobial wound gel, itch relief cream, and Medi honey (wound treatment). The second drawer contained bottles of barrier cream, zinc oxide, and xeroform (wound dressing). The third drawer contained gauze and varied dressing supplies. During an observation on 8/28/2025 at 8:55 AM the treatment cart on 4 [NAME] was unlocked and in the hallway. During an interview on 8/27/2025 at 12:46 PM, Licensed Practical Nurse #8 stated they were responsible for passing medications. The treatment cart and medication cart should be locked and tethered when unattended and the screen on the medication cart had to be in the off position. When they left the medication cart, they made sure it was locked and tethered to the wall for safety reasons. During an interview on 8/28/2025 at 9:10 AM, Registered Nurse Unit Manager #4 stated they expected medication and treatment carts to be locked when unattended for the safety of residents. Both carts contained medications that could be dangerous for residents. Unsecured Medication Cart: During an observation on 8/26/2025 from12:18 PM to 1:15 PM, the 6th floor [NAME] medication cart was unlocked and unattended near the dining room doorway. During an interview on 8/28/2025 at 10:20 AM, Licensed Practical Nurse #20 stated medication carts should be locked when not in use. The nurse assigned to the cart was responsible for ensuring the cart was locked when they walked away. The unit had wandering residents who took things. They did not recall the medication cart being unlocked during the lunch meal on 8/26/2025 but they could have been distracted or called into the dining room. During an interview on 8/28/2025 at 11:05 AM, Registered Nurse Unit Manager #21 stated medication carts should be locked whenever the nurse was not actively accessing medications. They had wandering and confused residents on the unit that attempted to take things from unauthorized places. During an interview on 8/29/2025 at 3:08 PM, the Director of Nursing stated medication carts should be kept locked when the nurse was not near the cart. Each cart had its own set of keys, and they were kept with the assigned nurse. The carts were kept locked to avoid residents or anyone else from getting into them. Improper Storage and Labeling of Medication: During a 5th floor Cunninham medication cart observation on 8/27/2025 at 12:17 PM with Licensed Practical Nurse #22, the following was observed: -1 opened bottle of ferrous gluconate (iron supplement) 324 milligram tablets with a manufacturer's expiration date of 6/30/2025. -1 opened bottle of Vitamin D 25 microgram tablets with a manufacturer's expiration date of 7/2025. -2 bottles of Atropine sulfate 1% ophthalmic solution (medicated eye drops) with a handwritten date of 5/10 and 5/8. -2 bottle of artificial tears with no open date -3 Trelegy inhalers, 2 Symbicort inhalers, 1 albuterol inhaler, 2 Fluticasone inhalers, 1 Incruse Ellipta inhaler, and 1 Breo Ellipta inhaler with no open date documented or had expired. During a 7th floor [NAME] medication cart observation on 8/27/2025 at 12:48 PM with Licensed Practical Nurse #53, the following was observed: -2 bottles of dry eye relief dated as opened 6/10/2025 and 7/9/2025. -Olopatadine 0.1% eye drops (medicated eye drops) opened 6/6/2025 -Systane dry eye drops opened 5/13/2025 - 1 Bevespi inhaler opened 5/2/2025 and 1 opened 6/24/2025 - 1 Anoro ellipta inhaler and 3 Trelegy inhalers not dated when opened -1 Anoro ellipta inhaler opened 7/9/2025 with packaging documented discard after six weeks During an interview on 8/27/2025 at 12:48 PM Licensed Practical Nurse #53 stated eye drops were good for 28 to 30 days after opened. The eye drops noted above were all expired. They arrived after the start of the morning shift and some of the medications were administered before they arrived. Inhalers were dated when opened and some discarded in 7 days, some 28 days, it depended on the medication. They administered inhalers from the cart, noticed they were not dated, and ordered new inhalers. They worked different floors and tried to get the medications administered and if they were expired or not dated, they tossed them out and ordered new ones from the pharmacy. During an interview at 8/28/2025 at 4:35 PM Registered Nurse Supervisor #55 stated eye drops should be labeled when opened. The expiration date depended on the medication but could be 14 days and expired based on the facility policy. They should be labeled when opened so the nurse knew how long they were good for. Inhalers should be labeled when opened and expired based on the pharmacy discard timeframe or per facility policy. They expected the nurses to go through the cart routinely to make sure eye drops and inhalers were labeled and discarded when expired. During an interview on 8/28/2025 at 4:46 PM, Registered Nurse Unit Manager #54 stated they expected eye drops to be labeled when opened and they expired 30 days after being opened. They had to be dated so staff would know when they expired. They expected inhalers to be labeled when opened and the expiration date depended on the inhaler. Inhalers needed to be labeled for infection control reasons and so staff knew when they should be discarded. The carts should be looked at daily for any expired medications by the nurse assigned to the medication cart. Expiration dates should be verified before administering any medication. Unlocked medication cart screens During an observation on 8/27/2025 at 11:53 AM the 4th Floor [NAME] team 4 medication cart had a computer screen with multiple resident names on the screen across from the dining room where several residents were sitting waiting for lunch. During an interview on 8/27/2025 at 12:46 PM, Licensed Practical Nurse #8 stated they were responsible for passing medications. The treatment cart and medication cart had to be locked and tethered when unattended and the screen on the medication cart had to be in the off position. When they left the medication cart, they made sure it was locked and tethered to the wall for safety reasons, and the screen was in the off position to ensure privacy for all residents. They forgot to put the screen on the off position today. During an interview on 8/28/2025 at 9:10 AM, Registered Nurse Unit Manager #4 stated they expected the resident information screen on the medication cart to be in the locked position when not being used so residents did not have access to other resident's confidential information. 10NYCRR 415.18(d) .

Based on observations, record review, and interviews during the recertification and abbreviated (NY002586082/iQIES 446001) surveys conducted 8/25/2025-8/29/2025, the facility did not ensure food was served at palatable and appetizing temperatures in accordance with professional standards for food service for 9 anonymous residents and 2 of 2 test trays (8/27/2025 and 8/28/2025 lunch meals) reviewed. Specifically, the lunch meal test trays on 8/27/2025 and 8/28/2025 were not flavorful or served at palatable and appetizing temperatures; and 9 anonymous residents at the Resident Council Meeting stated the food was often cold, not flavorful, and overcooked. Findings: The facility policy Resident Meals, dated 1/2020, documented each resident received meals that were nourishing and palatable. Food and nutrition staff would monitor and audit food trays, so they were palatable, attractive, and served at a safe and appetizing temperature. A new tray would be issued if it was not. The undated facility policy Tray Service to Residents, documented the Dining Services Department would ensure food carts were docked on each floor at scheduled times. Test Trays were to be performed monthly. Nursing Services was to open the cart doors once the retherm (food reheating) cycle was completed. Trays were then delivered to the residents. During a resident council meeting on 8/26/2025 at 10:00 AM, 9 anonymous residents stated the food was usually cold, overcooked, and not palatable. During a meal observation on 8/27/2025 at 12:26 PM, Resident #528 stated they would not eat the meal as it did not look appetizing and looked overcooked on one side. The tray was tested for temperature and palatability with the following results: -roasted seasoned potato was 148 degrees Fahrenheit and had no flavor.-wax beans were bland.-pot roast was 126 degrees Fahrenheit, looked dry, and was dark brown on one side. -soup was 145.8 degrees Fahrenheit and had no flavor.-juice in a small plastic container was 61.7 degrees Fahrenheit.-gelatin with fruit was 52.5 degrees Fahrenheit. During a meal observation on 8/28/2025 at 12:11 PM, Resident #470's tray was used as a test tray, and a replacement was requested. The tray was tested for temperature and palatability with the following results: -soup was 153.9 degrees Fahrenheit and tasted bland.-hamburger was 143.3 degrees Fahrenheit and tasted warm.-potato salad was 50.9 degrees Fahrenheit.-coffee was 139.1 degrees Fahrenheit.-cranberry juice was 55.2 degrees Fahrenheit and tasted warm. During an interview on 8/27/2025 at 12:46 PM, Licensed Practical Nurse #8 stated residents had stated the food did not taste good. The nurse would then ask for an alternate from the kitchen. One resident told them the meat was just a hamburger in a pool of grease, and the resident was offered some soup. The units usually had the supplies to make a resident a peanut butter and jelly sandwich as a replacement. The kitchen prepared the food portions of the meal tray and unit staff prepared drinks separately. During an interview on 8/27/2025 at 1:37 PM, Certified Nurse Aide #28 stated they used to work in food service in the past. They were aware residents complained about the food being cold and not liking the consistency. The food looked overcooked and dry many times in the past. During an interview on 8/28/2025 at 9:10 AM, Registered Nurse Manager #4 stated they received frequent resident complaints about food. The complaints included the trays taking too long to get to the unit, the food being cold, and items missing from the trays. The residents' meal trays were set up in the kitchen by dietary staff. During an interview on 8/29/2025 at 12:45 PM, Dietary Aide #29 stated they prepared resident foods and brought the meal trays to the units. The cooks tasted the food while cooking. Food temperatures should be cold items below 40 degrees Fahrenheit and hot items above 140 degrees Fahrenheit. The food should be flavorful. During an interview on 8/29/2025 at 12:52 PM, Food Service Supervisor #30 stated tray audits were done on a daily and random basis and were documented. Audits included palatability. Test trays were done to ensure proper food temperature, palatability, and presentation. Cooking was done in the commissary and kitchen staff only plated the food. If the food did not look the way it should, kitchen staff should make the Director of the Commissary aware. They stated the acquired test tray temperatures were out of range. Soups were made on the units and that may be why they tasted bland. During an interview on 8/29/2025 at 1:09 PM, Commissary Director #14 stated they made the food, including the entrees, starches, eggs, and cereal. They also prepared the different consistencies. The food was cooked in the commissary, and the cooks should taste the food. Each meal was cooked 5 days in advance. The pot roast should have some liquid in the pan to keep it moist. The roast was precooked from a vendor and only sliced by the facility. Once the food was sent to the tray line and plated, the trays were placed on a cart, the cart was sent to the assigned unit, and the carts were placed in a machine to warm/heat the food. Each cart was placed in a machine, and the warming timer was set by dietary staff. The temperature differences may have been due to the food positioning on the plate. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for two (2) of two (2) kitchens (basement and second floor main kitchens), and four (4) of fourteen (14) kitchenettes ([NAME] 13, [NAME] 2, 3, and 4 kitchenettes) reviewed. Specifically, the basement and second floor kitchens had unclean areas, standing water, and appliances in disrepair; [NAME] 3 kitchenette had expired food; [NAME] 2 kitchenette had expired food and undated foods; [NAME] 4 kitchenette had expired food; and [NAME] 13 kitchenette had out of range refrigerator temperature and food, and incomplete temperature logs. Findings include:The undated facility policy Pantry / Freezer Temperature Control, documented it was necessary to monitor the temperatures of the pantry coolers and freezers regularly in order to insure that the food items served to the residents were kept at acceptable temperature levels; a maintenance staff member would check and record the temperature of every pantry cooler and freezer on each floor of the [NAME] and [NAME] buildings daily; and during the remainder of the day, nursing staff would monitor for any changes in temperature and report to a kitchen manager if temperature was above 45 degrees Fahrenheit. Expired food:During an observation on 8/25/2025 at 2:14 the [NAME] 3rd floor kitchenette had two loaves of bread with expiration dates of 7/25/2025 and 8/21/2025 and one loaf of bread with green growth on it. During an observation on 8/25/2025 at 3:12 the [NAME] 2nd floor kitchen had brown bananas and a loaf of bread with an expiration date of 8/2/2025.During an observation on 8/26/2025 at 9:50 AM, the [NAME] 2nd floor kitchenette had one brown banana, two undated turkey subs in the refrigerator, a loaf of bread with an expiration date of 8/2/2025, and one loaf of gluten free bread with no expiration date. During an observation on 8/26/2025 at 9:56 AM the [NAME] 4th floor kitchenette had a breakfast muffin dated 8/13/2025. During an observation on 8/26/2025 at 10:30 AM, the [NAME] 3rd floor kitchenette had two loaves of bread with expiration dates of 7/17/2025; three loaves with an expiration date of 8/23/2025; one loaf with an expiration date of 8/25/2025; and one loaf with an expiration date of 8/21/2025.During an interview on 8/27/2025 at 12:46 PM, Licensed Practical Nurse #8 stated the kitchen stocked the kitchenette with bread and made sure food was not expired. During an interview on 8/27/2025 1:58 PM, Food Service Aide #62 stated they checked for expiration dates, but normally no one else did. The person that brought the bread to the unit was supposed to check the bread before they stocked it. The bananas were too ripe. Expired food including bread and bananas should be thrown out. They were not sure why the bread and bananas were not discarded.Refrigerator Temperatures:The [NAME] Unit 13's cooler/freezer log documented temperatures of 45 degrees Fahrenheit or higher 4 out of 29 days in June 2025;16 out of 30 days in July 2025; and 3 out of 26 documented days in August 2025. Additionally, one day in July 2025 had no documented temperature.During an observation on 8/26/2025 at 4:42 PM, the 13th floor main refrigerator thermometer read 62 degrees Fahrenheit, the surveyor's thermometer read 66 degrees Fahrenheit, and the facility thermometer read 65 degrees Fahrenheit.During an observation on 8/26/2025 at 4:51 PM, the 13th floor refrigerator had four egg salad sandwiches measuring 54 degrees Fahrenheit, and one Magic Cup (frozen nutritional supplement) measuring 56 degrees Fahrenheit. The temperature form for August 2025 had three temperatures of 48 degrees Fahrenheit. During an interview on 8/28/2025 at 10:03 AM, the Food Service Director stated maintenance staff documented the daily temperatures of the kitchenette coolers but was not sure who was responsible for ensuring cold food items were maintained under 41 degrees Fahrenheit. Cold food items were brought up to the units at 41 degrees Fahrenheit or lower. They were not sure why the egg salad sandwiches were in this refrigerator, as it was not common practice to take sandwiches off the food cart and place them into a kitchenette after food service was done. A 54-degree Fahrenheit egg salad sandwich was not acceptable. During an interview on 8/28/2025 at 3:32 PM, the Director of Maintenance stated Maintenance was responsible for testing the air temperatures within the unit refrigerators. Cold food items were supposed to be held between 35 and 41 degrees Fahrenheit. The temperatures of the egg salad and the Magic Cup on the 13th floor were not acceptable. Usually, they reviewed the unit temperature sheets once a month, and if an air temperature was high, they should contact the food service management staff and ask them to take a temperature of a food item in the specific refrigerator and then take it again 15 to 20 minutes later to ensure the refrigerator was working. During an interview on 8/28/2025 at 12:08 PM the Commissary Director stated the commissary kitchen prepared egg salad, and the basement kitchen staff made the egg salad sandwich in the basement kitchen. It was not in their scope of responsibility to check kitchenette refrigerators. The proper cold holding temperature range was 34 to 41 degrees Fahrenheit and a 54-degree Fahrenheit egg salad sandwich was not acceptable.Kitchen Cleanliness:The following observations were made in the basement and second floor kitchens:-on 8/25/2025 between 10:00 AM and 11:00 AM, there was approximately 0.5- 1.0 inch of standing water on the floor where staff were plating food-on 8/26/2025 at 4:16 PM, 12 ceiling tiles had food debris on them. -on 8/26/2025 at 4:27 PM, the second-floor kitchen had duct tape on the milk and juice cooler doors.-on 8/27/2025 at 3:33 PM, there was standing water throughout the main kitchen floor, especially near where food was being plated.-on 8/27/2025 at 3:36 PM, the basement kitchen dish machine was not working or moving and was not clean.-on 8/28/2025 at 10:08 AM, the basement kitchen dish machine contained a large amount of food debris.During an interview on 8/28/2025 at 10:03 AM, the Food Service Director stated they were waiting for conveyor repairs that loaded to the dish machine area. Water was supposed to be fed continuously onto the plates as they were being scraped on the dirty side of dish machine. That was an ongoing issue for a few months. Part of the general closing process was to scrape out any solid foods from the smaller drain area. They were not sure where the water on the floor around the tray line area in the basement kitchen was coming from and it should be cleaned/squeegeed to the nearest drain. Ceiling tiles were cleaned as needed and they were not aware of the stained ceiling tiles and grid in front of the dish machine. They were not sure if any work orders were made for the three chest coolers or how long the duct tape had been on those coolers. During an interview on 8/28/2025 at 3:32 PM, the Director of Maintenance stated they were not aware of milk crate cooler doors being held open by duct tape and had not received any related work orders. Duct tape was not a cleanable surface. Kitchen staff were responsible for cleaning ceiling tiles in the basement kitchen, and the Food Service Director should make sure it was done. The floor should be squeegeed throughout the day by any kitchen staff and standing water was not acceptable. Staff were supposed to lift the conveyor belt and rollers over the trough and fully clean it out every night before they left. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not maintain an effective pest control program so that the facility was free of pests for seven areas (the basement and 2nd floor kitchen, and [NAME] units 3, 5, 6, 8, and 10. Specifically, pest control was not maintained for fruit flies in the basement and 2nd floor kitchen, and [NAME] units 3, 5, 6, 8, and 10.Findings include:The facility policy Pest Control Program, revised 10/5/2017, documented the facility would maintain an on-going pest control program to ensure the building was kept free of insects and rodents. The undated pest sighting/evidence log documented fruit flies/gnats were found throughout the facility between 6/6/2025 and 8/7/2025. The pest control vendor service invoices documented small flies were found throughout the facility from 5/31/2025-8/26/2025. The causes included trash in garbage cans, unclean floor drains, food debris in the dish machine, The following observations of flying insects were made: -On 8/25/2025 between 10:00AM AM and 11:00 AM in the basement and second floor kitchens. -On 8/25/2025 at 1:51PM on 6C near the kitchen elevator. -On 8/26/2025 at 9:17 AM on 8C near the dining room, in front of room [ROOM NUMBER]; at 9:22 AM at the end of the hall near rooms 818-820; at 11:57 AM in the dining room with residents present and staff preparing tables for lunch. -On 8/26/2025 at 10:18 AM in the second-floor kitchen. -On 8/27/2025 at 12:30 PM throughout the second-floor kitchen. -On 8/27/2025 at 1:37 PM in the 10C kitchenette. -On 8/28/2025 at 9:44 AM on 5C in the back of the dining room during the breakfast meal; at 11:20 AM in the hallway across from room [ROOM NUMBER]. -On 8/28/2025 at 10:17 AM in the 10C television room. -On 8/29/2025 at 8:30 AM on 3C in the hallway near room [ROOM NUMBER]. -On 8/29/2025 at 9:22 AM on 8C in the elevator lobby. During an interview on 8/28/2025 at 10:03 AM the Food Service Director stated they were waiting for conveyor repairs to the dish machine area and water was supposed to be fed continuously onto the plates as they were being scraped on the dirty side of the dish machine. This dish machine issue did not help with the fruit flies. The tray line area should be cleaned/squeegeed to the nearest drain. The standing water did not help with the effort to eliminate fruit flies from the facility. Fruit flies were present on the units and basement kitchen for a few months. A vendor came weekly and fogged the kitchen. During an interview on 8/28/2025 at 12:08 PM, the Commissary Director stated there had been fruit flies in the second-floor kitchen since mid-summer. During an interview on 8/28/2025 at 3:32 PM, the Director of Maintenance stated overall, the amount of fruit flies had decreased in the two kitchens throughout the facility, and there was communication on the resident floors to run the water down the drains with chemicals to keep them clear. During an interview on 8/29/2025 at 8:47 AM Housekeeper #17 stated there was an abundance of fruit flies everywhere. During an observation and interview on 8/29/2025 at 9:20 AM, Licensed Practical Nurse #18 stated if they saw pests they tried to take a picture of if or capture it and let housekeeping know about it. As they were speaking a small flying insect circled the top of the medication cart. They stated the insect had been following them all morning with the sweets (applesauce) on their cart. During an interview on 8/29/2025 at 9:28 AM Unit Manager #52 stated pest control was a problem, they were everywhere, and it was annoying to swat at them all the time. During an interview on 8/29/2025 at 12:16 PM the Director of Housekeeping stated they were notified of fruit flies and saw fruit flies in the building. The pest control vendor came every Tuesday and whenever needed. 10NYCRR 415.29(j)(5)

Based on record review and interviews during the recertification and abbreviated (NY00375455/iQIES 446000) surveys conducted 8/25/2025-8/29/2025 the facility did not ensure allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated to prevent further potential abuse and mistreatment for one (1) of eight (8) residents (Resident #50) reviewed. Specifically, Resident #50 sustained injuries of unknown origin with unexplained bruising to the head, shoulder, and upper chest that was not thoroughly investigated to rule out abuse or mistreatment. Additionally, the resident's injuries of unknown origin were not reported to the New York State Department of Health within 24 hours as required. Findings include: The facility policy Adverse Incidents and Incident Reports, dated 10/21/2024, documented an injury of unknown origin was an injury with no known incident of origin and after investigating, abuse or care plan violation could not be ruled out. Injuries of unknown origin were reported to the Assistant Director of Nursing, the Director of Nursing, and the Administrator. The Administrative staff followed on-line reporting procedures and notified the Department of Health as the internal investigation was being conducted. The New York State Department of Health Nursing Home Incident Reporting Manual dated 8/2016 documented an injury of unknown origin was when both of the following conditions were met:-The source of the injury was not observed by any person and the source of the injury could not be explained by the resident.-The injury was suspicious because of the extent or location of the injury, or the number of injuries observed at one particular point in time, or incidences of injuries over time. The following two elements must be present for an incident to be reportable to the New York State Department of Health:-Injury without known incident.-The facility was unable to rule out abuse of care plan violations.Incidents resulting in serious bodily injury must be reported within two hours after forming a suspicion; all other incidents must be reported within 24 hours. Resident #50 had diagnoses including dementia and osteoporosis (weak, fragile bones). There was no documented diagnosis of thrombocytopenia (a medical condition which may cause increased bruising/ bleeding). The 3/6/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not have behavioral symptoms, did not exhibit wandering, and required supervision for walking and transfers. Interventions included in the event of a fall monitor/document/report as needed to physician pain or bruises. The Comprehensive Care Plan initiated 9/17/2024 and revised 3/27/2025 documented the resident had a right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Interventions included all staff would immediately report to their supervisors any suspected or witnessed incidents of abuse. The resident was at risk for falls related to poor safety awareness. The 3/11/2025 at 8:41 AM Licensed Practical Nurse Unit Manager #33 incident note documented bruising was noted by staff to the resident's right shoulder and right chest while providing morning care. Range of motion was at baseline for the resident and pictures were uploaded for weekly monitoring. There were no signs of pain or discomfort noted but they would administer as needed Tylenol due to the resident's inability to verbalize discomfort. An investigation was initiated. There was no documented evidence the resident was assessed by a registered nurse when the bruising was discovered. The 3/11/2025 Investigation Report completed by Licensed Practical Nurse Unit Manager #33 documented:- at 8:30 AM, bruising was noted to the resident's right shoulder and the right chest by staff while providing morning care. The resident's son was on the unit to wash the resident's hair and brought an area of bruising on the resident's right top of head, above their ear and towards their forehead to Licensed Practical Nurse Unit Manager #33's attention. -The investigation conclusion was obtained through staff statements and interviews and information in the chart. -The Certified Nurse Aide #34 statement for the investigation of injuries of unknown origin documented they were assigned the resident, the incident was unwitnessed, and they noticed the bruising during morning care. There were no patterns of activities or behaviors that could have contributed to the incident.-The Certified Nurse Aide #35 statement for the investigation of injuries of unknown origin documented they were not assigned the resident, and they did not witness the incident. The resident was unsteady on their feet and could have walked into the wall. -Certified Nurse Aides #36, #37, and #38 statements documented they were not assigned the resident, and they did not witness the incident. There were no patterns of activities or any behaviors that could have contributed to the incident. It was unknown if anyone else was involved in the incident. -The investigation conclusion documented the residents ambulated around the unit independently and the resident could have accidently bumped self on the edges of the doors while ambulating due to poor safety awareness. It was reasonable to say that no abuse, neglect, or mistreatment took place, all care plan interventions were in place, and no policy and procedure violations were noted. There was documented evidence how abuse, neglect, or mistreatment was ruled out with bruising to multiple areas on the resident's body. A 3/11/2025 at 8:53 AM Licensed Practical Nurse #33 progress note documented the resident was observed scratching their face which left bruising with small scratches along the left jaw line. The physician assistant and family were made aware. The 3/11/2025 Skin and Wound Evaluation documented the following new wounds:-Bruise to right lateral front scalp measuring 16 centimeters squared; 7.6 centimeters long by 2.8 centimeters wide.-Bruise to right chest measuring 60 centimeters squared; 14.3 centimeters long by 6.8 centimeters wide.-Bruise to right shoulder measuring 40 centimeters squared; 10.4 centimeters long by 5 centimeters wide.-Bruise to left jaw measuring 1.4 centimeters squared; 3.7 centimeters long by 1.3 centimeters wide.The 3/12/2025 Physician Assistant #32 acute visit progress note documented they were asked by nursing staff to evaluate the patient today due to multiple new areas of ecchymosis (bruising). Per nursing staff ecchymosis of the right shoulder and right chest increased and the patient seemed to be uncomfortable today. There was no documented fall or injury per the Nurse Manager. The Nurse Manager was suspicious the resident may have walked into a doorway. Per nursing staff, the resident's mentation was at baseline. Nursing staff had no further behavioral or symptomology concerns at the time of the assessment. They were unable to obtain a review of symptoms from the patient's own statement due to cognitive impairment. On exam, there was diffuse ecchymosis across the right anterior chest, anterior shoulder and posterior aspects of the shoulder. Tenderness was noted to the anterior shoulder and clavicular. Range of motion was guarded in all planes. The 3/12/2025 right shoulder radiology report (X-ray) documented a nondisplaced incompletely healed right lateral clavicular (collarbone) fracture. There was no documented evidence the resident's unexplained bruising to the head, shoulder, and upper chest, and was reported to the New York State Department of Health within 24 hours as required. The 3/13/2025 Licensed Practical Nurse Unit Manger #33 progress note documented x-ray results were discussed with the resident's daughter; they were made aware of the sentinel event investigation, the therapy evaluation requests, and pain control interventions. They voiced understanding and agreed with the plan. The 3/19/2025 New York State Complaint (NY00375455/ iQIES 446000, not a facility reported incident) intake information documented the resident's bruising was quite extensive and involved the resident's breast and arm as well. The resident was a memory care resident and could not tell the complainant what had happened. The complainant reported the facility had given an incomplete picture of how this injury occurred. During an interview on 8/29/2025 at 9:24 AM, Licensed Practical Nurse Unit Manager #33 stated on 3/11/2025 they were notified by (former/retired) Certified Nurse Aide #34 the resident had bruises that were discovered during morning care. The bruising was quite extensive. There was no way to determine where the bruising came from. The Accident Incident Report was investigated as an injury of unknown origin. The resident wandered the unit at that time and could only answer yes and no questions. Assistant Director of Nursing #31 should have reviewed the Accident and Incident report and was responsible to determine if it needed to be reported. There were time limits to reporting but they were not certain of them. The were not sure of the conclusion of the investigation.During an interview on 8/29/2025 at 2:34 PM, the Director of Nursing stated abuse, neglect, mistreatment, and care plan violations were reported to the Department of Health. They or one of the three Assistant Directors of Nursing, or the Administrator were responsible for reporting. They referenced the New York State Department of Health Nursing Home Incident Reporting Manual. The 3/11/2025 incident with Resident #50 was an injury of unknown origin because it was not witnessed. It was decided that the bruising occurred because of the resident's usual activities and did not need to be reported. Because the resident could not speak to what had happened and there were no witnesses, there was no real way of knowing what caused the bruises. The bruising was extensive, but the resident bruised easily because the resident had thrombocytopenia (a medical condition which may cause increased bruising/ bleeding). They just had to go by the whole picture and the statements that were provided. Licensed Practical Nurse #33 did the investigation and then it went to the Assistant Director of Nursing #31 for review and then they did the final sign off. The determination of whether it needed to be reported was made initially because it was time sensitive. The conclusion was the resident likely bumped into something because they did not have behaviors or exhibit aggression and therefore it did not need to be reported. The x-ray showed a partially healing clavicular fracture, so it was not acute, and that was discovered after the investigation was completed. During an interview on 8/29/2025 at 2:57 PM, Assistant Director of Nursing #31 stated injuries of unknown origin were only reported if you could not rule out abuse. Resident #50 was ambulatory and had thrombocytopenia and bruised easily. They ruled out abuse because it was determined the resident either bumped into something or leaned up against something and that would have had a significant bruising effect on them. They did not feel the incident was reportable. 10NYCRR 415.4

Based on observations, record review, and interview during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure residents were provided the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living including functional communication systems for one (1) of one (1) resident (Resident #63) reviewed. Specifically, Resident #63's primary language was not English, and they were not provided with translation services. Findings include: The facility policy Resident Rights and Notice of Resident Rights and Responsibilities, dated 4/30/2024, the facility informed the resident of their rights and responsibilities in a language that was understandable to the resident. If the resident had limited English proficiency, their rights and responsibilities were presented in the resident's primary language. For foreign languages commonly encountered in the community, the facility provided the resident with written translations of their rights and responsibilities and if not common to the community, rights were communicated orally through a competent interpreter.The facility policy Translation and/or Interpretation of Facility Services, dated 4/29/2019, documented individuals with limited English proficiency had meaningful access to information and services provided by the facility. Prior to admission, the admissions representative identified a language barrier. If an interpreter was needed, the unit social worker was notified to arrange services. All persons were informed of their rights to obtain competent oral translation services free of charge. Family members and friends were not relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. Resident #63 has diagnoses including diabetes, low back pain, and need for assistance with personal care. The 6/26/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, spoke a language other than English and needed or wanted an interpreter to communicate with a doctor or health care staff, and was dependent for most activities of daily living. The Comprehensive Care Plan initiated 11/5/2021 and revised 3/14/2022 documented the resident had a communication problem related to English being a second language with advancing dementia. Interventions included a translator was provided as necessary to communicate with the resident. The following observations were made of Resident #63:-On 8/25/2025 at 10:42 AM, lying in bed in a hospital gown, the call bell was on the floor under the bed. Verbal engagement was attempted, the resident just smiled and stated their name. They did not answer any questions. -On 8/26/2025 at 10:46 AM, seated in their high back wheelchair in the common area with other residents around flipping through a magazine.-On 8/27/2025 at 1:49 PM, lying in bed on their back with their eyes open. The room was silent; the television was off. Their call bell was under their pillow.-On 8/28/2025 at 9:43 AM, seated in their high back wheelchair, sleeping, in the common area with other residents around. At 1:39 PM, seated in their high back wheelchair in their room. Certified Nurse Aide #43 entered their room with a mechanical lift. There was no conversation between the resident and the certified nurse aide. At 1:42 PM, Certified Nurse Aide #43 exited the room. At 2:21 PM, Licensed Practical Nurse #42 and Assistant Director of Nursing #39 entered the room with washcloths. At 2:22 PM, Assistant Director of Nursing #39 exited the room. At 2:34 PM, Licensed Practical Nurse #42 stated Assistant Director of Nursing #39 came in to take a picture of the resident's healed thigh wound. They stated they applied nystatin (antifungal) under the resident's breasts and in their abdominal folds. During a telephone interview on 8/29/2025 at 9:51 AM, the resident's family member stated the resident did not speak any English. They visited the resident every weekend. They stated staff did not engage with the resident and there was no way for staff to communicate with them. They never saw staff use any translation services. When they came to visit, the resident was able to verbalize their needs to them in their primary language. They were able to converse with them during visits because they spoke the language. The resident was often soiled with urine and/ or feces and often stated they were hungry.During a telephone interview on 8/29/2025 at 10:03 AM, a second family member stated the resident did not speak any English. They visited once a week. The resident was often soiled when they came, and they told staff the resident needed their incontinence brief changed. The resident could not care for themselves. When they visited, they translated the resident's needs to the staff. They had never seen a translation service used. During an interview on 8/29/2025 at 10:43 AM, Certified Nurse Aide #43 stated Resident #63 understood English but did not speak it. They communicated with them through hand gestures. They thought the phone they used for charting had a translation application but could not recall when they used it last. The resident could point to what they wanted. During an interview on 8/29/2025 at 11:50 AM, Licensed Practical Nurse #42 the resident could say and understand some English words such as good morning and thank you but spoke a different language. They told the resident what they were doing but was not sure what they understood. Family came to visit and translated the residents needs. They were not sure if the facility had access to an interpreter. During an interview on 8/29/2025 at 12:02 PM, Licensed Practical Nurse Assistant Unit Manager #41 stated Resident #63 spoke a foreign language. The resident understood some English and would say good morning. If they asked the resident a question, they spoke in their native tongue. They did not know what the resident was saying. There was a phone number for a translation service, but they did not know what it was. They did not know why translation services were not being used but they had never utilized the service. Social work and nursing were responsible to determine an effective means of communication.During an interview on 8/29/2025 at 12:21 PM, the Director of Social Work stated determining an effective means of communication started on admission. The admissions team told social work and nursing if the resident had a primary language other than English. The facility had a contract with an interpreter service. The resident had been at the facility for years and they did not know why staff was not using the service. It was important to have effective communication to meet the resident's needs, and so they could participate in their care. 10NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not provide ongoing programs to support each resident in their choice of activities for one (1) of one (1) resident (Resident #10) reviewed. Specifically, Resident #10 was not offered meaningful activities that included their interests and preferences. Findings include: The facility policy Recreation Goals and Objectives, updated 12/10/2019 documented the recreation department provided comprehensive recreational programming for all residents. A blend of diversional/therapeutic pursuits played a key role in providing a balance between fun/pleasure and restoration/maintenance of functional skills. It was the departments policy to provide opportunities for voluntary involvement in recreational interests/activities within both the facility and community. Resident #10 had diagnoses including autistic disorder, cardiac arrest (heart attack), and anoxic brain damage (brain is deprived of oxygen). The 8/14/2025 Minimum Data Set documented the resident had severe cognitive impairment, did not have physical or verbal behaviors, did not reject care, was dependent on staff for all activities of daily living. The 02/12/2025 Minimum Data Set documented the resident preferred reading books, newspapers, magazines; listening to music; participating in favorite activities; spending time outdoors; and participating in religious activities or practices. The Comprehensive Care Plan initiated 9/20/2021 and updated 2/26/2025 documented the resident was independent in choosing leisure activities with support from staff meeting emotional, cognitive, physical, and social needs related to an anoxic brain injury, autism, and other medical conditions not specifically noted. Interventions included ensuring activities attended were comparable with the resident's interest and age appropriate. The resident needed 1:1 in room visits and activities if not able to attend out of room events. The resident preferred Black Entertainment Television, Music Television, The Fresh Prince, music, and going outside. The 5/27/2025 quarterly Recreation Assessment documented the resident did not participate in any group activities. 1:1 activity interests included music, hearing stories, and going outside. The resident enjoyed watching television on the Black Entertainment Television channel, The Fresh Prince, and anything with actor Will [NAME]. When the resident looked away for a long period of time, that was the que they were done with the visit. The recreation activity log for June documented individual engagement with Recreational Therapist #27 was provided:-on 6/2/2025 -on 6/9/2025-on 6/23/2025 -on 6/30/2025 The recreation activity log for July documented individual engagement with Recreational Therapist #27 was provided:-on 7/4/2025 -on 7/7/2025-on 7/14/2025 -on 7/21/2025 -on 7/28/2025The recreation activity log for August documented individual engagement with Recreational Therapist #27 was provided:-on 8/25/2025 -on 8/28/2025 The following observations of the resident were made:-on 8/25/2025 at 12:31 PM sitting alone in their room in a chair in front of the television with a crime show playing. -on 8/28/2025 at 10:07 AM in bed sleeping. They smiled when asked if they liked the Actor Will [NAME] and again when asked if they liked the Fresh Prince. When asked if they could see the television from their bed they frowned. When asked if they liked what was playing on the television they frowned and closed their eyes. During an observation and interview on 8/28/2025 at 10:45 AM, Certified Nurse Aide #11 stated the resident did not communicate verbally and smiled/frowned and shook their head to communicate. They never saw activities working with the resident and the resident loved when staff came in the room and interacted with them. Resident #10 smiled. The resident was transferred from the bed to a chair that was placed parallel to the bed and staff left the room with the television out of view for the resident. During an interview on 8/28/2025 at 11:00 AM, Resident #10 was asked if they could see the television and they attempted to turn their head towards the television and frowned. They were asked if they liked music and smiled and frowned when asked if they liked the show playing on the television. During an interview on 8/29/2025 at 9:09 AM, Licensed Practical Nurse #11 stated Recreation Therapist #27 worked with residents to engage them in activities like trivia, coloring, and ice cream time. Resident #10 did not refuse care. They never saw Recreation Therapist #27 do an activity with Resident #10. They stated they cared for the resident after they were out of bed on 8/28/2025 and the positioning of the chair did not allow the resident to view the television. They liked to watch The Fresh Prince and listen to music. There used to be a video of many Fresh Prince episodes the resident watched continuously but they were not sure what happened to the video. During an interview on 8/28/2025 at 1:12 PM, Director of Recreation #63 stated they were responsible for making sure the resident floors had planned events and activities. Activities were important for the residents to have fun, and residents had the opportunity to relax and decrease their stress level. They offered a variety of activities that included exercise, dance, movies, BINGO, rosary, holy hour, mass, pizza day and taco Tuesday every month. Additionally, they did 1:1 activities with residents that were more confined to their rooms. The activities were documented in the electronic medical record by the recreation therapist. They expected each resident to be offered an activity at least once a week, but it should be three times a week. After looking at the electronic record for Resident #10 they stated they expected more 1:1 and group activities offered to the resident. During an interview on 8/29/2025 at 2:44 PM, Recreation Therapist #27 stated they were the assigned recreation therapist for the resident's floor. Recreation therapy was important to residents because it brought joy and independence to residents, gave them something to do, and worked on emotional, spiritual, and cognitive needs. They did one activity daily Monday thru Friday, and activities rotated between three floors on the weekends. They offered both group and independent activities with the residents and activities were offered at least twice a week, but they tried for three times a week. Resident #10 loved activities like watching anything with Will [NAME] and the Fresh Prince, rhythm and blues music, as well as going outside. They forgot to include or offer any activities in August prior to 8/25/2025 including 1:1 activities for Resident #10 and they had been on vacation. Activities should have been offered to the resident in their absence. 10NYCRR 415.5(f)(1)

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (1) of three (3) residents (Resident #546) reviewed. Specifically, Resident #546's bilevel positive airway pressure machine (a noninvasive ventilator that helps with breathing) was not cleaned as ordered and had brown debris in the mask. Findings Include: The facility policy Bilevel positive airway pressure, Continuous positive airway pressure Trilogy, effective 2/2020 documented non-invasive ventilator support was provided to patients with compromised airways or chronic pulmonary/cardiac diseases. Use of the machine required a physician's order, and the respiratory therapist was notified when used. The facemask was cleaned daily with sterile water and left to dry. The tubing was cleaned weekly with sterile water and left to dry. Resident #546 had diagnoses including obstructive sleep apnea (pausing of breathing during sleep, chronic respiratory failure with hypoxia (low level of oxygen in the blood), and chronic obstructive pulmonary disease (restricted airway). The 8/12/2025 Minimum Data Set assessment documented the resident had intact cognition and used bilevel positive airway pressure therapy. The Comprehensive Care Plan initiated 8/6/25 and updated 8/7/2025 documented the resident had actual/potential for altered respiratory status/difficulty breathing related to acute and chronic hypercapnic (elevated carbon dioxide levels in the blood), chronic obstructive pulmonary disease, and respiratory failure. Interventions included the use of oxygen at four liters by nasal cannula and continuous positive airway pressure/bilevel positive airway pressure therapy. The undated resident care instructions documented use of continuous positive airway pressure/bilevel positive airway pressure therapy. The 8/6/2025 Physician #10 order documented bilevel positive airway pressure therapy at bedtime. During an observation on 8/25/2025 at 11:58 a bilevel positive airway pressure machine was in Resident #546's room. The inside of the mask had brown debris in the base. During an observation on 8/27/2025 at 4:14 PM Resident #546 was in bed sleeping using their bilevel positive airway pressure therapy. The mask covered their nose and mouth, and the base of the mask contained brown debris. During an interview on 8/28/2025 at 8:45 AM, Resident #546 was in the dining room and stated at home they cared for their bilevel positive airway pressure machine, cleaned the facemask and put distilled water in the chamber daily. They did not clean the machine in the facility as staff was responsible for cleaning the machine. They used the therapy every night and when they napped during the day. The mask was dirty, and they wanted it cleaned. During an observation on 8/28/2025 at 8:48 AM the bilevel positive airway pressure mask contained brown debris throughout the mask. The Treatment Administration Record documented clean bilevel positive airway pressure equipment with sterile water and let dry every day shift clean BiPAP face/nasal mask cushion. Signed off every day in August. Licensed Practical Nurse #12 signed off as completing 8/25, 8/26, 8/27, and 8/29/2025.During an interview on 8/28/2025 at 8:50 AM, Certified Nurse Aide #11 stated they were not allowed to touch bilevel positive airway pressure machines, and the nurses were responsible for all care related to bilevel positive airway pressure therapy. During an interview on 8/29/2025 at 10:52 AM, Licensed Practical Nurse #12 stated use of bilevel positive airway pressure therapy required a physician's order. Once the order was entered, use and cleaning was documented on the treatment administration record. They were only responsible for cleaning the mask daily to limit the potential for infection and ensured distilled water was in the compartment for humidification. Respiratory Therapy was responsible for all other care regarding the therapy. They worked 8/25-8/27 and again 8/29 and did not clean the mask. On 8/25/2025 the resident was wearing the mask all day, and they forgot to clean it every other day they worked. They signed off they cleaned the mask and should not have and stated they were going to clean it because it had a lot of brown debris in the mask. During an interview on 8/29/2025 at 8:57 AM, Respiratory Therapist #6 stated they were notified when residents were admitted to the facility using bilevel positive airway pressure/continuous positive airway pressure therapy. They were responsible for putting in the order and the initial assessment of the machine. Nursing was responsible for cleaning the mask daily because nasal and saliva drainage collected in the mask and facial oils could breakdown the mask. It was an infection control issue, and the mask could lose durability. They gave the resident a new machine when they were admitted because the machine they came with was too dirty to use. After looking at the mask they stated it was filthy and needed cleaning. During an interview on 8/29/2025 at 11:37 AM, Registered Nurse Unit Manager #9 stated a physician's order was required for bilevel positive airway pressure/continuous positive airway pressure. The order created a template that automatically populated on the treatment administration record so the nurse would know when to clean the facemask, when to change the tubing, and when to clean the continuous positive airway pressure. Resident #546 was admitted to the facility and utilized bilevel positive airway pressure therapy. They expected masks to be cleaned as ordered for infection control reasons. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure pain management was provided to residents who required such services consistent with professional standards of practice for one (1) of one (1) resident (Residents #21) reviewed. Specifically, Resident #21 did not have their prescribed pain patch placed as ordered and they did not have the effectiveness of their pain treatment documented.Findings include:The facility policy Pain Assessment, Management, and Evaluation, dated 12/16/2024, documented the resident would receive appropriate and timely assessment, evaluation, and treatment with pain-relieving drugs, adjunctive drugs, and non-drug therapies as needed and in accordance with best practice standards. Pre-pain assessment and post administration pain assessment must be completed on all pain medications in the indicated areas. In the Electronic Medical Record when an order was written for a routine pain medication, the order automatically triggered a pre pain level to be documented. An additional order must be written labeled routine post that would trigger a post pain level to be documented. The facility policy Medications: Ordering Process, dated 4/29/2025, documented the residents' need to receive medications in a timely basis was the facility's priority. Medications were to be ordered to maintain an adequate supply for a 48-72-hour supply available. Medications were not to be circled as unavailable. Medication was to be obtained via the electronic via the electronic interim box or call the pharmacy to have the medication sent from the backup pharmacy. The floor nurse was responsible to order floor stock medications from the ordering company.Resident #21 has diagnoses including spondylopathy (degeneration of the lower spine), postherpetic neuralgia (damage to the nerves from shingles), and osteoarthritis (joint disease). The 8/7/2025 Minimum Data Set documented the resident was cognitively intact, was on scheduled pain medication, received non-medical interventions for pain, and had moderate pain. The 8/16/2025 Comprehensive Care Plan documented the resident had acute/subacute/chronic pain related to history of herpes zoster and postherpetic neuralgia, osteoarthritis, and bilateral lower edema. Interventions included to monitor, document, and report to the nurses any complaints of pain or requests of pain treatment from the resident, notify the physician if interventions were unsuccessful or if the complaint was a significant change from the resident's past experiences of pain, observe and report changes in the resident's routine, and provide the resident and their family with information about pain and options available for pain management, and document the discussed preferences.The 6/9/2025 physician order documented apply a lidocaine pain relief external patch 4% (topical pain patch) to the right lower extremity and back topically one time a day for pain; please put on in the morning and remove 12 hours later at 8:00 PM. There was no documented pre- and post-administration pain scale related to the lidocaine pain relief patch. The August 2025 Medication Administration Record documented on 7/22/2025, 7/23/2025, and 7/24/2025 the lidocaine patch was not administered and to see the nurses' notes. The 7/22/2025, 7/23/2025, and 7/24/2025 Order Administration Notes (nursing notes) documented the resident's lidocaine pain patch was out of stock. During an interview on 8/26/2025 at 9:28 AM, Resident #21 stated quite often the facility was out of the pain patches for their back and they recently went four days without it. The nurse from the day before had to get them from another floor. During a follow up interview on 8/27/2025 at 2:01 PM, Resident #21 stated they had osteoarthritis in their hands, knees, and back and they were in pain all the time. Their lidocaine patch was not applied in a few days as the supply was not ordered in time. They stated they went without the patch, and they had a lot of back pain. During an interview on 8/28/2025 at 11:03 AM, Central Supply Staff #45 stated it was their responsibility to deliver all supplies to the units. The units would call down and leave messages for what they needed, and they delivered it. They stated lidocaine patches at 4% were kept as a regular stock item. The unit secretaries called them with the quantity of patches they needed. If it was a weekend and something was needed, the supervisor and security had a key to Central Supply. During an interview on 8/28/2025 at 11:20 AM, Licensed Practical Nurse #46 stated Resident #21 was evaluated for pain by interview. It was documented under vitals but Resident #21's pain levels had not been documented since June. The resident should have been evaluated for their pain. They were supposed to reapproach the resident after pain intervention administration to see if it was effective. Usually, a resident had a pop up on their Medication Administration Record to record the effectiveness of the intervention, but Resident #21 did not. During an interview on 8/28/2025 at 11:31 AM, Licensed Practical Nurse Unit Manager #47 stated if a medication was an over-the-counter stock medication it came from Central Supply. The unit secretary normally called Central Supply to obtain a needed stock medication. Lidocaine patches were stock medication. If a resident ran out of lidocaine patches, they would be obtained from central supply. If it was a weekend, the nurse should call the supervisor. If the facility was out of lidocaine patches, the provider should be notified. Resident #21 went three days without a lidocaine patch. They did not know why Resident #21 had missed three days of patches. Typically, a resident had a supplementary pain scale entered when they had a pain intervention order. The nurses documented pain evaluations under vital signs, and the resident did not have any documented that month. 10NYCRR 415.12

Based on observations, record review, and interviews during the recertification survey conducted 8/25/2025-8/29/2025, the facility did not ensure that residents who required dialysis (treatment to filter waste products from the blood when the kidneys do not work) received such services consistent with professional standards of practice for two (2) of two (2) residents (Residents #7 and #336) reviewed. Specifically, Residents #7 and #336 did not have pre-and post-dialysis assessments as ordered. Findings include:The facility policy Dialysis Care, dated 4/2025, documented residents receiving dialysis were to have a care plan and all dialysis observations, assessments, and care must be documented in the medical record on each dialysis day prior to dialysis and upon return. The order set and template were to be added to the resident's orders which included the Dialysis: Daily Observation/Assessment and interfacility transfer report order. The Dialysis Observation/Assessment was completed on each dialysis day, prior to dialysis and upon return. 1) Resident #7 had diagnoses including end stage kidney disease, dependence on renal dialysis, and dementia with behavioral disturbance. The 7/9/2025 Minimum Data Set assessment documented the resident was cognitively intact, had no behaviors, and was on dialysis. The 4/5/2023 Comprehensive Care Plan documented the resident received hemodialysis related to renal failure with an arteriovenous fistula (connection between an artery and a vein used for dialysis access) in the right upper arm and attended dialysis on Tuesday, Thursday, and Saturday at 11:15 AM. Interventions included to monitor the resident's vital signs and monitor, document and report any signs of infection to the access site, renal insufficiency, peripheral edema, and bleeding. The 5/2/2025 physician order documented to complete the dialysis assessment before and after dialysis two times a day every Tuesday, Thursday, and Saturday. Go into the resident's clinical chart, under assessments tab, select new, select Dialysis Observation/Assessment and complete. The resident's July 2025 and August 2025 Medication Administration Record documented the pre-and post-dialysis assessments were completed every Tuesday, Thursday, and Saturday except for post-dialysis on 8/26/2025 when the resident was not available. The resident's electronic medical record documented: -July 2025: one pre-dialysis assessment on 7/17/2025 and two post-dialysis assessments on 7/8/2025 and 7/10/202025. -August 2025: one pre-dialysis assessment on 8/23/2025 and two post-dialysis assessments on 8/7/2025 and 8/28/202025. There was no documented evidence the resident had consistent pre and post dialysis assessments three times a week on dialysis days as ordered. During an interview on 8/29/2025 at 12:39 PM, Licensed Practical Nurse #22 stated if a resident went to dialysis on their shift, they should obtain vital signs before and after dialysis, fill out the dialysis communication form in the resident's dialysis book to send with them, check the dialysis site, and check the communication book form when the resident returned. The dialysis communication form should be filled out prior to dialysis and then reviewed upon return from dialysis. The pre- and post-dialysis assessments were recorded on the communication form for pre-dialysis and on the treatment administration record or a progress assessment when the resident returned from dialysis. If the pre- and post-dialysis assessments were marked as completed in the medication administration record it meant the nurse got the vital signs, filled out the communication form, and the dialysis site was fine. The pre-assessments they completed for dialysis were marked on the communication form. During an interview on 8/29/2025 at 1:39 PM, Registered Nurse Unit Manager #54 stated when a resident went to dialysis, the licensed practical nurse should obtain their vital signs, record them on the dialysis communication form, check the dialysis site, and send the communication book with the resident to dialysis. Upon return from dialysis, the licensed practical nurse should assess the resident's dialysis site and dressing, obtain vital signs, document the vital signs in the treatment administration record and the dialysis assessment, and check the dialysis communication book to ensure there were no issues. The licensed practical nurses were supposed to complete pre- and post-dialysis assessments. If pre- and post- dialysis assessments were signed off as completed in the medication administration record, they should have been completed. They did not review if assessments and the communication book sheets were completed. They did a medication administration record and treatment administration record audit looking for blank boxes to indicate the assessments were not completed. They were unaware most of Resident #7's pre- and post-dialysis were not completed for July and August 2025. The assessments should be completed as it was an order. 2) Resident #336 had diagnoses including end stage kidney disease and dependance on renal dialysis. The 8/17/2025 Minimum Data Set assessment documented the resident had intact cognition, had end stage renal disease, and received dialysis. The Comprehensive Care Plan initiated 7/8/2025, documented the resident had renal insufficiency related to end stage renal disease. Interventions included dialysis, dietary consultation, and lab work. The 6/28/2025 Medical Director #10 order documented hemodialysis Tuesday, Thursday, and Saturday at 7:05 AM with 6:00 AM pick up. The 8/18/2025 Nurse Practitioner #65 progress note documented Resident #10 was examined with diagnosis including chronic kidney disease and end stage renal disease. The resident was sent to the hospital on 6/23/2025 because their fistula (connection between an artery and vein used for dialysis) malfunctioned. They previously had a fistula revision on 5/12/2025. There was no documented vital signs or assessment documented on the dialysis interfacility transfer patient report for June, July, or August 2025. During an observation and interview on 8/25/2025 at 11:15 AM, Resident #336 stated they went to dialysis Tuesday, Thursday, and Friday and went with a communication book. The nurse took their vital signs and documented them on a paper that was put in their book for the dialysis center. The book contained the 8/21/2025 sheet and they were not sure where the August sheets were if they were not in the book. During an observation on 8/29/2025 at 9:41 AM Resident #336's dialysis communication book included only documentation for pre dialysis on 8/21/2025 and 8/26/2025. During an interview on 8/29/2025 at 9:41 AM, Registered Nurse Unit Manager #9 stated residents that received dialysis had vital signs completed and documented in a communication book before leaving for dialysis and when they returned. The nurse documented any new issues with the resident, any medications the resident received prior to dialysis, any issues with the fistula, and if applicable the status of the portacath (implanted device for long term access to the vein) dressing. When the resident returned vital signs were taken and the fistula and/or partacath site were assessed and documented on the sheet in the communication book. They expected this to be completed on all dialysis residents. Resident #336 received dialysis and should have all the documentation in the dialysis book. They stated only the 8/21/2025 and 8/26/2025 sheets were in the book and lacked documented post dialysis information. They were not sure where the remainder of the sheets were or why the post dialysis assessments were not documented. During an interview on 8/29/2025 at 12:12 PM, Licensed Practical Nurse #12 stated when a resident received dialysis vital signs were taken before and after dialysis. The purpose of the communication book was for dialysis to know what medications the resident had taken and if they were stable to receive dialysis. They had one resident that received dialysis, Resident #336. They only thing they did when the resident returned from dialysis was take vital signs. They did not look at the fistula or the portacath or document anything in the communication book because it was only used by the shift that sent the resident to dialysis. 10 NYCRR 415.12(K)

Based on observations, interviews, and record review during the recertification survey conducted 8/25/2025-8/29/2025, the facility did establish and maintain an infection 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 one (1) of five (5) residents (Resident #282) reviewed. Specifically, Resident #282 was on enhanced barrier precautions and Certified Nurse Aides #56 and #57 did not wear proper personal protective equipment while performing care. Findings included:The facility policy Infection Prevention and Control Program for Long Term Care Facilities, dated 10/30/2024, documented the program was to systematically identify and reduce the risk of acquiring and transmitting infections among residents, visitors, and healthcare workers. Employees were to adhere to all policies and procedures related to infection control.The facility policy Enhanced Barrier Precautions, dated 1/28/2025, documented Enhanced Barrier Precautions were an infection control intervention to reduce transmission of resistant organisms by employing gown and glove use during high contact resident care activities. Staff were required to use gown and gloves during high-contact resident care to prevent the transmission of organisms. Those activities included dressing, bathing, toileting, and providing hygiene. This type of precautions would be used for any resident with an indwelling medical device or wound.Resident #282 had diagnoses including right below knee amputation. The 8/21/2025 Minimum Data Set assessment documented the resident had intact cognition; was dependent for mobility, toileting hygiene, bathing, and dressing; required moderate assistance for personal hygiene; was occasionally incontinent of bladder; frequently incontinent of bowels; had an unstageable pressure ulcer; and had surgical wounds. The 6/25/25 revised Comprehensive Care Plan documented the resident required enhanced barrier precautions related to below knee amputation. Interventions included ensure personal protective equipment, gowns, gloves, and alcohol-based hand rub were readily accessible to staff near or outside the resident's room; trash can was placed inside the room near the exit for discarded personal protective equipment; physician order in place for enhanced barrier precautions; special instructions updated to reflect need for enhanced barrier precautions; enhanced barrier precautions signage outside of the resident's room; and personal protective equipment required when performing high contact resident care activities. The 8/26/2025 Kardex (care instructions) documented special instructions of enhanced barrier precautions related to a wound. During an observation on 8/27/2025 at 1:37 PM, Resident #282's room had two Enhanced Barrier Precautions signs on the wall next to the doorway. Certified Nurse Aides #56 and #57 were performing personal hygiene and positioning the resident. The aides wore gloves and did not wear surgical gowns while performing care The aides left the room at 1:40 PM. During an interview on 8/28/2025 at 10:27 AM, Licensed Practical Nurse #20 stated the resident was on enhanced barrier precautions due to an open area. Facility staff were educated on precautions and personal protective equipment yearly and as needed. The purpose of precautions was to prevent the transmission of germs from a resident to staff or another resident. Staff should wear a gown and gloves while performing resident care. The nurse stated they looked into the room when the aides were performing care and neither aide was wearing a gown. During an interview on 8/28/2025 at 10:46 AM, Certified Nurse Aide #56 stated they received infection control education including personal protective equipment education in the past. Personal protective equipment should be worn to prevent the transmission of diseases. Any room where that equipment was required had a sign on the doorway. The required personal protective equipment was stationed near that room. They stated Resident #282 was on precautions and staff should wear a gown and gloves while performing care. They stated they forgot to put it on prior to caring for the resident. During an interview on 8/28/2025 at 11:05 AM, Registered Nurse Manager #21 stated Resident #282 had an open wound and was on enhanced barrier precautions. Staff should wear a gown and gloves while performing direct resident care to prevent cross-contamination of germs. During an interview on 8/28/2025 at 4:06 PM, the Registered Nurse Infection Preventionist stated the expectation of enhanced barrier precautions was when staff performed direct resident care, they wore gowns and gloves. Staff knew what type of precautions a resident was on as it was documented in the resident record, a sign was on the doorway, and the appropriate personal precaution equipment was stored outside the resident's door. The resident should have a physician order for the type of isolation precautions needed. Personal protective equipment for enhanced barrier precautions included a gown and gloves while performing direct resident care. 10NYCRR 415.9(a)(b)

49831 Based on observation, record review, and interview during the recertification survey conducted 4/15/2024-4/23/2024 the facility did not ensure resident rights to personal privacy and confidentiality of their personal and medical records for 8 of 8 residents (Residents #1, #10, #133, #158, #305, #323, #325, and #397) reviewed. Specifically, Residents #1, #10, #133, #158, #305, #323, #325, and #397 identifying and personal information was posted in a public area visible to others. Findings include: The undated facility policy, Identifying Protected Health Information documented the facility was committed to ensuring the privacy and security of individual health information. To support this commitment, the facility would ensure that the appropriate steps were taken to properly identify and secure individuals' protected health information as required. Any health information relating to the past, present, or future physical or mental health or condition of an individual or the provision of health care to an individual would be protected. During observations on 4/18/2024 at 10:33 AM and 4/19/2024 at 11:49 AM personal identifying information for Residents #1, #10, #305 and #325 was posted in a public area on the 4th floor. The identifying information included personal resident information (room number, first name, last name, lab information, primary payor, bed status, diet, diet and liquid texture, and aspiration risk and confirmation). The information was posted in the 4th floor dining area to the left of the microwave and was highlighted yellow. During observations in the 11th floor dining room on 4/15/2024 at 12:12 PM, 4/17/2024 at 8:49 AM, 4/18/2024 at 9:04 AM, 4/19/2024 at 8:58 AM, and 4/22/2024 at 8:50 AM personal identifying information for Residents #158 and #397 was posted in the 11th floor dining room. The information was in a glass case and on a pillar in the middle of the dining room in a public area. The identifying information included personal resident information (the resident room number, the first name, last name, ordered diet including diet and liquid texture with aspiration risks highlighted, and special diet instructions). During observations on 4/16/2024 at 9:20 AM, 4/17/2024 at 8:59 AM, 4/19/2024 at 9:03 AM, and 4/22/2024 at 9:07 AM personal identifying information for Residents #133 and #323 was posted in a public area on the 13th floor next to the fireplace diagonal from the kitchen area. The identifying information included personal resident information (the resident room number, first and last name, and aspiration precautions). During an interview on 4/22/2024 at 10:46 AM, registered nurse Unit Manager #27 stated the posted resident information was a violation of resident's rights and the Health Insurance Portability and Accountability Act (a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge) as it divulged private information. They stated it was a facility policy to post the residents on aspiration precautions. They tried to make their unit posting as generic as possible so that there was not a lot of information with highlights. During an interview on 4/22/2024 at 3:18 PM, the Director of Social Work stated staff were educated about the Health Insurance Portability and Accountability Act annually and during orientation. They stated a resident listing that included a full name, diet order, diet texture, liquid consistency, and special instructions posted in a dining room without cover would be considered a Health Insurance Portability and Accountability Act or resident rights violation. During an interview on 4/22/2024 at 3:45 PM, the Director of Nursing stated staff were educated about resident privacy and rights when hired and during monthly meetings. They had a list of the residents, and they highlighted the residents who were on aspiration precautions. They stated they did not have the resident aspiration list covered before and it was posted on the pillar in the dining room for the certified nurse aides to review. The list should only contain resident name, highlighted in yellow with ASP for Aspiration precautions at the top of the list. During an interview on 4/23/2024 at 9:40 AM, the Director of Health Information stated a resident list with personal information, that was not covered and posted on a unit in full view of others was not appropriate. During an interview on 4/23/2024 at 12:07 PM, certified nurse aide/unit secretary #17 stated the Health Insurance Portability and Accountability Act meant staff should not disclose resident information to anyone unless it was to an individual identified in the chart as being allowed to have the information. They stated the aspiration risk sign should be covered because it was a violation of the residents' privacy. During an interview on 4/23/24 at 12:40 PM, registered nurse Unit Manager #16 stated in accordance with the Health Insurance Portability and Accountability Act they should not discuss resident information or leave resident information visible because other people could see the information. During an interview on 4/23/2024 at 12:55 PM, Assistant Director of Nursing #18 stated the Health Insurance Portability and Accountability Act protected residents' personal information. The residents on aspiration precaution list should be visible for staff only and the information should be covered to protect the residents' privacy. 10NYCRR 415.3(d)(1)(ii)

Based on observation, record review, and interview during the recertification and abbreviated (NY00321560, NY00336003, NY00320334, NY00318518, NY00315691 and NY00330793) surveys conducted 4/15/2024-4/23/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 6 of 14 resident units ([NAME] Units 3, 4, 8, 10, 11, and 13) reviewed. Specifically: - on [NAME] Unit 3, room [ROOM NUMBER]-W had overflowing laundry bags, the bathroom was visibly dirty and had a strong urine odor, and the room floors were sticky. - on [NAME] Unit 4, room [ROOM NUMBER]-W's alternating pressure mattress machine had a missing right hook to secure the machine, and a ceiling tile was missing. - [NAME] Unit 11 had sticky floors; room [ROOM NUMBER]-W had a dirty wall, and liquid and debris on the floor; and room [ROOM NUMBER]-W had a broken stone windowsill. - [NAME] Unit 8's and 13's common area ice and water machine had white dried matter along the grate/catcher plate, the table, the bottom of the shelf it was on, the floor underneath the machine, and the wall to the side of the machine. - [NAME] Units 4 and 10 had fruit flies. Findings include: The undated facility policy, Cleaning and Disinfection/Non-critical care and shared equipment documented the facility would ensure that the appropriate infection prevention and control measures were taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations. Resident rooms were cleaned and disinfected in accordance with environmental services policies and procedures. The undated facility policy, Safe & Homelike Environment documented the facility provided a homelike environment for those that resided in the facility. The residents had a right to a safe, clean, and comfortable environment. The facility provided residents with furnishings that met individual's desires, the layout of the facility did not pose a safety risk to residents and facilitated resident independence, and the facility ensured residents received necessary care and services. The facility policy, Pest Control Program revised 10/5/2017, documented the facility established an effective pest control program that assured the facility would be pest and rodent free. The facility was professionally inspected weekly and monthly based on observations or findings, and treatments would be scheduled. The undated facility policy, Work Order System documented the facility utilized an electronic workorder system that was accessible to all staff to submit identified items that needed repairs, areas of concern, and pest control. The following observations and interviews were made on [NAME] Unit 3: - On 4/15/2024 at 11:34 AM, room [ROOM NUMBER]-W had a large clear trash bag of dirty clothes in the private bathroom and the floor of the room was sticky. At 1:19 PM, the resident stated they had a bag of clothes in the bathroom but there was no staff to wash them. - On 4/16/2024 at 8:28 AM and 3:31 PM, there was a large overflowing clear bag of dirty clothes in room [ROOM NUMBER]-W's private bathroom. The room's floor was sticky. - On 4/17/2024 at 8:30 AM, there was a large clear trash bag full of clothes in room [ROOM NUMBER]-W's private bathroom. At 12:28 PM, there was a brief with a brown smear on the floor in room [ROOM NUMBER]-W's private bathroom next to an overflowing clear trash bag of laundry. The floor was sticky and there was a urine odor in the room noticeable from the hallway. There was urine and feces observed in the unflushed toilet. - On 4/17/2024 at 8:37 AM, the resident in room [ROOM NUMBER]-W stated the certified nurse aide came into their room last night and left the dirty linen on the floor and it smelled. They stated it had been picked up by the certified nurse aide that did their morning care. At 9:40 AM, certified nurse aide #5 stated dirty linen was left on the floor from the night shift in room [ROOM NUMBER]-W which was not dignified and could be a potential infection or fall risk. During an interview on 4/18/2024 at 10:37 AM certified nurse aide #8 stated laundry came to the unit twice a week on Tuesday and Thursday. They stated because clothing was backed up for residents, they sometimes had to wash resident clothes themselves. They stated they were going to washroom [ROOM NUMBER]-W's clothes yesterday because they were overflowing and had run out of pants, however they did not have time to wash the dirty clothing. They stated they had seen residents in the same clothes for two days and that was not dignified. They have noticed a smell of urine in the room and believed it came from another resident dumping urine in room [ROOM NUMBER]-W. During an interview on 4/18/2024 at 11:29 AM licensed practical nurse Unit Manager #4 stated laundry was picked up every Tuesday and it was brought back by laundry, but they were unsure of the timeframe. They stated laundry staff had a hard time keeping staff, and sometimes laundry was off the unit for more than four days. If laundry is piled up in a room, it could lead to odors. During an observation and interview on 4/22/2024 at 9:01 AM [NAME] Unit 5 had one blue cart of linen that was full and there were 10 additional bags of linen on the ground next to the blue cart. Laundry worker # 72 stated each floor had a specific day when laundry was picked up. They stated laundry backed up because some residents go through more clothing due to incontinence, and they were also short staffed. During an interview on 4/23/2024 at 9:28 AM the Director of Nursing stated they expected laundry to be picked up on laundry day. If laundry was not picked up timely it could lead to odors and bugs. They stated it was not dignified to have laundry backed up in a resident's room or for a resident to smell feces or urine from dirty clothing. The following observations were made on [NAME] Unit 4: - On 4/15/2024, 4/16/2024, and 4/17/2024, room [ROOM NUMBER]-W's alternating air mattress machine was unsecured on the right side due a missing hook. - On 4/16/2024 at 10:10 AM, room [ROOM NUMBER]-W had a ceiling tile that was lifted and turned, and not secured in the ceiling support holder. - On 4/19/2024 at 9:20 AM, room [ROOM NUMBER]-W was missing a ceiling tile, the pieces were resting on the floor leaned against the heater. During an interview on 4/22/2024 at 3:57 PM, registered nurse Unit Manager #16 stated they put in a work request for the ceiling tile in room [ROOM NUMBER]-W a couple weeks ago as critical. When they tried to adjust the tile back into place on 4/19/2024, it broke completely in half and fell to the floor. During an interview on 4/23/2024 at 12:24 PM, housekeeper #62 stated they were responsible for cleaning resident rooms. They swept, dusted, removed trash, and mopped every room as needed. They did not recall any missing or broken ceiling tiles in room [ROOM NUMBER]-W. They would report any broken items to the Unit Manager or unit secretary and a work order would be filed. They would also add it to their own paperwork as the Housekeeping Manager would review it. The following observations were made on [NAME] Unit 11: - On 4/15/24 at 11:12 AM, resident room [ROOM NUMBER] had a whole section of stone windowsill next to the stationary armchair lifted and broken. There was a slightly jagged edge and a large gap underneath the stone windowsill from where it was lifted. - On 4/15/2024 at 10:27 AM, resident room [ROOM NUMBER] had a bed against the wall with brown matter smeared on the wall. - On 4/16/2024 at 10:50 AM, resident room [ROOM NUMBER] had a brown liquid drip mark on the wall behind the headboard of the resident's bed. - On 4/17/2024 at 8:51 AM, 9:59 AM, and 3:35 PM resident room [ROOM NUMBER] had a urine odor. There was a brown dried liquid drip mark on the wall behind the headboard. - On 4/18/2024 at 9:03 AM, the floors were sticky all around the 11th floor dining area. At 9:10 AM, the floors from common TV area down to room [ROOM NUMBER] were sticky. At 11:40 AM, the floor on the side of dining room between the counter and sink combination and round table was sticky. At 11:43 AM, the floor in front of the elevators was sticky. - On 4/19/2024 at 1:21 PM, resident room [ROOM NUMBER] had a large clear liquid puddle in the center of the room on the floor. - On 4/19/2024 at 9:39 AM, the floor to the left of the elevators was sticky. During an interview and observation on 4/16/2024 at 10:53 AM, certified nurse aide #80 stated if they found something broken in a resident room or there was a maintenance issue, they put a work order into their electronic communications system for maintenance. They stated they were unaware of the broken windowsill in resident room [ROOM NUMBER]. During an interview and observation on 4/16/2024 at 10:55 AM, certified nurse aide #70 stated they were assigned to resident room [ROOM NUMBER] that day and was unaware of a broken windowsill. During an interview on 4/23/2024 at 10:13 AM, housekeeper #81 stated if there was a spill or debris on a resident's floor, all staff were responsible for cleaning it. They stated if staff saw something, they were expected to clean it up and not wait on housekeeping. If there was a smear or liquid on a resident's wall whoever saw it was responsible for cleaning it. During an interview on 4/23/2024 at 10:18 AM, licensed practical nurse Unit Manager #82 stated they expected both housekeeping and nursing to clean any messes they saw on the floor. Whoever saw it first should clean it. They stated if there was a smear on a wall, whoever found it should clean it. However, if it is obviously a resident's bowel movement, the certified nurse aides were to clean it and then housekeeping followed through. Pest Control: The following observations were made: - On 4/15/2024 at 12:12 PM, there was a fruit fly in the dining room during the lunch meal [NAME] unit 10. - On 4/23/2024 at 10:06 AM, there were fruit flies in room [ROOM NUMBER]-W on [NAME] Unit 4. Resident use equipment cleanliness: The following observations were made of water/ice machines on resident units: - On 4/15/2024 at 10:10 AM on [NAME] Unit 8, the dining area water/ice machine had a dried white substance around the base of the machine, along the table, on the bottom of the shelf, on the floor underneath the machine, and the wall to the side of the machine. - On 4/15/2024 at 11:39 AM on [NAME] 13, there was an active leak beneath the ice machine with two catch basins full of water. - On 4/16/2024 at 9:03 AM on [NAME] Unit 13, the ice/water machine had white dried matter under and around the leg of the ice machine, and along the grate catcher plate in the bottom of the ice machine. At 9:05 AM, the red wall outlet plate the ice machine was plugged into was splattered with white matter. - On 4/17/2024 at 9:07 AM, on [NAME] Unit 13 there was a sticker on the water/ice machine documenting it was cleaned and sanitized on 1/31/2024. There was white build up on the catch grate and plate and discoloration splatter on the metal back plate under the ice nozzle. The counter under the machine had white build up. The red wall outlet plate the ice machine was plugged into, was splattered with white matter. During an interview on 4/15/2024 at 11:48 AM Maintenance worker #83 stated they cleaned the ice machines last week. 10 NYCRR 415.29(j)(1) 48446 48632

Based on record review, observation, and interviews during the recertification survey conducted 4/15/2024-4/23/2024, the facility did not ensure information on filing grievances was available for 11 of 11 anonymous residents present at the Resident Council meeting. Specifically, 11 anonymous residents present at the Resident Council meeting stated they did not know how to file an anonymous grievance. Findings include: The facility policy, Complaint Management Policy dated 2/21/2022 documented all residents would be informed at admission of their right to file a grievance and the information would be posted throughout the facility. Complaints could be filed either in written or in oral format to any staff member. The Director of Nursing served as the grievance official. During a Resident Council Meeting on 4/15/24 at 2:04 PM, eleven anonymous residents stated they were unaware of who the facility grievance officer was. They were told they had to report their concerns to their social worker. They stated they did not always receive follow up on grievances expressed and did not feel they could express concerns. The 11 anonymous residents were unaware they could file a grievance anonymously. During an observation on 4/17/2024 at 9:03 AM, a sign on the 13th floor documented to address any grievances, concerns, or unresolved issues firstly to the Unit Manager or Social Worker, secondly to the grievance officer, who was the Director of Nursing, or thirdly to the Ombudsman. Next to the sign was the number for the New York State Complaint hotline labeled Patient Care Hotline and the New York State Ombudsman poster. The compliance officer contact information was not documented. During an interview on 4/22/24 3:45 PM, the Director of Nursing stated a family member or resident could call them or write an email or letter to report a concern and they would follow up based on the information provided. They stated every grievance they received was written on the grievance log unless it was about a resident who stated they did not receive care, that would be an incident report, not a grievance. They stated grievances included concerns about discharge, the financial department, or missing items. They stated a resident filed an anonymous grievance by contacting them directly or having the social worker contact them. An anonymous grievance could be filed by giving a letter to security to put in their mailbox, sliding it under their office door, or by contacting the Ombudsman. They were aware it was a resident's right to file a grievance anonymously. During an interview on 4/22/24 at 5:01 PM, the Director of Social Work stated the Director of Nursing was the grievance officer. They stated a resident filed a grievance and the staff utilized their grievance form and then turned it into the Director of Nursing. They were unaware of a process in the facility for residents to file an anonymous grievance. They were aware it was a resident right to be able to file an anonymous grievance. During an interview on 4/23/24 at 11:05 AM, the Administrator stated the residents or family could submit anonymous grievances through the compliance officer or through the Ombudsman. They stated they believed the compliance officer number was in the resident handbook. If a resident wanted to remain anonymous, the resident could contact them directly or contact the compliance officer. 10NYCRR 415.3(C)(1)(ii)

Based on observation, record review, and interview during the recertification and abbreviated (NY00315691, NY00318518, NY00320334, NY00321560, NY00329469, NY00330471, NY00331762, and NY00332641) surveys conducted 4/15/2024 through 4/23/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the residents medical and nursing needs for 3 of 4 residents (Residents #62, #150 and #201) reviewed. Specifically, Resident #201 did not have a comprehensive care plan developed to include outside privileges or smoking outside on facility grounds; Resident #62 did not have a positioning pillow, palm guard, or pressure reduction boots as planned; and Resident #150 was not wearing their pressure reducing heel boots as planned. Findings include: The 8/8/2022 facility policy Comprehensive Care Planning, documented the facility must develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The services were to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The 4/19/2023 facility policy Smoking Policy, documented the facility was tobacco free. Any form of smoking, including but not limited to e-cigarettes, vaping, and all other uses of tobacco and marijuana products were prohibited on all facility properties. Facility properties included all land, building, structures, parking lots, and means of transportation owned by the facility. No one could smoke along any pathway or walkway leading to or from the parking area, nor at the picnic tables on any of the grassy areas or the parking lots. The 10/2023 facility policy Off Unit/Leave of Absence, documented that the facility would provide residents opportunities to leave the unit that provides safe and appropriate experiences for interacting outside. The attending physician/designee would provide an order for Leave of Absence and would evaluate the order on a minimum of every 30, 60, or 90 days. The order may be completed from the standing order in the medical record. The purpose of the policy was to be aware when a resident was off the unit and their location within or outside the facility. Residents must notify nursing on the unit and sign out and back in on the Resident Sign-Out book. The facility policy Skin and Wound - Pressure Injury Prevention, Identification, Treatment and Documentation of Pressure Injury dated 8/17/2022 documented each resident received treatment and services to promote healing and prevent new pressure injuries from developing. Use heel offloading devices such as pressure reducing boots or heel lifts on heels for protection. The most important function in management of pressure damage was pressure relief. 1) Resident #201 had diagnoses including nicotine dependence, noncompliance with other medical treatment and regimen due to unspecified reason and need for assistance with personal care. The 3/13/2024 Minimum Data Set assessment documented the resident was cognitively intact, had limited range of motion in both upper and lower extremities on both sides, and was independent with wheelchair use, The comprehensive care plan initiated on 8/2/2021 documented the resident had potential for alteration in mood state related to anxiety, depression, and history of nicotine dependence. Interventions included one on one visits as needed, allow time to express feelings as needed, behavior health referrals as needed, provided emotional support to the resident as needed, provider evaluation and/or re-evaluation of psychotropic medications, observe for desired and undesirable effects, reduce environmental stimuli, respect wishes for privacy, and validate feelings. The care plan did not include resident centered interventions for nicotine dependence. The 11/24/2023 incident note by registered nurse Unit Manager #28 documented Resident #201 was observed outside in a wheelchair smoking a cigarette. When questioned about smoking they stated they needed to smoke because the place drove them crazy. The 11/24/2023 social work note by social worker #60 documented a room search was conducted and 4 empty boxes of cigarettes and one lighter were found. The resident turned over the light and boxes were thrown away. There were no documented interventions added to Resident #201's care plan based on the smoking incident in November 2023. During an observation and interview on 4/16/2024 at 8:17 AM, Resident #201 was sitting in their wheelchair in the driving lane of the back parking lot between the visitor and employee lots. The resident stated they enjoyed the sunshine. During an observation on 4/18/2024 at 6:45 PM, Resident #201 attempted to smoke outside, concealed their cigarette, and remained under the awning of the building for several minutes. During an interview on 4/19/2024 at 11:26 AM, certified nurse aide #77 stated Resident #201 usually let the nursing staff know when they were leaving the floor. They left the floor to go downstairs and outside to smoke. The resident was usually in between the 2 front doors or the covered patio next to the employee parking lot. They sat down there and would ask anyone they saw for cigarettes or assistance with lighting a cigarette. The resident had a few other friends that did the same thing. Certified nurse aide #77 stated they had not seen the resident with a lighter but had seen them smoking outside. An electronic communication from the Administrator dated 4/20/2024 at 2:11 PM documented Resident #201 did not have any out of pass assessments or smoking assessments. During an interview on 4/22/2024 at 11:13 AM, registered nurse Unit Manager #28 stated that if the resident was not on the unit, they would go downstairs to find them. The resident was good about telling staff when they were leaving the unit. The resident would not explain where they were going, only that they would return for the next mealtime. The resident did not have an off the unit assessment and therapy listed them as independent with a wheelchair. If there was an emergency in the building, they would call the front desk security to see if they could see the resident. Resident #201 was caught smoking back in November. The current care plan just states a history of smoking. The Minimum Data Set assessment nurse was responsible for quarterly updates and reviews of the care plan, but registered nurse Unit Manager #28 was responsible for updates on episodic issues. An electronic communication from the Administrator dated 4/22/2024 at 11:14 AM, documented Resident #201 did not have any sign-out sheets for leaving the unit from 10/1/2023- 4/22/2024. During an interview on 4/22/2024 at 3:55 PM, Assistant Director of Nursing #23 stated that if a resident was off the unit the floor staff would have to account for them in the event of an emergency. If the resident was outside, they would have to be alert and oriented. There was no specific assessment for whether a resident could be outside. Resident #201 was appropriate to go outside unsupervised. The resident was not a risk to wander or elope. They were aware the resident was a smoker, but the grounds were non-smoking, and the resident was educated. The resident could use their cell phone if they needed assistance when they were off the unit. During an interview on 4/22/2024 4:43 PM, the Administrator stated that if a resident was caught smoking a full investigation should have been completed and interventions added to the resident's care plan and care card based on the findings of the investigation. Residents could leave the facility if they were alert and oriented but should not be in parking lots. If a resident was found in a parking lot staff should intervene. Interventions should be added for safety. There was no assessment to determine ability to go outside. The facility was responsible for keeping the resident safe even when they were outside. Resident #201 was not an elopement risk, if they said they were going outside, they would come back. The resident would communicate via cell phone. During an interview on 4/23/2024 at 1:27 PM, the Director of Nursing stated that creating person-centered care plans was a project. They used to do them on paper and were trying to make them personalized. The Director of Nursing would check to see if an elopement assessment was done for a resident if there was concern, but they checked for completeness, not accuracy. There were no smoking audits as they were a smoke free facility. The expectation was that the resident would have a care plan for the smoking habit. If the resident was caught smoking 3-4 times, they would get a wander alert device. 2) Resident #62 was admitted to the facility with diagnoses including stroke with hemiplegia (one sided weakness), obesity, and chronic obstructive pulmonary disease (chronic lung disease). The 1/25/2024 Minimum Data Set assessment documented the resident was cognitively intact, required extensive of assistance of two for most activities of daily living, was non-ambulatory, and had functional limitation in range of motion in all 4 extremities. The comprehensive care plan initiated 6/3/2021 documented the resident had activities of daily living self-care performance deficits related to limited mobility. Interventions included for left hand contracture, palm guard with roll at all times, resident was allowed to remove the palm guard during the day for a break. The comprehensive care plan initiated 8/12/2022 documented the resident had potential for skin impairment related to fragile skin, complex medical conditions, and the resident preferred to lie on their back while in bed. due to immobility. Interventions included the resident was to wear pressure reduction booties when in bed, a bariatric (referring to obesity) wound surface mattress with positioning pillows to protect skin. The following observations of Resident #62 were made: - on 4/17/2024 at 1:26 PM in bed without pressure reduction booties on their feet. The booties were not observed in the room. Resident #62 stated the pressure reduction booties were removed from their room several months ago and had not been replaced. The resident stated the pressure reduction booties made them more comfortable because they were always in bed. - on 4/18/2024 at 12:24 PM and 3:44 PM in bed. There were no pressure reduction booties on their feet, no positioning pillow, and no left palm guard. - on 4/19/2024 at 8:31 AM in bed without pressure reduction booties on their feet or a positioning pillow. - on 4/19/2024 in bed without pressure reduction booties on their feet or a positioning pillow. During an interview on 4/18/2024 at 3:46 PM certified nurse aide #19 stated they used the care plan to know resident specific care instructions and they were individualized for each resident. They stated Resident #62 was not care planned for pressure reduction booties. If a resident was care planned for p booties and did not have them, they could have skin breakdown on their heels. During an interview on 4/18/2024 at 4:17 PM licensed practical nurse #12 stated residents received individualized care based on their care plan. Failure to follow the care plan could impact resident outcomes. They believed Resident #62 was care planned for positioning pillows as they leaned to the right and looked like they might fall off the bed. During an interview on 4/19/2024 at 9:12 AM certified nurse aide #10 stated Resident #62 should wear a palm guard in their left hand because they had a contracture. They stated failure to wear the palm guard could increase the contracture. They stated the resident always leaned to the right like they are going to fall out of bed because they could not use their left side. They bought the resident a neck pillow to help with positioning, but they had never seen a positioning pillow. They did not believe the neck pillow, or the positioning pillow was on the care plan. During an interview on 4/19/2024 at 10:57 registered nurse Unit Manager #14 stated residents' care plans were individualized and drove the care card which is what the certified nurse aides used to know what care was necessary for each resident. They stated most residents on their unit were transferred from the rehabilitation unit and the care plan was initiated there. They stated they updated the care plan when the physician, therapy, or other discipline had recommendations for the residents. They stated pressure reduction booties were used to offset pressure to prevent skin breakdown on the heels. A positioning pillow was used to change a resident's position to prevent skin breakdown. If a resident was ordered to have pressure reduction booties or a positioning pillow and they did not, they could develop wounds, be uncomfortable, have pain, and increase the potential for infection. If a resident refused the booties or pillow it would be documented in a progress note. There was no documentation stating the resident refused either the booties or the positioning pillow. They stated they expected the items to be in the room if they were recommended. During an interview on 4/19/2024 at 12:15 PM physical therapist #15 stated that positioning devices were assessed for safety by therapy with the individual resident. They stated a risk benefit analysis had to be done prior to implementing that intervention to make sure the positioning device was safe and not being used as a restraint. They stated Resident #62's positioning pillow was not a therapy recommendation but a nursing intervention. 3) Resident #150 had diagnoses including diabetes, failure to thrive, and stroke. The 2/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required substantial assistance for hygiene, dressing, bed mobility, and transfers, was at risk for developing pressure ulcers/injuries, did not have pressure ulcers/injuries, and had pressure reducing devices for the chair and bed. The comprehensive care plan initiated on 1/29/2024 documented the resident had an activities of daily living deficit related to decreased mobility. Interventions moderate assistance of 1 when rolling left and right, the resident must wear pressure reducing boots as resident is supine (lying on back) in bed; bed to chair transfer dependent on 2 with mechanical lift, pressure reducing boots on when in wheelchair. The resident had potential for alteration in skin integrity related to decreased mobility and non-ambulatory. Interventions included elevate/float heels with pillows while in bed. A physician order dated 2/3/2024 documented to apply LNard boots (used for pressure reduction and/or foot stabilization) in the AM when out of bed and remove at night. The care instructions active as of 4/22/2024 documented to bilateral lower extremities apply LNard boots in AM when out of bed and remove at night. Pressure reducing boots on when in wheelchair and elevate/float heels with pillows while in bed. The resident was observed out of bed in their wheelchair without pressure relieving boots or LNard boots: - on 4/16/2024 at 8:26 AM in the dining room wearing blue nonskid socks and their feet were resting on the footrest of their wheelchair. - on 4/22/2024 at 12:12 PM in the dining room wearing blue nonskid socks and their feet were resting on the footrest of their wheelchair. - on 4/23/2024 at 10:19 PM in the common activities area wearing blue nonskid socks and their feet were resting on the footrest of their wheelchair. The 4/2024 Treatment Administration Record documented to bilateral lower extremities apply LNard boots in AM when out of bed and remove at night. The treatment administration record documented the LNard boots were in place at 8:00 AM on 4/16/2024 by licensed practical nurse #78 and on 4/22/2024 by licensed practical nurse #79. During an interview on 4/23/2024 at 10:44 AM, certified nurse aide #49 stated they would look in the Kardex for resident specific care instructions. They were responsible for the resident today and was not aware they required any special pressure prevention devices to their heels. They reviewed the Kardex care instructions on the computer and stated the resident should have had pressure reduction booties on or at least offered. During an interview on 4/23/2024 at 11:03 AM, certified nurse aide #8 stated the Kardex provided instructions for the individual resident needs. They stated the Kardex documented in the section of chair to bed transfer it showed that the resident required pressure reduction booties on when out of bed in their wheelchair. They did not think to look in that area. During an interview on 4/23/2024 at 11:23 AM, licensed practical nurse #50 stated the Kardex provided the directions for staff to be able to care for the residents. Residents were expected to have the splints or devices worn as ordered and directed. Nurses should sign for them in the treatment administration record. The LNard boots were to prevent skin breakdown. During an interview on 4/23/2024 at 11:34 AM, licensed practical nurse #48 stated the Kardex information was generated by the care plan, and they should match. The computer documented an order to wear LNard boots in AM and off when in bed every day. They needed them for risk of pressure, and they should have them on their feet. During an interview on 4/23/2024 at 11:45 AM, registered nurse Unit Manager #51 stated staff used the residents care plan to know how to provide care. The computer displayed the resident required LNard boots when out of bed and they expected them to be worn to prevent pressure. During an interview on 4/23/2024 at 12:55 PM, Assistant Director of Nursing #18 stated staff should use the Kardex or the care plan to care for each resident. The programs worked together, and the information should match. The ordered heel protectors should be applied unless the resident refused and then documented accordingly. 10NYCRR 415.11(c)(1)

48446 48632 50561 Based on observation, record review, and interviews during the recertification and abbreviated surveys (NY00315691, NY00318518, NY00321560, NY00329469, NY00330555, NY00332641, NY00334153, NY00336003, and NY00338231) conducted 4/19/2024-4/23/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 10 of 13 residents (Residents #62, 117, 124, 133, 150, 215, 305, 325, 384, and 414) reviewed. Specifically: - Resident #62 had unkempt hair, excessive facial hair, and unkept fingernails; - Resident #117 had unkept fingernails; - Resident #124 had unkept fingernails, greasy hair, and excessive facial hair; - Resident #150 remained in bed due to mechanical lift battery issues and was poorly positioned for meals; - Resident #133 was poorly positioned in bed for breakfast meals; - Resident #215 was not toileted as planned and had excessive facial hair; - Resident #305 was not toileted for over 5 hours; - Resident #325 had greasy hair and was not toileted as planned; - Resident #384 did not receive a shower as planned; and - Resident #414 did not receive a shower as planned and had excessive facial hair. Findings include: The facility policy Resident Nail Care dated 8/8/2022 documented residents received fingernail and toenail care to prevent potential discomfort or injury. Any nursing staff was able to provide nail care. The facility policy Aspiration Precautions and Standards of Care dated 11/1/2022 documented measures to prevent or lessen the risk of food, fluids, or other ingested material from entering the respiratory tract. Residents were to maintain an upright position throughout the meal and 30 minutes after. The facility policy Meal Service dated 11/1/2022 facility policy documented a staff member must be assigned to monitor the residents during the meal if there were residents that ate in their room and were not on aspiration precautions. The facility policy Quality of Life- Dignity dated 1/10/2023 documented each resident should be cared for in a manner that promoted and enhanced their sense of well-being, level of life satisfaction, feeling of self-worth and self-esteem. Examples were personal grooming such as hair styling, nails, and facial hair. The facility policy Activities of Daily Living (ADLs) dated 3/12/2024 documented the facility would provide the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless avoidable. Examples included hygiene, mobility, and dining. The resident who was unable to carry out activities of daily living would receive the necessary services to maintain grooming and personal hygiene. 1) Resident #133 had diagnoses including cerebral palsy (a condition affecting movement and posture), stroke affecting the left side with weakness, and gastroesophageal reflux disease. The 2/9/2024 annual Minimum Data Set assessment documented the resident was cognitively intact, had functional limitation impairment of both legs, required set up assistance for eating, maximum assistance for rolling left or right, was totally dependent for bed mobility, and received a therapeutic diet. The 12/22/2022 physician order documented the resident was on a no added salt, unmodified texture diet with thin liquids. The 2/26/2024 revised comprehensive care plan documented the resident had a hiatal hernia (the upper stomach bulges through the diaphragm), gastroesophageal reflux, had a stroke with left sided weakness, had cerebral palsy, and had activities of daily living deficits. Interventions included sit upright after meals, diet as ordered, monitor for difficulty swallowing, monitor for coughing/choking when lying down, speech therapy as needed, anticipate, and meet needs, moderate assistance of 1 from lying to sitting position, and maintain good body alignment. During an interview on 4/15/2024 at 1:47 PM Resident #133 stated staff told them they did not have time in the morning to pull the resident up in bed to eat breakfast properly and this was a frequent occurrence. Resident #133 was observed: - on 4/16/2024 at 9:06 AM, in bed with the head of the bed raised and a pillow behind their head. The resident had an over bed tray table in front of them and the height of the table was raised to the resident's mid face. The resident had to reach up to get the food off the tray. At 9:48 AM, the tray table remained raised to the resident's mid face, the resident was slouched in the bed, and their voice sounded gurgled. The resident cleared their throat and stated it was hard to eat their food that way. The resident reached up to get a banana after turning the tray so they could reach it due to the height of the table. - on 4/17/2024 at 9:22 AM, sliding down in the bed, almost chin to chest, with the head of the bed elevated. The over bed tray table had a meal tray on top and was positioned at chin level to the resident. The resident reached up and pulled a banana and small container of eggs down to their chest to eat. The resident coughed while talking. The resident's voice sounded gurgled. The resident stated staff did not have time that morning to pull them up in bed. - on 4/18/2024 at 9:15 AM, lying in bed with the head of bed raised. The over bed tray table was chin height. The resident had to reach up to retrieve food items from the tray. At 12:27 PM, the resident stated they would prefer to get out of bed for breakfast, but staff had told them multiple times in the past they did not have time. The family was in the room and stated the resident did not like to eat in bed and it was not safe for the resident to eat while lying in bed. The resident agreed they did not like to eat in bed and felt it was not safe. - on 4/19/2024 at 9:21 AM, lying in bed in a slumped posture. The tray table had a meal tray on the top and was at nose height of the resident. The resident reached up and pulled down a small plate of eggs, they placed the plate on their chest, so they did not have to reach up for each bite. - on 4/22/2024 at 9:04 AM slouched in bed eating breakfast. The head of the bed was raised, and the tray table was level with their chin. The resident had to raise their arm to reach food with their fork and move the fork down to their mouth. At 9:29 AM, the resident was attempting to rotate the tray to reach other items at the back of the tray. While drinking from a cup, the resident took breaths and tilted the cup for small sips. During an interview on 4/22/2024 at 10:10 AM, certified nurse aide #30 stated they floated to the unit that day and the licensed practical nurse wrote down resident needs on their assignment sheet. Any resident eating in bed should be properly positioned upright to prevent aspiration (inhaling food/fluids into the lungs) of food or drinks. During an interview on 4/22/2024 at 10:20 AM, certified nurse aide #64 stated they floated to the unit for this shift. Resident specific care was documented in the care plan and care instructions. Residents eating in bed had to be positioned upright. Their tray table should be a comfortable height to eat from and not at chin level or higher. The resident had not expressed to them a desire to be out of bed prior to eating. During an interview on 4/22/2024 at 10:33 AM, licensed practical nurse #31 stated resident specific care was in the care instructions. Awake residents should be out of bed for breakfast unless they did not want to. Any resident needing assistance with eating should be out of bed. If a resident ate in bed, they should be sitting upright with the tray table at chest height to enhance access to meal tray. The aides should round the unit during meals to ensure residents were not having difficulty eating. The nurse had seen the resident slumped in bed having difficulty eating in the past and immediately corrected the situation. During an interview on 4/22/2024 at 10:46 AM, registered nurse Unit Manager #27 stated care plans were updated by the Unit Manager and the appropriate disciplines. Cognitive residents were asked each meal if they wanted to get out of bed for the meal. Resident #133 was able to voice their preference and typically did not want to get out of bed for breakfast. Staff delivering meal trays should ensure the resident was positioned fully upright for the meal and not sliding down in bed during the meal. They stated they rounded the unit during breakfast, the resident was sitting up in bed with pillows under their arm and did not ask to be pulled up in bed. Resident #133 had use of 1 arm to eat and had a difficult time reaching the meal tray with that arm. 2) Resident #124 had diagnoses including epilepsy (seizure disorder), contractures of both hands (tightening of muscle, tendons, ligaments), and morbid obesity. The 3/6/2024 Minimum Data Set assessment documented the resident was cognitively intact, had functional limitations in both arms and legs, used a wheelchair, was dependent for toileting and hygiene, required maximal assistance for upper body dressing/personal hygiene (such as combing hair/shaving), and received physical therapy. The 2/2/2024 updated comprehensive care plan documented the resident was at risk for alteration in skin integrity, was able to make own preferences and choices, had left hemiplegia (one-sided weakness), and had activities of daily living deficits. Interventions included keep skin clean and dry, weekly skin checks by nurse, observe skin with routine care, honor preferences, range of motion with care, physical therapy referrals as needed, provide sponge bath when a full bath could not be tolerated, check fingernail length and trim/clean on bath day and as necessary, dependence on 2 for scheduled shower day every Tuesday on evening shift, maximum assistance of 1 with personal hygiene, and dependence of 1 with upper body dressing. During an observation on 4/15/2024 at 12:32 PM, Resident #124 had a full beard and stated they were supposed to be shaved today. They preferred to be shaved at least every other day, but they were not. The resident stated they were unable to shave themselves and their beard was itchy. They stated they scratched their face when itching due to long, sharp fingernails. The 4/17/2024 care instructions documented the resident was dependent for upper and lower body dressing, 2 staff for all care due to behaviors, bilateral palm grips during sleep, make sure hands were clean, provide regular range of motion on fingers of both hands, maximum assistance of 1 for personal hygiene, dependence of 2 for shower/bath every Tuesday on evening shift, and keep skin clean and dry. The following observations of Resident #124 were made: - on 4/17/24 at 9:12 AM, lying in bed eating breakfast with certified nurse aide #65 sitting in the room supervising. The resident's hair appeared greasy and tangled with white flakes. The resident stated they were given a bed bath the evening before. The resident's fingernails were grown to the tips of the fingers and had pointed edges in various areas on each nail. - on 4/18/24 at 8:30 AM, in their room sitting in a wheelchair. The resident's hair was uncombed, and their fingernails were unkept. - on 4/19/24 at 10:00 AM, resting in bed. Their fingernails were unkept and had brown debris underneath. Their hair appeared greasy and there was facial stubble about 1/8 inch long. The 4/2024 nurse aide task documented the resident was provided personal hygiene every day shift and most evening shifts, received upper body dressing every day shift and most evenings, had a skin observation done every day shift and most evenings and nights. The resident received a shower/bath on evening shifts of 4/15/2024 and 4/16/2024. During an interview on 4/29/24 AM at 2:05 PM, registered nurse Unit Manager #66 stated each resident was scheduled for a bath or shower once a week and as needed. If the bath/shower was refused by the resident, a bed bath was offered. If a bed bath was given, the resident's hair was washed using a shower cap. Resident activities of daily living preferences were obtained from the resident or representative upon admission and then quarterly and entered the care plan and care instructions. Certified nurse aides were expected to review each assigned resident's care instructions daily prior to resident care, unless they were full time on the unit and familiar with the resident, then they should review them weekly. Any changes to the care instructions were discussed during morning report. Unit nurses were responsible to ensure all care was provided. The Unit Manager and Assistant Unit Managers rounded frequently on the unit to ensure care was done. Weekly skin checks were done by a unit nurse on shower/bath days for each resident. Nail care was done on shower days and nails should be trimmed as needed according to resident preferences. Facial hair should be trimmed or shaved per resident preferences on shower days and as needed. Facial hair length was also based on resident's preferences and preferences, such as having a beard or whiskers, should be in the care plan. Nails should be no longer than the tips of the fingers and filed smooth to prevent scratches. Resident #124 only wanted bed baths and often refused shaving. This should be in the care plan and instructions and documented as refusals. Hair washing was included in the shower/bath task and fingernail care and shaving were in the personal hygiene task. Resident #124's hair should not have been greasy unless they refused to have their hair washed. During an interview on 4/29/2024 at 2:15 PM, certified nurse aide #63 stated resident specific care was documented in the resident's care instructions and was reviewed daily. They stated they reviewed each resident's instructions prior to entering the room to provide care. Each resident should receive a shower/bath weekly according to the unit shower list. The unit nurse performed a skin check with each bath/shower. Nail care, hair washing, and shaving were to be done on the bath/shower day. Residents should also be shaved when facial hair was clearly visible or per resident preferences. If a resident refused care, staff were to reapproach and tell the nurse if the refusal continued and documented in the medical record. Any nursing staff could trim nails unless otherwise specified. Resident #124 usually asked when they wanted to be shaved. They stated they noticed Resident #124's hair was greasy in appearance and offered to wash it on 4/29/2024 in the morning. If a resident was given a bed bath, staff were to wash their hair using a shower cap washing device. Nails should be trimmed so the resident did not scratch themselves with long nails. During an interview on 4/29/2024 at 2:25 PM, licensed practical nurse #67 stated skin checks, nail care, and hair care were done on a resident's bath/shower day. If a resident refused care, the aide told the nurse who would reapproach the resident. All refusals were documented in the task section and a progress note made by the nurse. Nurses were responsible for ensuring resident care was completed by the aides as planned. Resident rounding was done by the nurse when performing resident care such as treatments and medications. Any issues were addressed with the aide. They stated they checked Resident #124 that morning and noted they had greasy hair. Aides were allowed to trim nails unless the resident was diabetic, and Resident #124 was not. Nails should be trimmed when at the tip of the finger or longer. If a resident refused a bath/shower after reapproaching, they generally did not get one until the next week. Hair care and nails could be done anytime and by any nursing staff. 3) Resident #384 had diagnoses including hemiplegia (one-sided weakness), obesity, and diabetes. The 4/11/2024 Minimum Data Set assessment documented the resident was cognitively intact, required substantial assistance for bathing and toileting, and did not refuse care. The 3/24/2024 comprehensive care plan documented a deficit with self-care related to fatigue. Interventions included to encourage the resident to participate in care. The resident was alert and oriented and able to make decisions regarding their care. During an interview and observation on 4/15/2024 at 4:18 PM, Resident #384 was unshaven. They stated they only received a shower once a week and did not receive one on 4/12/2024 as scheduled. The usual certified nurse aide was off, and they did not get washed up that day. There was a strong smell of urine in the room. The certified nurse aide task record for Resident #384 was not signed as completed on 4/12/2024. There was no progress note documenting the resident refused their shower 4/12/2024. During an interview and observations on 4/16/2024 at 8:14 AM, Resident #384 stated there was emesis on the floor. They stated the call bell had been on since 7:30 AM that morning and staff had not answered it yet. The call light was on. There was emesis with food particles on the floor. The room smelled of urine and the resident's urine drainage bag was half full. Staff entered the room at 8:22 AM to answer the call light and the nurse cleaned up the emesis at that time. At 9:58 AM, the resident was in bed and there were large yellow spots on the right side of the bed sheets. The resident stated they had vomited on that area of the sheets. At 3:13 PM, the resident was sitting in a chair. The resident stated they had been washed but they had not received a shower and would like one. There was a large wash basin in the room with a yellow liquid. The resident stated they had vomited in the basin. During an interview on 4/17/2024 at 9:40 AM, certified nurse aide #5 stated showers were on the schedule at the nursing station. A resident not receiving activities of daily living would have poor hygiene which could cause an infection and was undignified. During an interview on 4/19/2024 at 10:57 AM, registered nurse Unit Manager #14 stated care refusals were documented in the care plan. A refusal intervention was to reapproach the resident and notify the nurse for documentation purposes. Nail care, shaving and hair washing were done as needed even if not on their scheduled shower day. Repercussions of not providing appropriate care included pneumonia, infection, tooth decay, overall feelings of uncleanliness, negative psychosocial effects, and dignity issues. They expected that all planned care be provided. During an interview on 4/22/2024 at 9:06 AM, licensed practical nurse #44 stated the aides provided residents a shower on their assigned shower day. Residents should be washed each day. Resident #384 should have received a shower on 4/12/2024. They stated there were times when scheduled showers were not done by a certified nurse aide who was covering for a regular aide. Resident #384 was assigned a shower each Friday. The resident never refused a shower since they had been caring for them. During a follow-up interview on 4/22/2024 at 9:36 AM, registered nurse Unit Manager #14 stated if a resident did not get a shower and wanted one, it could impact their overall feelings of wellness, skin breakdown, and infection prevention. They expected that each resident received their shower on their scheduled day. Resident #384 did not refuse care and was cognitively intact. It was not acceptable that the resident put the call light on at 7:30 AM and staff did not answer it until 8:22 AM. 10NYCRR 415.12 (a)(3)

Based on observation and interview during the recertification survey conducted 4/23/2023 -4/23/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with currently accepted professional principles for 5 of 12 medication carts ([NAME] units 3, 4, 8, 10, and 14) reviewed, and 1 of 6 medication rooms ([NAME] unit 5) reviewed. Specifically, the medication cart on [NAME] unit 3 had nicotine patches without resident labels; [NAME] unit 4 had expired medications; [NAME] unit 8 has insulin without a labeled open date; [NAME] unit 10 had inhalers not in the correct pharmacy box and without labeled open dates and unlabeled eye medications; [NAME] unit 13 had personal food items stored with resident medications; and [NAME] 5 medication room had a refrigerator with a significant amount of ice buildup. Findings include: The facility policy Over the Counter (OTC) Medications- Floor Stock dated 4/5/2019 documented that eye drops, nasal spray, and eardrops should be obtained from the pharmacy to ensure proper resident specific labeling. Each week the Director of Nurses' designee would review supply of house stock. Newly obtained stock items would be placed in the back to ensure proper rotation and that items were used before the expiration date. The existing stock would have expiration dates checked. Any items found expired would be removed immediately. The proper disposal of expired or unused [over the counter] medications was to place them in the same place as the pharmacy medication returns. The facility policy Drug and Biological Storage: Medication Refrigerators dated 10/11/2021 documented that all injectable drugs and biologicals delivered to the facility would have pharmacy labels on the outside container as well as the drug vial, should the container and vial be separated. Once the injectable drug was opened a sticker noting the date the vial was opened and the initials of the nurse should be placed on the vial, or the information written directly on the vial. Medication Carts During an observation and interview on 4/17/2024 at 10:27 AM, [NAME] Unit 3 medication cart 1 had a nicotine 14 mg patch without a resident label. Licensed practical nurse #6 stated the nicotine patch was for a current resident but was not labeled and should have been. They stated if medications were not labeled properly, there could be an error and be given to the wrong resident. During an observation and interview on 4/17/2024 at 11:23 AM, [NAME] Unit 13 medication cart had a glazed donut stored in an opened clear plastic bag in the small second drawer under the narcotic locked box. Registered nurse Unit Manager #27 stated they looked at the cart at 6:00 AM that morning and there was not a donut stored in the medication cart. They stated the donut should not be in the medication cart. During an observation and interview on 4/17/2024 at 3:27 PM, [NAME] Unit 4 medication cart 1 had three bottles of expired medications: 1 stock bottle of oyster shell calcium 500 milligram labeled expired on 2/2024, 1 stock acidophilus with pectin 140 milligram bottle labeled expired 3/2024, and 1 resident specific medication citalopram hydrobromide 40 milligram, expired 11/27/2023. Licensed practical nurse #54 confirmed the 2 stock medications and 1 resident specific medication in the top drawer were expired. They stated the medication nurse was responsible for all the medications within their cart, and they should check the medications before dispensing them. During an observation and interview on 4/17/2024 at 3:30 PM, [NAME] unit 8 medication cart 1 had 2 vials of open insulin without labeled open dates, and there was no labeled pharmacy bag for the insulin vials. There was a blank sticker on the vial for the open date with the resident's name. Licensed practical nurse #73 stated the vial had been opened and belonged in a pharmacy bag with the open date on it. It was important to know the open date of the insulin because the effectiveness of the medication may be reduced after a certain amount of time. During an observation and interview on 4/17/2024 at 3:52 PM, [NAME] unit 10 medication cart 1 had 2 Trelegy Ellipta (inhaler for lung disease) without open dates. The pharmacy label documented to discard 6 weeks after opening. There was a resident specific Systane 0.4-0.3% eye gel medication and Azelastine hydrocholoride 0.1% nasal spray without labeled open dates, or expiration dates on the containers. Licensed practical nurse #74 stated all medications should be labeled with an open date. They were not sure when the 2 inhalers were opened and should be discarded due to lack of dates on the packages. The eye drops and nasal spray should have been labeled with a date open sticker and without the label they should be discarded because the medication could be expired. Medication room During an observation and interview on 4/17/2024 at 1:45 PM, the [NAME] unit 5 medication room refrigerator had significant ice buildup inside and the refrigerator temperature logbook documented the medication refrigerator should be maintained between 36-46 degrees Fahrenheit, when the temperatures were out of range: adjust thermostat, if temperature was not maintained place a high priority work order. Registered nurse Unit Manager #14 stated there was at least 6 inches of ice buildup in the refrigerator and the overnight nurse from 11:00 PM to 7:00 AM was responsible to document in the logbook and confirm appropriate temperatures were maintained. It was important to check the temperatures to ensure the medications were stored properly. During an additional observation and interview on 4/19/2024 at 9:48 AM, licensed practical nurse #13 stated that night shift was responsible for writing the refrigerator temperatures in the logbook. They stated there was about 3 inches of ice in the middle and 5 inches around the edges. They stated if the temperature check was not completed the refrigerator could have been out of range and this would affect medication storage. During an interview on 4/22/2024 at 1:45 PM, Assistant Director of Nursing #23 stated that once insulin was opened it should be labeled with the resident's name label and the open date. There was a little sticker that went on the vial and the pharmacy label should be on the bag where the vial of insulin would be stored. Insulin vials were specific to each resident. If there was no open date listed the insulin vial should be discarded and a new one ordered. There could be a change in effectiveness after opening a medication. The opened nasal spray should have a date on the resident sticker on the bottle, or an expiration date. If it did not have either, the medication should be discarded. The inhalers should have open dates listed, if it was not listed the medication should be discarded and a new one ordered. The inhaler inside the box should match the label on the box. If medications were not labeled and stored properly there was the potential for the resident to get the wrong medication, or an expired medication which may no longer be effective. 10 NYCRR 415.18(d) 48632 48895

Based on observation, record review, and interview conducted during the standard survey, it was determined the facility did not ensure necessary treatment and services were provided to promote healing, prevent infection, and prevent new pressure ulcers from developing for 1 of 7 residents (Residents #10) reviewed for pressure ulcers. Specifically, Resident #10 experienced harm related to pressure ulcers, when the skin on her coccyx area progressed from redness to a Stage II and then to a Stage III pressure ulcer, as the facility did not accurately assess the resident's risk for skin breakdown; did not initiate skin treatments timely or, as ordered by the physician order; did not ensure care plan interventions were reviewed for effectiveness; and medical staff and/or the wound care nurse were not notified when the pressure ulcer progressed to a Stage III. Additionally, the resident developed pressure ulcers on the bottoms of both heels when preventative interventions were not consistently implemented. Findings include: The facility's Pressure Ulcer Policy dated 12/2008, documented a resident found to have pressure ulcers would receive the necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. Interventions included: - the nurse would contact the Wound Care Nurse for consultation regarding treatment, staging and pressure relief measures; - the attending physician was to be notified to assure he agrees with treatment protocol; - The Nurse Manager or designee would complete the risk for or actual pressure ulcer part of the comprehensive care plan including goals, and interventions and make sure the appropriate interventions are placed on the Aide Assignment Sheet; - If the resident had a deterioration in condition and/or meal consumption is below 50%, turn and position resident every 2 hours from side to side, avoid back position except for meals and use a pillow to keep resident positioned. The resident should never be positioned on the wound and provide pressure relief mattress per the wound nurse; - for a Stage III pressure ulcer, the wound should be cleansed at each dressing change; - for a resident with [MEDICAL CONDITION] of the lower extremities, the resident should be provided with off loading of both heels utilizing a pillow. The facility's Guide to skin/wound protocols dated 6/10/2014, documented: - for a Stage II pressure ulcer, provide pressure relief, such as do not position on affected area, change position at least every 2 hours, protect skin from exposure to moisture, urine and feces. Cleanse the wound at each dressing change with normal saline or dermal wound cleanser; - for a Stage III pressure ulcer the resident, may need a special mattress and call the wound nurse. Provide a turning schedule, back to bed schedule and repositioning schedule. If necrotic tissue was present utilize an enzymatic [MEDICATION NAME] agent, apply liberally and change daily. Resident #10 was admitted with [DIAGNOSES REDACTED]. COCCYX An admission skin assessment dated [DATE], documented the resident's coccyx had redness; the the skin was blanchable (skin loses redness with pressure) and intact. A Braden scale (tool used for predicting pressure ulcers) dated 9/15/2015, documented the resident was at low risk for developing pressure ulcers. A nutrition note by the registered dietitian (RD), dated 9/16/2015 documented the resident's height was 59 inches; her usual body weight was 120 pounds; and most recently weighed 125 pounds, having a good appetite. The note documented skin does not warrant nutrition interventions at this time. A comprehensive care plan (CCP) dated 9/17/2015, documented the resident had an actual alteration in skin integrity as she had redness on her coccyx. Interventions included to monitor weekly, pressure reducing device to bed and wheelchair, keep skin clean and dry and reposition every 2-4 hours. A skin assessment dated [DATE], documented present on the coccyx is a redness and the skin site is healed. On 9/22/2015, the CCP was updated to specify the resident was at risk for impaired skin integrity related to bladder incontinence and decreased mobility. NO changes were made to the interventions. The social worker progress note dated 9/24/2015 documented the interdisciplinary team held the CCP meeting on that date. The note documented the resident was cooperative with care; was alert, oriented and able to make decisions. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired, she required extensive assistance for all activities of daily living (ADLs) and she did not have any pressure ulcers. The MDS documented the resident was frequently incontinent of bowel and bladder. A nurse practitioner (NP) progress note dated 10/12/2015, documented the resident was diagnosed with [REDACTED]. A NP progress note dated 10/13/2015, documented the resident was doing worse in therapy and had some mental changes. A physician progress notes [REDACTED]. There was no documented plan for the pressure areas in the progress note and there were no new physician orders. A nutrition note, dated 10/15/2015, documented the resident's weekly weights were: - 124.2 pounds the last week in 9/2015; - 168.7 pounds and 166.5 pounds for Week 1 in 10/2015; - 1663.4 pounds for Week 2 in 10/2015. A skin assessment dated [DATE] at 1:51 PM, documented the resident had a Stage II pressure ulcer on her coccyx measuring 1.0 centimeters (cm) x 1.5 cm. The pressure ulcer was superficial, the wound bed was red and a treatment was ordered. A physician order [REDACTED]. A physician order [REDACTED]. There was no documented evidence in the medical record of an assessment, or the rationale for changing the treatment to the coccyx. The October 2015 treatment administration record (TAR) documented the protective barrier cream was discontinued on 10/21/2015. The [MEDICATION NAME] and Allevyn to the coccyx was documented to start on 10/22/2015 at 2 PM. There was no documented evidence on the TAR the [MEDICATION NAME] and Allevyn treatment was initiated until 10/24/2015. A skin assessment dated [DATE], documented the resident continued to have a Stage II pressure ulcer to the coccyx measuring 5.5 cm x 2.5 cm x 0.3 cm and most of the wound bed was red with a small amount of slough (moist dead tissue) present. The NP was notified of the wound, not getting better and the treatment was changed. A NP progress note dated 10/26/2015, documented the resident had a worsening wound on her coccyx, the plan was to change the treatment and, to try and keep her off her bottom as much as possible. There was no documentation of the NP's plan on the resident's CCP. A physician order [REDACTED]. A NP progress note dated 10/28/2015, documented the resident was not, looking good and the staff felt she was not eating and drinking well. The NP documented the resident continued to have loose stools (2-3 times daily) related to her [MEDICAL CONDITION] and the plan was to obtain some laboratory values and start [MEDICATION NAME] (antibiotic) for the [MEDICAL CONDITION]. A NP progress note dated 10/29/2015, documented the resident's laboratory values did not show the resident was dehydrated. A skin assessment dated [DATE], documented the resident had a Stage III on her coccyx measuring 7.0 cm x 3.8 cm and the wound bed was not visible. The assessment documented there was necrotic (black dead tissue), slough and eschar (dead tissue) present to the wound and there was a treatment in place. There was no documented evidence the physician, NP or Wound Care Nurse were notified the pressure ulcer had progressed to a Stage III and there was no documented evidence the resident's plan of care was reviewed or revised. A physician order [REDACTED]. A skin assessment dated [DATE], documented the resident had a Stage III on her coccyx measuring 5.5 cm x 3.8 cm and the wound base was not visible. The wound contained necrotic tissue, eschar and slough. The assessment documented the resident had pressure reducing devices in bed and wheelchair and the turning and positioning schedule was being implemented. An certified nurse aide (CNA) Assignment Sheet (care instructions) provided to the surveyor on 11/12/2015, documented the resident was non ambulatory, incontinent, had a [MEDICATION NAME] cushion and a pressure relief mattress and was to be placed back to bed after lunch and repositioned every 2 hours. The CNA Assignment Sheet did not document the NP's plan of 10/26/2015 to to try and keep her off her bottom as much as possible. During treatment observation on 11/13/2015 at 1:55 PM, the licensed practical nurse (LPN) #10 removed the resident's Allevyn dressing on her coccyx which was soiled with stool and had become unattached at the lower aspect of the dressing. The resident had a large unstageable pressure ulcer to her coccyx. The pressure ulcer measured approximately 6 cm x 3 cm. The wound was covered with slough and small amount of necrotic tissue at the upper aspect of the pressure ulcer. There was a very foul odor when the old dressing was removed. The LPN changed her gloves then applied [MEDICATION NAME] to the wound bed, covered it with [MEDICATION NAME] and then Allevyn. The LPN did not cleanse the wound prior to applying the new dressing. LPN #10 was interviewed on 11/13/2015 at 2:20 PM, and stated she did not cleanse the wound after removing the old dressing and applying a new one as the order did not specify to clean the wound. During an interview with CNA #17 on 11/16/2015 at 1 PM, she stated the resident was incontinent of bowel and bladder. The resident was gotten out of bed prior to breakfast and was put back to bed after lunch. She stated the resident liked to sleep on her back and at times refused to be turned and positioned. She stated the resident did not have a specialized mattress. During an interview with LPN #18 on 11/17/2015 at 10:35 AM, she stated if a resident refused to be turned and positioned, she would document in a progress note. She stated at times the resident would refuse to be turned and positioned. When she did the resident's dressing she always cleansed the wound prior to putting on a new dressing even if the order did not specify to as it was standard nursing practice. During an interview on 11/17/2015 at 11 AM with the Clinical Coordinator registered nurse (RN) #19, she stated she was responsible for monitoring the resident's pressure ulcer and updating the care plan. She stated she had spoken to the NP regarding changing the treatment and was not sure if or when the NP evaluated the pressure ulcer. She stated she had not consulted with the facility's Wound Care Nurse. When the resident developed the Stage II pressure ulcer she updated the resident's care plan for turn and position every 2 hours and back to bed after lunch. The resident was incontinent of stool and was being treated for [REDACTED]. She would call the NP for a different treatment order if the area was not getting better and she did not know why there was no assessment in the progress note when the treatments were changed. She stated she may have forgotten to chart. She was not aware the resident was refusing to be turned and positioned off of the pressure ulcer and the resident did not have a speciality mattress as all residents had pressure relief mattresses on their beds. She stated when the dressing was changed, the pressure ulcer should always be cleansed with normal saline prior to applying a new dressing as that was the facility's policy. When the physician orders [REDACTED]. The RN reviewed the physician orders [REDACTED]. During an interview with the RN Unit Manager on 11/17/2015 at 12:30 PM, she stated the Clinical Coordinator was responsible for monitoring skin impairments and updating the care plans. She was not aware the resident's pressure ulcer had progressed from a Stage II to a Stage III and I'm sure the Wound Care Nurse is involved. She was not aware the resident was refusing to be turned and positioned and if that were the case, other interventions could be initiated. She stated if the resident was refusing care it was addressed in the CCP. During an interview with the Wound Care Nurse on 11/17/2015 at 1:45 PM, she stated she had not assessed the resident's pressure ulcer and the only time she was consulted regarding the ulcer was when the clinical coordinator asked if they could use [MEDICATION NAME] on the wound bed. She stated it was standard nursing practice to cleanse a wound with normal saline prior to applying a new dressing. If a resident was not compliant with turning and positioning an appropriate intervention was an alternating air mattress. During an interview with the NP on 11/17/2015 at 2 PM, she stated she was not sure when the last time she had looked at the resident's pressure ulcer and did not assess it when it progressed to a Stage III. When the surveyor told the NP the current status of the resident's coccyx pressure ulcer, she said she intended for the resident to be on a strict back to bed schedule, back to bed after breakfast and after lunch, to facilitate healing. She stated she did not write a specific order and she should have done so. She was not aware the resident was up in her wheelchair in the morning and only put back to bed after lunch. The NP stated the resident declined and when she was treated her for the oral candidiasis (thrush), the resident improved and increased her intake. During a follow-up interview with the Wound Care Nurse on 11/17/2015 at 2:45 PM, she stated she just assessed the resident's pressure ulcer. She stated she should have been contacted sooner regarding the pressure ulcer, as she would have recommended a speciality alternating air mattress, changing the treatment to daily not every other day and placing the resident on a strict back to bed schedule. She stated on the day a treatment was ordered she would expect the treatment be placed on the resident that day and not wait until the next day to start. During an interview with the resident's physician on 11/18/2015 at 8:45 AM, he stated he would expect to be notified if a resident had a worsening pressure ulcer to ensure proper interventions were in place. He stated he was not aware the resident's pressure ulcer to her coccyx had progressed to a Stage III. He stated he would expect the Wound Care Nurse to be involved as she was the specialist for wounds. He stated he was not aware the resident was non-compliant with turning and positioning and if she was, they could initiate a speciality mattress which would do the offloading for them. He stated pressure ulcers should be cleansed whenever a dressing was changed to remove any debris, bacteria and drainage. HEELS The facility policy, Heel Ulcer Prevention Policy and Procedure dated 7/26/2015, documented a resident with [MEDICAL CONDITION] in the lower extremities was at risk of developing pressure ulcers and interventions included all at risk resident's were to use the Prevalon boots to off-load the heels. An admission skin assessment dated [DATE], documented the resident had redness on top of her left foot and on her right great toe. A comprehensive care plan (CCP) dated 9/17/2015, documented the resident had an actual alteration in skin integrity as she had redness on her left foot and right great toe. Interventions included reposition every 2-4 hours and keep skin clean and dry. There were no documented plans for pressure relief for the resident's feet. A Braden scale (tool used for predicting pressure ulcers) dated 9/15/2015, documented the resident was at low risk for developing pressure ulcers. A skin assessment dated [DATE], documented the resident continued to have redness on the top of her left foot and on her right toe. A skin assessment dated [DATE], documented the resident continued to have redness on the top of her left foot and on her right toe. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired, required extensive assistance for all activities of daily living (ADLs) and she did not have any pressure ulcers. A nurse practitioner (NP) progress note dated 10/26/2015, documented the resident was seen for increased [MEDICAL CONDITION]. The NP documented the resident had non-pitting (no indentation when the area is pressed) [MEDICAL CONDITION] in both lower extremities and especially around her ankles. The plan was Ace wraps to both legs, on in the morning and off at night. A skin assessment dated [DATE], documented blood blisters were found on the bottom of both the resident's heels. The right heel blood blister measured 2 centimeters (cm) x 2 (cm) and the left heel blood blister measured 4 cm x 4 cm and a treatment was ordered. A physician order [REDACTED]. A skin assessment dated [DATE], documented a blood blister to the right heel measured 2 centimeters (cm) x 2 (cm) and the left heel blood blister measured 4 cm x 4 cm. The Prevalon boots remained in place. A certified nurse aide (CNA) Assignment Sheet (care instructions), printed 11/11/2015, documented the resident was non ambulatory; was to be positioned off her bottom; and had a pressure relief mattress There was no documented care instructions regarding providing any pressure relief to the resident's feet. The resident was observed on 10/12/2015 at 3:55 PM, 4:20 PM, 5:25 PM and 5:50 PM lying in bed with her heels resting directly on the mattress. The Prevalon boots were on a chair across the room. The resident was observed on 10/13/2015 at 10:05 AM, 11:10 AM, 12:15 PM and 1:05 PM, sitting in her wheelchair with non slip socks on both of her feet. Both feet were resting on the footrest of the wheelchair with her heels directly against the back of the footrest. The resident's heels were observed during a treatment observation on 10/13/2015 at 1:55 PM, with licensed practical nurse (LPN) #10. The resident had ace wrap to both feet and the right heel was not covered with the ace wrap. The resident had dark purple, fluid filled blisters to both heels. The resident was observed on 11/16/2015 at 8:15, 8:35 AM and 12:50 PM sitting in her wheelchair with non slip socks on both feet, resting directly on the foot rests of the wheelchair with her heels directly against the back of the footrest. During an interview with certified nurse aide (CNA) #17 on 10/16/2015 at 1 PM, she stated the resident wears Prevalon boots while in bed and non slip socks on her feet during the day. She stated it was the responsibility of the CNAs to apply the Prevalon boots and they would know to apply them by looking at the Aide Assignment Sheet. The CNA looked at her Aide Assignment Sheet and stated the Prevalon boots were not on there and she knew to apply the Prevalon boots as she took care of the resident full-time. During an interview with LPN #18 on 11/17/2015 at 10:35 AM, she stated it was the responsibility of the CNA to apply the Prevalon boots and it was the responsibility of the LPNs to ensure the resident had them on and they would sign off in the treatment administration record. During an interview with the Clinical Coordinator registered nurse (RN) #19 on 11/17/2015 at 11 AM, she stated if a resident developed [MEDICAL CONDITION] to the lower extremities, it could make them more prone to pressure ulcers. She stated the resident developed the blisters as a result of pressure being applied to the areas and she initiated the Prevalon boots and skin prep to toughen the skin on the heels. She did not initiate any pressure prevention to the feet when the resident initially developed [MEDICAL CONDITION]. She stated it was the responsibility of the CNAs to apply the Prevalon boots while the resident was in bed and the CNAs would know to apply them by looking at the Aide Assignment Sheet. She stated there was no pressure relief interventions for the resident's heels while she was out of bed. During an interview with the Wound Care RN on 11/17/2015 at 1:45 PM, she stated the resident was admitted with redness to her feet and the resident, probably already had deteriorating tissue on the heels when she was admitted . During an interview with the resident's physician on 11/18/2015 at 8:45 PM, he stated resident's with [MEDICAL CONDITION] to the lower extremities were more prone to pressure ulcers and interventions to off load pressure to the heels should be initiated. He stated pressure relief should be done while the resident was up and out of bed as well as when they were in bed. 10NYCRR 415.12 (c)(1)(2)

Based on record review and staff interviews conducted during the partial extended survey (#NY 863), it was determined for residents residing on Units 6, 7 and 8, (including Resident #1 who resided on Unit 6), the facility did not provide services that meet professional standards of quality. Specifically, the facility failed to ensure admission diet orders were written and clarified by the attending medical practitioner. This resulted in actual harm to Resident #1 with the potential for more than minimal harm to residents residing on Units 6, 7 and 8, that is immediate jeopardy. Findings include: Resident #1 was admitted to the facility on [DATE] following a surgical repair of a left [MEDICAL CONDITION] (July 8, 2012). The resident's ongoing [DIAGNOSES REDACTED]. On July 16, 2012, the diet technician documented in a progress note that the resident was admitted from the hospital and the resident's diet order was "regular unmodified" with nectar thick liquids. The New Admission Physician order [REDACTED]. The hand written order was for a regular unmodified diet with nectar thick liquids. The NP's dictated "Admitting Note" dated July 16, 2012 documented the resident had a clinical swallow evaluation on July 10, 2012 "which recommended nectar thickened liquids with pureed trials resulting in her oral holding and the need for verbal cues to swallow." The resident was on aspiration precautions, and needed assistance with her oral intake. The NP documented "her diet will be soft with nectar-thickened liquids." The NP was interviewed on October 1, 2012 at 2:40 PM regarding the physician orders. She reviewed the admission orders [REDACTED]. She stated, upon admission, the dietitian reviewed the information received by the facility, discussed the diet with the resident and/or family member and the dietitian wrote the diet on the initial orders. She said she communicated with the dietitian prior to an order being written and was aware of the diet prior to signing the orders. When asked to clarify the conflicting admission diet order for Resident #1 with the "admitting note" for this resident, she stated a regular unmodified diet was "similar" to a soft diet. The registered dietitian (RD) was interviewed on October 1, 2012 at 3:25 PM and stated the facility policy was for either the RD or the diet technician to do the nutrition screen within 24 hours of admission. The screen included reviewing the "paperwork" and writing the diet order. The RD stated she did not write the July 16, 2012 order for Resident #1 to have a regular unmodified diet. On October 2, 2012 between 4:00 PM and 4:30 PM, a surveyor interviewed the diet technician who was assigned to Resident #1's unit on July 16 and 17, 2012. She stated when a resident was admitted to the facility, she reviewed any paperwork that was available prior to the admission. The policy was for the screen to be completed by the RD or the diet technician within 24 hours of the admission. She stated if the paperwork on admission was "straightforward" she wrote the order on the physician orders. The NP always checked the order and was "ultimately responsible." She said she always worked with the same NP and this was their normal routine. She stated if there was any question or doubt about the consistency or diet order, she discussed it with the NP. In reviewing the admission order for Resident #1, the diet technician stated it was her own handwriting on the order form. In summary, the facility did not ensure physician diet orders were completed by a qualified practitioner as it is not in the scope of practice for nutrition staff to write physician orders. (Refer to F323, example #1) 10NYCRR 415.11(c)(3)(i)

Based on observation, record review and staff interviews conducted during the partial extended survey (#NY 863), it was determined for 6 of 6 residents (Residents #1,2,3,4, 5 and 6) reviewed for accident hazards, the facility did not consistently provide an environment free of hazards, and did not provide adequate supervision to prevent accidents. Specifically, for Resident #1, the facility failed to develop and implement a safe feeding plan for a resident identified with swallowing difficulties. Additionally, when the resident was found unresponsive in the dining room, the facility failed to implement emergency measures in a timely manner. For Residents #2, 3, 4, 5 and 6, the facility failed to maintain updated feeding plans, and implement the feeding plans for these residents who were identified on aspiration precautions. This resulted in actual harm for Resident #1 and no actual harm with the potential for more than minimal harm that resulted in immediate jeopardy and substandard quality of care for Residents #2, 3, 4, 5 and 6. Findings include: 1) Resident #1 was admitted to the facility on [DATE] following a surgical repair of a left hip fracture ([DATE]). The resident's ongoing [DIAGNOSES REDACTED]. FAILURE TO DEVELOP AND IMPLEMENT A SAFE FEEDING PLAN The following information was provided to the facility on admission from the discharging hospital: - The History and Physical Exam Report completed at the hospital on [DATE] documented the resident was admitted to the hospital following a fall. - The Operative/Procedure Report dated [DATE] documented the resident had a left intertrochanteric fracture and an open reduction and internal fixation (ORIF) procedure was performed. The postoperative plan was for "cautious fluid administration." - A Clinical Swallow Evaluation completed on [DATE] documented the resident was on a regular diet prior to hospitalization , with no history of dysphagia per the resident's "children." The resident had not had any oral intake since admission. The speech therapist documented the resident tolerated nectar thick liquids and "puree trials resulted in oral holding" with the need for verbal cues to swallow. The resident needed additional verbal cues to clear residue after swallowing. The resident was not able to tolerate the trial of puree food and the resulting recommendation included "nectar thick liquids only", aspiration precautions and total assistance with oral intake. A follow up with the communication disorder unit was to occur the following day ([DATE]) to monitor tolerance and "ADAT" (advance diet as tolerated). The follow up evaluation was not included in the documentation provided to the facility at the time of admission or during the resident's stay. - The eKardex Report (electronic record for medication administration) documented on [DATE], the resident's diet was a regular adult diet with nectar thick liquids and Ensure Plus. - On [DATE] the Loretto System Assessment, completed by the Loretto "screener" at the discharging hospital, was faxed to Loretto. The "Confidence Sheet" related to Nutrition documented: diet as regular, nectar thick liquids; aspiration precautions, and "diff (difficulty) swallowing pills. The form did not identify any chewing or swallowing problem and did not document the resident had an SLP (speech language pathologist) evaluation. - The hospital Discharge and Referral Orders dated [DATE] documented the resident's diet as "nectar thick liquid, soft foods." - The hospital Discharge Summary, dictated on [DATE] at 12:57 PM, was faxed to the facility at 4:03 PM on [DATE] . The summary included a [DIAGNOSES REDACTED]." The discharge disposition was documented as "improved" and to discharge the resident on a "pureed thickened liquid diet." At 3:30 PM on [DATE], the diet technician documented in a progress note the resident was admitted from the hospital and had no chewing/swallowing difficulty "per transfer paperwork" and the resident's diet order on admission was "regular unmodified" with nectar thick liquids. The New Admission Physician order [REDACTED]. The NP's "Admitting Note" dated [DATE] documented the resident had a clinical swallow evaluation on [DATE] "which recommended nectar thickened liquids with pureed trials resulting in her oral holding and the need for verbal cues to swallow." The resident was on aspiration precautions, and needed assistance with her oral intake. The NP's assessment and plan documented "her diet will be soft with nectar-thickened liquids" and documented she would wait for the dietitian to review the resident's swallowing evaluation. The NP was interviewed on [DATE] at 2:40 PM and she stated her normal procedure following a resident's admission was to review all the information that accompanied the resident from the discharging facility. She said the discharge summary did not always come with the resident and sometimes came following the resident's admission. The NP stated her routine was to communicate with dietary and write a diet order based on the recommendation from dietary. She stated staff would not see her admission note on the day of admission as she dictated the note and it did not return to the unit on the same date. When questioned about a soft diet (per her note) and the order for an unmodified diet, the NP stated they were similar. She stated it was not the facility practice to write orders for aspiration precautions and this information would be based on the resident's comprehensive care plan (CCP). She stated if the resident was on aspiration precautions, she would have expected the resident to be seated at a table where staff were going to feed her. The NP did not include the [DIAGNOSES REDACTED]. The diet technician who wrote the admitting dietary note was interviewed on [DATE] between 4:00 PM and 4:30 PM. She stated her procedure was to gather the information on the day of admission, prior to 4 PM, when the diet needed to be called down to the kitchen. To gather this information, she visited the resident, talked to family (if present) and reviewed the information from the discharge facility. She said she reviewed "all paperwork" available, including, for example: the screen (from Loretto screener), lab work, medications, hospital admission information, skin condition, swallow evaluation (if provided), and review for a history of falls, skin tears, and [DIAGNOSES REDACTED]. As she did not recall the situation with Resident #1, the surveyor asked her to review the hospital discharge information and explain what diet she would have recommended based on the information provided. (the hospital discharge summary was not provided to her as it was faxed to the facility after the diet technician wrote her admission note). Upon reviewing the information, she stated she would use the information from the swallowing evaluation and referred the surveyor to the portion of the evaluation that documented "current diet - regular" and nectar thick liquids. She stated the swallow evaluation did not say anything about pureed or ground food and thought the evaluation was "inadequate." Upon seeing the Kardex orders for [DATE], she stated she would have possibly used that information and recommended the regular diet with nectar thick liquids. She stated, if she saw the discharge order for the soft diet with nectar thick liquids, she would have recommended that diet, and had she seen the discharge summary, she would have recommended the pureed diet with honey thick liquids. She stated, if the discharge summary arrived after the resident and after she reviewed the hospital information, nursing would inform her of the additional information, and she would review it at that time. She did not know if she was ever made aware of Resident #1's discharge summary. For this resident who arrived with conflicting information related to her diet consistency from the discharging provider, the facility did not clarify the information upon admission, prior to writing the diet order. FAILURE TO PROVIDE EMERGENCY MEASURES Review of the facility menu for the evening meal on [DATE] revealed the entree was kielbasa. On [DATE] the licensed practical nurse (LPN) documented in a progress note the resident was "noted to be unresponsive after supper." The supervisor was called and the resident was "put to bed." The supervisor assessed the resident. The LPN was interviewed on [DATE] at 5:50 PM. She stated she started her [DATE] shift on the unit at 3 PM. She recalled the following from [DATE]: - The resident was with her family member, complained of pain, and Lortab "I think" was given to the resident " about 4 PM; - The resident's family member brought her into the dining room and when the meal (supper) came (approximately 5:20 PM), the LPN and family member watched the resident from the hall outside the dining room (through the glass), and the resident was feeding herself; - The family member and LPN were pleased the resident was feeding herself and the LPN stated "days" (7 to 3 shift) said they had to help her a little with her meal; - The LPN stated the resident was seated at a long table in the front of the dining room on the right hand side and ate independently. The LPN went to the front left corner of the dining room to assist the residents who needed to be fed; - The LPN could not recall if someone brought her attention to Resident #1 or if she just looked over and noticed she was slumped over in the chair and pale. She stated she "looked like she was already gone" - The LPN tried to wake her up but received no response. The resident was seated with her eyes closed and "looked like she was sleeping but her color was pale" - The LPN did a sternal rub, received no response and did not start resuscitation as she knew the resident was a DNR; - The supervisor was called and the LPN wheeled the resident back to her room and the resident was placed in bed prior to the RN Supervisor assessing the resident; - The LPN stated the RN checked the resident to see if there was food in her mouth when she was in bed; and - The LPN stated the resident did not seem to be eating at the time she observed her in the dining room, as she did not have a utensil in her hand, so she did not think the resident was choking. On [DATE] the registered nurse (RN) documented in a progress note, she assessed the resident by looking to see if her air way was clear "and it was". The resident had no breath sounds, no heart sounds and the RN documented the resident expired at 6:05 PM. The medical examiner was notified as she had a recent fall with resulting surgery. The RN Supervisor was interviewed on [DATE] between 4 PM and 4:30 PM. She stated the following from her recollection of [DATE]: - she received a call from Unit 6 to come to the unit for an emergency; - the resident was being transferred to the bed when she arrived on the unit; - she checked the resident's respiratory status and checked for lung sounds, and stated her airway was clear; - as the resident was DNR, she did not start resuscitation and she "pronounced her." The RN Supervisor, when interviewed on [DATE] between 4 PM and 4:30 PM stated staff told her the resident had not been eating at the time they discovered her unresponsive. She stated if she had choked and was unresponsive in the dining room, she would have checked her before they moved her. Her understanding from the staff was they moved her as she was not eating, and for "dignity" they removed her from the other residents in the dining room. The RN Supervisor was asked about aspiration precautions, when she was interviewed on [DATE] between 4 PM and 4:30 PM. She stated staff (for example nurses and CNAs) would need to check to be sure the resident received the right consistency solids and fluids, and according to the facility policy, the nurse needed to watch the resident closely related to her swallowing and chewing ability. The RN stated the information regarding aspiration precautions was on the aide assignment sheet and also identified by dietary with a colored napkin. The RN Manager was interviewed on [DATE] at 9:50 AM. She stated, when a resident was a new admission, she (or the RN clinical coordinator) assessed the resident and if they thought the resident could eat independently, they would assign the person to a table near a staff person. If the resident was identified with aspiration precautions, she would seat her at a table near a "feeder table" or "where staff is sitting". She would not seat her at an "independent" table. When the RN Manager was asked about the table in the right front corner of the dining room (table identified by the LPN as where Resident #1 was seated) she said the table was for residents who were independent with need for cuing only. The NP documented in a discharge summary, dated [DATE], the resident was given hydrocodone with Tylenol at 4:30 PM on [DATE] due to complaining of hip pain. "Shortly thereafter" she became diaphoretic, "complaining about some increased pain," became unresponsive and since she was a DNR (do not resuscitate), no resuscitation was attempted. The forensic autopsy report dated [DATE] documented the resident expired due to aspiration of foreign body and asphyxia. The report documented that a rectangular piece of sausage that was 2 centimeters (cm) by 1.5 cm by 1.5 cm was lodged in the larynx below the epiglottis. The facility did not have a plan in place to monitor the resident related to aspiration precautions,and did not provide emergency treatment when found unresponsive in the dining room, at meal time. In summary, the facility failed to develop and implement a safe feeding plan, and failed to provide emergency measures. 2) Resident #2 was admitted to the facility in May, 2009 and had [DIAGNOSES REDACTED]. A Speech and Language consult was requested on [DATE] as a result of her pocketing (holding food within the cheeks of the mouth) food. The resident's diet was identified as ground with nectar thick liquids and thin liquids in Provale cup only (a cup used to improve independent hydration for dysphagia). The resident was unable to cooperate with the evaluation and the speech therapist requested to be contacted again if the resident developed signs and symptoms of dysphagia. On [DATE] a Speech and Language consultation was requested by the dietitian, as the resident's diet had been changed to puree related to an unresponsive episode, and the resident's status had improved since admission. The recommendations resulting from the consultation included: - upgrade the diet to "soft solids" with thin liquids; - aspiration precautions; - alternate solid swallows with liquid swallow to clear lingual residue; and - position upright at 90 degrees for meals. A physician progress notes [REDACTED]. On [DATE], a nursing progress note documented the resident was noted to pocket food after lunch and a finger sweep was done to remove food from both inner cheeks. The most recent physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment for decision making, and required set up and supervision for eating. Nutritional approaches included a mechanically altered diet. The comprehensive care plan (CCP) updated on [DATE] documented the resident had the potential for aspiration related to chewing/swallowing problems including decreased lingual strength and "pockets food." The plan included "feeding strategies per SLP" (speech pathologist) and included sitting upright for all oral intake, no straws, oral care after meals, and monitor for signs and symptoms of aspiration. On [DATE] at 5:20 PM, 2 certified nurse aides (CNAs #1 and 2) on the resident's unit were interviewed regarding aspiration precautions. CNA #1 who was familiar with the unit stated information "may be on the corkboard" on the wall in the dining room, in a book. A blue binder referred to as the "Feeding Strategies" was located in the dining room near the corkboard on Unit 6 on [DATE] at 5:25 PM. The initial page in the book was labeled "Aspriation Precautions Updated List" and was dated [DATE]. Resident #2's name was listed and documented the resident was on a puree diet with thin liquids, alternate solids with liquids, seated upright, no straws, and oral care. The activities of daily living (ADL) assignment sheet used by the CNAs at the time of the survey, documented the following for the resident's needs: set up, a pureed diet and "see feeding strategies book." The resident was observed on [DATE] between 5:30 PM and 5:50 PM. The resident was seated at the table in the dining room with her meal in front of her. The resident was slouched in the chair with her head and chin close to her chest. She was not observed to be assisted or supervised when eating and did not alternate solids and fluids when feeding herself. In summary, for this resident identified to be an aspiration risk, the facility did not follow the plan of care for aspiration precautions, as identified in the comprehensive care plan, and in the blue binder (as directed in the CNA assignment sheet). 3) Resident #3 had [DIAGNOSES REDACTED]. Review of the resident's record revealed the resident was evaluated by speech therapy on [DATE], [DATE], [DATE] and [DATE]. The "Aspiration Precautions Updated List" located in the resident's dining room on [DATE] at 5:20 PM, and dated [DATE] documented the resident's plan as follows: "puree thin liquids/ small bites, single sips (straw), must attempt each bite of puree with single sip of liquids, observe for swallow after each bite/sip." A speech therapy treatment note dated [DATE] documented the resident had dysphagia, oropharyngeal phase, with onset September, 2005. A clinical swallow evaluation was completed recommending a puree diet with nectar thick liquids. The current physician orders [REDACTED]. The order for the precautions included: seat upright for meals, remain upright for 30 to 45 minutes after meals - reduce size of sips (single), alternate liquid and solids, verbal reminders to swallow, and constant supervision fed by staff. The physician progress notes [REDACTED]." The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and required total assistance eating. The nutritional approach identified the resident to be on a mechanically altered diet. On [DATE], the diet technician documented in a progress note, the resident was on a pureed diet with nectar thick liquids related to aspiration precautions. She documented the CNA reported the resident had no problems with chewing or swallowing food on the current diet and received a "blue napkin" ( to mean she needed thickened liquids) at meals. The comprehensive care plan (CCP), updated on [DATE] documented the resident had a potential for aspiration related to chewing/swallowing problems and was on aspiration precautions. The plan included feeding strategies per the speech language pathologist: sit upright (90 degrees) for meals, remain upright for 30 to 45 minutes after meals, reduce size of sips and half size teaspoonfuls, alternate liquids and solids, and verbal reminders to swallow. The activities of daily living (ADL) assignment sheet used by the CNAs at the time of the survey, documented the resident required total help feeding, was on a regular pureed diet with nectar thick liquids and to "see feeding strategies book." On [DATE] at 5:15 PM CNAs #1 and 2 on Resident #3's unit were interviewed related to aspiration precautions. CNA #1 stated this unit was her usual unit and, when explaining the procedure in the dining room, stated the residents with blue napkins required encouragement eating, and the red napkins meant the resident was on thickened liquid. She hesitated and said "or maybe I have it backwards." She stated specific instructions for feeding/aspiration precautions were either found in the nursing office, or "maybe on the corkboard" and she pointed to a board in the dining room. The blue binder/book was labeled "feeding strategy book." CNA #2 did not respond to the questions and stated this was not his usual unit. On [DATE] between 5:20 PM and 5:35 PM, the resident was observed being assisted in the dining room with the evening meal. The staff member assisting the resident gave the resident a drink and the resident was observed taking several sips at once, using a straw. The CNAs (CNAs # 2,3, and 4)who were assisting Resident #3 and the other residents at the table on [DATE] between 5:30 PM and 5:50 PM were interviewed regarding assisting the residents. CNA #3 stated she "checks the strategy binder for aspiration precautions" and how the resident was to be fed. CNA #4 stated she checked the binder "usually every other day" in case there were changes and said "it changes so frequently." CNA #2 stated he did not know what residents were on aspiration precautions as he did not normally work on this unit. In summary, for Resident #3 who was identified at risk for aspiration, the facility did not follow the plan of care as identified in the physician's orders [REDACTED]. The blue binder was not up to date as it was dated [DATE] and identified Resident #3 on thin liquids, whereas the resident's diet was nectar thick liquids. 10 NYCRR 415.12(h)(1)(2)

Based on record review and staff interview conducted during the partial extended survey (#NY 863), the Administrator and Director of Nursing (DON) failed to administer the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, administration failed to ensure the facility had systems in place to ensure: - therapeutic diets were ordered by the appropriate medical practitioner; - safe feeding plans were identified and updated for residents with swallowing difficulties; - aspiration precautions were identified and plans implemented; and - emergency measures were implemented in a timely manner. This resulted in actual harm for Resident #1 with the potential for more than minimal harm that is Immediate Jeopardy to the health and safety of residents, including Residents #, 2, 3 4, 5 and 6, and residents on Units 6, 7 and 8. Refer to F281, and F323. Findings include: The Administrator was interviewed on [DATE] at 1:30 PM. He stated he was not aware of the problems until the surveyors arrived [DATE], and was not aware of the severity until "today" after obtaining the autopsy results for Resident #1. The Administrator stated he should be aware of any problems within the facility and said it was a huge task "in this size facility." The Administrator discussed the concerns with the Director of Nursing (DON) "today" and the plan was to get the "team" together and review what went wrong. The Director of Nursing (DON) was interviewed on [DATE] at 11:45 AM. She had not been aware of the details of Resident #1's death and had not completed an investigation. She stated the following: - Due to the discrepancy in preadmission information pertaining to Resident #1's diet, clarification should have been obtained prior to writing the diet order; - Nursing staff did not follow the facility procedure upon finding Resident #1 unresponsive in the dining room. She stated everyone had CPR/[MEDICATION NAME] training and staff should have followed that training for anyone choking or unresponsive; - Updated information pertaining to aspiration precautions should have been in the "blue binder" and care plan; and -The facility does not have a written policy for the admission process. 10 NYCRR 415.26

Based on record review and staff interview conducted during the partial extended survey (#NY 863), the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues that caused serious harm to Resident #1, and with the potential to cause serious harm to Residents #2,3,4,5, and 6 who were identified at risk for choking. Additionally, the facility did not identify issues related to medical orders not written by the attending medical practitioner for residents on Units 6, 7, and 8. Specifically, QA failed to recognize the facility: did not provide adequate supervision for residents at risk for aspiration; did not follow protocol when a resident was found unresponsive in the dining room; and did not ensure physician orders [REDACTED]. This resulted in actual harm for Resident #1 with the potential for more than minimal harm that was Immediate Jeopardy to the health and safety of Residents #2, 3, 4, 5 and 6, and residents who resided on Units 6, 7 and 8. Refer to F281 and F323. Findings include: The Administrator was interviewed on October 2, 2012 at 1:30 PM and stated he was not aware of the problems until "yesterday" when the surveyors arrived at the facility and started the investigation. QA had not discussed these issues and the Director of Nursing (DON) was the chairman of the committee. The DON was interviewed on October 2, 2012 at 11:45 AM and had not interviewed staff regarding the problems identified, until made aware by the surveyors. As a result, a quality assurance plan was initiated on this date,as a first step, and all dietary staff were in the process of reviewing all resident records for accuracy of dietary orders and for aspiration precautions. 10 NYCRR 415.27(a-c) :