Every finding on record at Morningstar Residential Care Center

Based on record review and interviews during the abbreviated survey (IQIES #2572456), the facility failed to establish consistent mechanisms for documenting and communicating a resident's choice regarding advance directives to the staff responsible for the resident's care for one (1) of three (3) residents, Resident #1. Specifically, Resident #1 was found without a pulse and without respirations, and staff did not initiate cardiopulmonary resuscitation (emergency procedure performed when someone's breathing or heartbeat has stopped) per the resident's wishes documented on their Medical Orders for Life Sustaining Treatment, resulting in the resident's death. Additionally, the facility failed to ensure there was a process for verification of medical orders related to residents' advance directives. The facility's failure to verify Resident #1's advance directives including the Medical Order for Life Sustaining Treatment form places all 104 residents in the facility who had advance directives in place at risk. This resulted in actual harm that was Immediate Jeopardy to residents' health and safety.Findings include:The [DATE] facility policy Physician Order Management Policy, documented advance directives must be entered using an order template search; it was the only way the system could identify the order as an advanced directive. New orders would be reviewed using a multiple nurse check approach on each shift and by the 11:00 PM - 7:00 AM night supervisor to ensure the new order met the basic prescribing standard and checked for transcription accuracy. The [DATE] facility policy Advance Directives, documented the Care Center would educate appropriate staff regarding advance directives. The Medical Orders for Life Sustaining Treatment form was the primary reference at the facility. Should the resident present as a repeat admission, with information that indicated there was an advance directive in the previous medical record, social services and/or nursing staff had the responsibility to review the existing advanced directive with the resident/significant other to validate its current status. Resident #1 had diagnoses of osteoarthritis of both knees, sepsis without septic shock (a life-threatening complication of an infection) and urinary tract infection. The [DATE] Minimum Data Set (an assessment tool) documented the resident had intact cognition, clear speech, could understand others and was understood, and had a urinary catheter. The [DATE] Medical Order for Life Sustaining Treatment form documented Resident #1's wishes were for Full Code (initiate cardiopulmonary resuscitation). The [DATE] Comprehensive Care Plan documented Resident #1 wished to have advance directive orders in place and refer to the Medical Orders for Life Sustaining Treatment form. Interventions were to notify the physician with changes and review annually. The [DATE] at 10:07 AM hospital discharge summary documented the resident was admitted for septic shock related to a urinary tract infection, had stabilized and was ready for discharge. The hospital discharge summary progress note did not reference the resident's advance directive status. The physician orders in the electronic medical record documented:- On [DATE] at 3:15 PM, a telephone order was created by Licensed Practical Nurse #9 for Resident #1's advance directives. The order documented Do Not Resuscitate (do not initiate cardiopulmonary resuscitation) and Do Not Intubate (do not use mechanical ventilation);- On [DATE] at 05:09 PM, Licensed Practical Nurse #10 confirmed the Do Not Resuscitate/Do Not Intubate physician order; and- On [DATE] at 10:00 AM, Physician #6 signed the order electronically. The [DATE] at 3:53 PM Nursing admission Assessment by Licensed Practical Nurse #10 documented Resident #1 had a Do Not Resuscitate/Do Not Intubate advance directive status. There was no documented evidence nursing staff reviewed advanced directives with the resident/significant other to validate its current status. A [DATE] at 5:54 PM nursing progress note by Licensed Practical Nurse #10 documented the resident was readmitted this shift, orders and Medical Orders for Life Sustaining Treatment were in place. There was no documented evidence the Medical Orders for Life Sustaining Treatment were in place. The [DATE] progress note by Nurse Practitioner #7 documented the resident was seen for a hospital follow up visit and their advanced directive wishes were discussed. Resident #1 was to remain a Full Code status. The [DATE] at 6:30 PM, Resident #1's Medical Order for Life Sustaining Treatment form was signed by Nurse Practitioner #7 and documented Full Code (initiate cardiopulmonary resuscitation). There was no documented evidence the advance directive order for Full Code was entered or verified in the electronic medical record. The [DATE] (untimed) facility investigation summary completed by the Administrator documented the facility discovered a transcription error by Licensed Practical Nurse #9 that resulted in the resident not receiving cardiopulmonary resuscitation per their wishes. Licensed Practical Nurse #4 responded, discovered the resident had no respirations or pulse, checked the physician orders (in the electronic medical record) instead of the resident's Medical Orders for Life Sustaining Treatment form and the resident had expired. The facility investigation concluded that staff did not follow the facility's advance directive policy by initiating cardiopulmonary resuscitation when the resident's Medical Orders for Life Saving Treatment form indicated a Full Code status. The [DATE] at 7:50 AM witness statement by Licensed Practical Nurse #4 documented at 7:25 AM, they were called to Resident #1's room, observed the resident to be without respirations and pulse, notified the Director of Nursing and then obtained the paper Medical Orders for Life Sustaining Treatment form. They did not initiate cardiopulmonary resuscitation, and stated due to the resident's current condition, they did not think to initiate it. Licensed Practical Nurse #4's statement did not include they first referred to the physician orders in the resident's electronic medical record prior to obtaining the Medical Orders for Life Sustaining Treatment form (as noted in the facility investigation). The [DATE] at 3:55 PM nursing progress note by the Director of Nursing documented at approximately 7:37 AM, they were called to Resident #1's room. Upon entering, it was observed the resident had no signs of life and rigor mortis (a stiffening of the joints and muscles occurring a few hours after death) had set in. The staff handed them the resident's Medical Orders for Life-Sustaining Treatment form and it was determined the resident's wishes were a full code status (initiate cardiopulmonary resuscitation). The Director of Nursing documented due to signs of irreversible death; cardiopulmonary resuscitation was not initiated. During an interview on [DATE] at 9:20 AM with Licensed Practical Nurse #9, they stated Resident #1 was readmitted from the hospital on [DATE] during the 3:00 PM - 11:00PM shift. They did not recall the resident returning with a Medical Orders for Life Sustaining Treatment form. They entered a physician order into the computer as a telephone order for Do Not Resuscitate and Do Not Intubate. An unknown staff member informed them of the resident's advanced directive status, and they did not verify the status. Orders for advance directives were placed in the computer and there was a box where you could check either verified or unverified. The box was not checked off as verified until a second nurse checked the order for accuracy to ensure safety of the order. Typically, you would notify the physician and inform them orders were being entered into the computer and check the Medical Orders for Life Sustaining Treatment form or verify the advance directives with the resident or family if there was no form. Licensed Practical Nurse #9 did not recall notifying the physician or checking with the resident/family. Licensed Practical Nurse #9 stated they left for the weekend and expected a second nurse to confirm the order. They observed the order was verified when they returned to work on [DATE] and stated it was Licensed Practical Nurse #10 who confirmed the order. During an interview on [DATE] at 9:48 PM with Licensed Practical Nurse #10, they stated if a resident returned from the hospital with no Medical Orders for Life Sustaining Treatment form, they would initiate a new form and speak to the resident and/or their representative to determine their wishes. Licensed Practical Nurse #10 confirmed Resident #1's advance directive order of Do Not Resuscitate/Do Not Intubate in their electronic medical record by checking the verified box. They were informed of the resident's advance directive status by Licensed Practical Nurse #9, took their word for it, and did not verify the order or phone the physician. Licensed Practical Nurse #10 stated they should not have taken another staff members word regarding the resident's advance directive status; they should have confirmed it and called the physician or discussed it with the resident or family. During a telephone interview on [DATE] at 12:13 PM with Physician #6, they stated when a resident was readmitted from the hospital, nursing would send the physician orders to sign. Orders would include medications and advance directives. The resident's orders were input into their electronic medical record by nursing and were verified by another nurse before the physician received them. Physician #6 stated they signed Resident #1's advance directive order for Do Not Resuscitate/Do Not Intubate on [DATE] remotely, without verifying the order was correct. They stated they were not aware the order was incorrect until the interview from the surveyor. Physician #6 relied on nursing to do their order confirmation checks prior to sending orders for the physician's signature. During an interview on [DATE] at 2:14 PM with the acting Administrator, they stated they assisted the Director of Nursing with the facility investigation regarding the incident with Resident #1. They were not aware Resident #1 returned from the hospital with no Medical Orders for Life Sustaining Treatment form and assumed Licensed Practical Nurse #9 verified and compared the form before placing the order in the computer. They were not aware a Do Not Resuscitate order was placed in the computer. It was not standard practice or acceptable for a nurse to accept a staff member's word regarding Resident #1's advance directive status. Licensed Practical Nurse #9 should have called a medical provider if they did not know the advance directive status. Telephone orders were only entered when the provider was notified, and the order was given verbally over the phone. During a follow up interview with the acting Administrator on [DATE] at 1:30 PM, they stated the facility policy for advance directive orders was verification with the resident and/or representative, the three-step order verification process by the nurses, and final verification by the physician. 10NYCRR 400.21(c)-------------------------------------------------------------------------------------------------------------------------------Immediate Jeopardy was identified, and the facility Administrator was notified on [DATE] at 5:17 PM. Immediate Jeopardy was removed on [DATE] at 3:30 PM prior to survey exit based on the following corrective actions: - The facility policy Advance Directives, and Cardiopulmonary Resuscitation-Basic Life Support Policy, were reviewed on [DATE] and updated following the incident. - Three (3) staff were immediately re-educated on [DATE] on the facility's Cardiopulmonary Resuscitation- Basic Life Support Policy, which included the Medical Orders for Life Sustaining Treatment needed to be followed and was the only identifier of resident wishes.- Education was also provided on [DATE] for Physician Order Management policy and how to correctly input an advance directive order. - On [DATE], [DATE], and [DATE] facility wide audits were conducted to compare/ensure resident's physician orders matched their Medical Orders for Life Sustaining Treatment forms and were in 100% compliance. - Mock Code Blue drills were conducted on [DATE] on all three (3) shifts for all nursing staff.- On [DATE], staff were immediately re-educated on the facility's Medical Orders for Life Sustaining Treatment form and verification of Physician orders with the medical order for life sustaining treatment form being the only identifier of resident's wishes. - Interviews were conducted on [DATE] to determine compliance with staff training and education including medical provider, nursing and social services staff.

Based on record review and interview during the abbreviated survey (NY00323539/IQIES 652830), the facility did not ensure residents with pressure ulcers or at risk of pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #3). Specifically: Resident #3 developed a new pressure ulcer that was not assessed and was not treated timely. Two weeks after the wound developed, the facility investigated the pressure ulcer and concluded the wound was not assessed, there was no treatment order implemented, and was not documented.Findings include:The facility policy, Pressure Ulcer Prevention Program, revised 1/31/2017, documented the facility should have a system in place that assured assessments were timely and appropriate, interventions were implemented, monitored and revised as appropriate; and changes in condition were recognized, evaluated, reported to the resident's attending practitioner and other health care professionals, i.e., wound nurse, as appropriate. Resident #3 had diagnoses including heart failure and weakness. The 7/12/2023 Minimum Data Set assessment documented the resident's cognition was intact and they required partial/moderate assistance with rolling left and right and partial/moderate assistance with chair/bed-to-chair transfers. The resident had no unhealed pressure ulcers.The 7/14/2023 Comprehensive Care Plan documented the resident was at risk of skin breakdown related to deconditioning. Interventions included risk assessments, keep skin clean and dry and massage with emollients during cares.Between 7/14/2023 and 8/31/2023, there was no documented evidence in the electronic record that the resident had any skin related concerns.The 9/1/2023 Wound Flow Sheet completed by former Director of Nursing #5 documented the resident had a new unstageable pressure ulcer (full thickness skin and tissue loss) on the left heel that was 2.5 centimeters (width) by 2.7 centimeters (length) by 0.4 centimeters (depth). The wound had moderate seropurulent (thin, watery, yellow to tan) drainage and the wound bed had necrotic tissue (non-viable tissue). A treatment order was obtained, and new interventions included a low air loss mattress, a pressure reducing cushion and mattress, and foam booties.The 9/1/2023 physician order documented Santyl (wound treatment) to the left the heel and cover with a dry dressing daily. The undated/unsigned facility investigation (later determined in interview it was completed by former Director of Nursing #5) documented on 9/1/2023, they became aware Resident #3 had an unstageable pressure injury on their left lateral (to the side, away from midline) heel that was 2.5 centimeters by 2.7 centimeters by 0.4 centimeters. After interviews and investigation, it was concluded the resident's pressure injury was noted by a certified nurse aide (later determined to be Certified Nurse Aide #1) on 8/18/2023. The certified nurse aide notified the licensed practical nurse (later determined to be Licensed Practical Nurse #3) and the licensed practical nurse reported it to the registered nurse supervisor (later identified to be Registered Nurse Supervisor #4). There was no documentation found regarding the resident's wound by the licensed practical nurse or the registered nurse supervisor, a treatment was not implemented and there was no documentation of notification to the Residential Care Coordinator, the Director of Nursing or the physician. Staff statements documented:- on 9/1/2023, from Certified Nurse Aide #1, on 8/18/2023, they found an open wound on the resident's left heel and reported it to Licensed Practical Nurse #3 who had Registered Nurse #4 evaluate the resident's heel.- from Licensed Practical Nurse #3 (undated), about 3 weeks ago, Certified Nurse Aide #1 reported a wound to them on the resident's heel that appeared to be a pressure ulcer. Licensed Practical Nurse #3 notified Registered Nurse #4 who assessed the resident and never mentioned a treatment plan. When they saw Registered Nurse Supervisor #4 later that shift, they asked about the plan for the resident's foot and Registered Nurse Supervisor #4 stated they did not know. When they asked if Registered Nurse Supervisor #4 wanted the resident's wound placed on the report, Registered Nurse Supervisor #4 stated it did not need to go on report, and they would discuss it with Resident Care Coordinator #5 the next day. Licensed Practical Nurse #3 stated they did not document the resident's wound and should have.- on 9/5/2023, from Registered Nurse Supervisor #4, they did not recall the events of the resident's heel on 8/18/2023. They typically documented a note after they assessed a resident and because the event was not documented, they were not told to assess the resident.- on 9/7/2023, Certified Nurse Aide #2 documented they were aware Certified Nurse Aide #1 found a wound on the resident's heel and reported it to Licensed Practical Nurse #3 who reported to Registered Nurse Supervisor #4 who looked at the resident's wound. Certified Nurse Aide #2 overheard Licensed Practical Nurse #3 ask Registered Nurse Supervisor #4 if they wanted the resident's wound placed on report however they did not hear their answer as they had walked away.The plan on the investigative summary documented head to toe assessments would be completed on all residents. Re-education was to be provided to all nursing staff regarding reporting and documenting of skin issues, and weekly skin checks on every resident on the unit for a duration of four weeks.The resident's 9/1/2023 through 11/30/2023 wound notes and the Treatment Administration Record documented the resident continued with weekly wound evaluations and wound treatments were completed as ordered. The left heel wound was documented as healed on 12/3/2023.During a telephone interview on 8/8/2025 at 9:45 AM, Certified Nurse Aide #1 stated when they found a resident had a new skin concern, they would notify the nurse. On 8/18/2025, they recalled finding a wound on the resident's left foot and they reported it to Licensed Practical Nurse #3 who reported it to Registered Nurse #4. They were not sure if the resident's wound was assessed.During a telephone interview on 8/8/2025 at 10:47 AM, Licensed Practical Nurse #3 stated when a new skin issue was found, they reported it to the supervisor. On 8/18/2023, Certified Nurse Aide #1 reported the resident had a wound. They looked at the resident's wound on the left heel and reported it to Registered Nurse Supervisor #4. Certified Nurse Aides #1 and #2 witnessed them report the resident's wound to Registered Nurse Supervisor #4.On 8/8/2025 at 11:03 AM, Registered Nurse Supervisor #4 was not reached in an interview.During an interview on 8/8/2025 at 11:08 AM, former Director of Nursing #5 stated if a resident had a new skin issue, they expected the nurse to notify the provider and get a treatment order immediately. On 9/1/2023, they were notified the resident had a new wound on the left heel and initiated an investigation. The investigation revealed the wound was first observed on 8/18/2023 by Certified Nurse Aide #1 who reported it to Licensed Practical Nurse #3. Licensed Practical Nurse #3 reported it to Registered Nurse Supervisor #4 and there was no documentation of the assessment, or a treatment ordered. They notified the provider and got an order for a treatment for the resident. The resident did not receive timely care for their wound. Corrective measures included changing the process for weekly skin checks and how those checks were communicated and documented, having a Stop and Watch form completed by the staff finding the wound, and educating the nursing staff on the new processes. They disciplined Licensed Practical Nurse #3 and Registered Nurse Supervisor #4 for their failure to document the resident's wound and failure to obtain a treatment order. Skin check documentation was added to Quality Assurance until 100% compliance and they did not recall if they reached 100% compliance. The resident received weekly nursing assessments after 9/1/2023 and they could not recall if the wound on the resident's left heel healed.During an interview on 8/12/2025 at 8 AM, Physician #7 stated they expected nursing staff to assess new wounds when found, the physician to be notified as soon as possible and the wound documented in a progress note. They were not at the facility when this incident occurred and ten days without a treatment order was not timely. The resident did not suffer any untoward effects, and the wound eventually healed. The facility took corrective actions to prevent recurrence. 10NYCRR 415.12(c)(1)-------------------------------------------------------------------------------------------Past non-compliance was identified, and the Administrator notified on 8/14/2025.The facility provided verification the following corrective actions were completed.- on 9/1/2023, Resident #3 was assessed, the provider notified, and a treatment order was implemented.- Resident #3 was provided weekly wound assessments and daily wound treatments from 9/1/2023 through 12/3/2023. The wound was healed on 12/3/2023. - on 9/1/2023, a facility investigation was initiated regarding the resident's pressure ulcer.- on 9/1/2023, the facility's Skin Care Protocol was reviewed and revised.- on 9/7 and 9/8/2023, skin checks were completed on all facility residents.- on 9/23/2023, Licensed Practical Nurse #3 and Registered Nurse #4 received written disciplinary notices for their failure to obtain a treatment order from the physician and failure to document the resident's new pressure ulcer.-from 9/19 to 10/4/2023, the facility re-educated all certified nurse aides, licensed practical nurses and registered nurses on the new Skin Care Protocol that included reporting and documenting skin concerns.- the facility conducted weekly skin check audits over four weeks. Skin check documentation was added to Quality Assurance until 100% compliance was reached.- during the 8/5/2025 abbreviated survey, two sampled residents were reviewed and observed with no concerns. The facility was found to be in regulatory compliance related to wound assessment and treatment.

Based on observations, record review, and interviews during the recertification and abbreviated (NY00370054) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for three (3) of three (3) nursing units (Units A, B, and C) reviewed. Specifically, water temperatures were not maintained at comfortable levels on Units A, B, and C between 2/4/2025-4/1/2025. Findings include: The facility policy Maintaining A Safe, Clean, Comfortable and Homelike Environment, dated 10/24/2024 documented the residents had the right to a safe, clean, comfortable, and homelike environment. The undated Daily Maintenance Rounds documented the water temperature range was acceptable between 90 degrees Fahrenheit and 120 degrees Fahrenheit. The 2/2025 through 4/2025 daily maintenance rounds water temperature logs documented the following temperatures at each of the three tested sites: Unit-A, Unit-B, Unit-C. - on 2/4/2025, 86.3 degrees Fahrenheit, 85.2 degrees Fahrenheit, 86.9 degrees Fahrenheit. - on 2/6/2025, 105.5 degrees Fahrenheit, no data B-Unit, 77.0 degrees Fahrenheit. - on 2/7/2025, 91 degrees Fahrenheit, 94.0 degrees Fahrenheit, 88.0 degrees Fahrenheit. - on 2/8/2025, no recorded temperatures. - on 2/9/2025, no recorded temperatures. - on 2/10/2025, no data A-Unit, 84.0 degrees Fahrenheit, 91.0 degrees Fahrenheit. - on 2/12/2025, 86.0 degrees Fahrenheit, 88.0 degrees Fahrenheit, 88.0 degrees Fahrenheit. - on 2/13/2025, no data A-Unit, no data B-Unit, 86.0 degrees Fahrenheit. - on 2/14/2025, 104.0 degrees Fahrenheit, 85.0 degrees Fahrenheit, no data C-Unit. - on 2/15/2025, no recorded temperatures. - on 2/16/2025, no recorded temperatures. - on 2/17/2025, no data A-Unit, 73.0 degrees Fahrenheit, no data C-Unit. - on 2/18/2025, 101.0 degrees Fahrenheit, 88.0 degrees Fahrenheit, 100.0 degrees Fahrenheit. - on 2/19/2025, no data A-Unit, 93.0 degrees Fahrenheit, no data C-Unit. - on 2/20/2025, 103.0 degrees Fahrenheit, 92.0 degrees Fahrenheit, 89.0 degrees Fahrenheit. - on 2/21/2025, 105.0 degrees Fahrenheit, 90.0 degrees Fahrenheit, 85.0 degrees Fahrenheit. - on 2/22/2025, no recorded temperatures. - on 2/23/2025, no recorded temperatures. - on 2/24/2025, no data A-Unit, 87.0 degrees Fahrenheit, no data C-Unit. - on 2/25/2025, 103.9 degrees Fahrenheit, 83.0 degrees Fahrenheit, 82.0 degrees Fahrenheit. - on 2/26/2025, 101.0 degrees Fahrenheit, 89.0 degrees Fahrenheit, 100 degrees Fahrenheit. - on 2/27/2025, 102.0 degrees Fahrenheit, 99.0 degrees Fahrenheit, 85.0 degrees Fahrenheit. - on 2/28/2025, no data A-Unit, 80.0 degrees Fahrenheit, 80.0 degrees Fahrenheit. - Data was not recorded for the following dates:3/8/2025,3/9/2025,3/11/2025,3/15/2025, and 3/16/2025. - on 3/20/2025, 102.2 degrees Fahrenheit, 78.0 degrees Fahrenheit, 87.0 degrees Fahrenheit. - on 3/22/2025, no recorded temperatures. - on 3/23/2025, no recorded temperatures. - on 3/25/2025, 90.0 degrees Fahrenheit, 93.0 degrees Fahrenheit, 85.0 degrees Fahrenheit. - on 3/27/2025, no data unit A, No data unit B, 91.0 degrees Fahrenheit. - on 3/29/2025, no recorded temperatures. - on 3/30/2025, no recorded temperatures. - on 4/1/2025, 90.0 degrees Fahrenheit, 93.0 degrees Fahrenheit, 85.0 degrees Fahrenheit. - Data was not recorded on the following dates: 4/5/2025, 4/6/2025, 4/12/2025, 4/13/2025, 4/17/2025, 4/19/2025, 4/20/2025, 4/26/2025, 4/27/2025, and 4/30/2025. The resident council minutes dated 2/24/2025 at 1:32 PM included a complaint regarding the lack of hot water. One resident voiced concerns regarding having been told to get hot water they had to get up before 6:00 AM. Resident council minutes dated 3/3/2025 at 10:59 AM documented an issue with the lack of hot water. The Maintenance Director was in attendance and explained that parts for the boiler were ordered and once the parts arrived the hot and cold-water problem would be fixed. During an interview on 4/30/2025 at 12:13 PM, Resident #27 stated they were without hot water for weeks and the situation had been quite bad. They stated there was nothing good about taking a cold shower. The resident was told the facility was waiting on the parts needed to fix the hot water issue. It was very uncomfortable, but the water temperature was better now. During an interview on 05/02/2025 at 1:19 PM the Director of Maintenance stated they started in the position in mid-February. There was an issue with the lack of hot water in March with the lowest temperature approximately 92.0 degrees Fahrenheit. They were made aware of the resident concerns when they attended the resident council meeting. They stated 92 degrees Fahrenheit was not an optimal temperature. The residents complained the water was too cold to shower comfortably. The Director of Maintenance stated they reported the issue to the Administrator who directed them to work on the solution. They consulted with the facility's plumbing company who discovered the problem was with the mixing valves. The issue was resolved. They continued to test the water daily to assure the proper temperatures. Improper water temperatures could affect the resident's ability to maintain good hygiene and comfort. During an interview on 05/02/2025 at 2:54 PM the Administrator stated the hot water was important for the care of the residents. There was a problem for a period of a few weeks with the hot water not having been at a comfortable temperature. The maintenance department worked on a solution, and they replaced the mixing valve which resolved the issue. 10 NYCRR 415.29 (f)(6), (j)(1)

48446 Based on observations, record review, and interviews during the recertification and abbreviated (NY00370054 and NY00327240) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of three (3) meals reviewed (dinner meal on 4/28/2025, and lunch meals on 4/29/2025 and 5/1/2025). Specifically, food was not served at palatable and appetizing temperatures and was not palatable. Additionally, five (5) anonymous residents during a resident council meeting and five (5) residents (Resident #31, 53, 59, 60, and 306) interviewed stated the food did not taste good, was bland, lacked flavor, and was cold. Findings include: The facility policy Food: Quality and Palatability, revised 9/2017 documented food was prepared by methods that conserved nutritive value, flavor, and appearance. Food was palatable, attractive, and served at safe and appetizing temperatures. During an observation on 4/28/2025 at 6:03 PM Resident #60's meal tray was tested , and a replacement was provided. The following temperatures were taken in the presence of Certified Nurse Aide #21: - confetti corn 71.4 degrees Fahrenheit (planned as a cold vegetable). - pork cutlet 76.6 degrees Fahrenheit (planned as a cold entree). The soup was bland. The corn was cold, covered with a white film, and tasted sour. During an observation on 4/29/2025 at 1:11 PM Resident #88's meal tray was tested , and a replacement was provided. Temperatures were taken in the presence of Certified Nurse Aide #5 and included milk at 56 degrees Fahrenheit. The pureed vegetable and the mashed potatoes were bland, and the milk tasted warm. During an interview on 4/30/2025 at 12:19 PM, Licensed Practical Nurse #20 stated there were a lot of resident complaints the food was cold and lacked flavor. Items such as ice cream were missing from their trays there was no substitutes for the missing items. Cereal was provided without milk, they never got fresh fruit, and soda was not stocked on the unit for use when a resident has an upset stomach. During an interview on 5/01/2025 at 11:35 AM, Certified Nurse Aide #19 stated residents complained the food was cold and did not taste good. When residents complained they were offered a substitute. Most days residents did not have enough liquids because there was no soda or juice on the unit, and it was only served with trays. During an interview on 5/1/2025 at 12:56 PM, Registered Dietitian #3 stated snacks like pudding, granola bars, and ice cream were available on all units for residents to have between meals. The kitchen staff was responsible for stocking the kitchenettes and the Director of Food Services ordered the snacks. Residents did complain the food did not taste good and was sometimes tough to chew. Sometimes the residents might not eat the meal and want a snack later in the day. If residents did not eat, they could have weight loss, depression, and lack of interest in meals. During an interview on 5/1/2025 at 1:12 PM, District Food Services Manager #36 stated the onsite manager completed test trays as part of the monthly audit. Once a month food was followed from the kitchen to the residents' rooms and temperatures of the food was taken in the hall. Hot foods should be greater than 130 degrees Fahrenheit except soup and coffee should be 150 degrees Fahrenheit. Cold food should be less than 45 degrees Fahrenheit. Milk that was 56 degrees Fahrenheit was too warm, confetti corn was supposed to be served cold, and 71.4 degrees Fahrenheit was too warm, the pork cutlet was supposed to be served cold, and 76.6 degrees was too warm. They tasted the food when they were in the building and cooks tasted every meal, recently adding pureed for taste testing. It was important to serve food at correct temperatures for palatability and safety for the residents. This was the residents' home, and it was dignified to eat a quality meal. 10NYCRR 415.14(d)(1)(2) 48675 52766

48446 Based on observations, record review, and interviews during the recertification survey conducted [DATE] - [DATE], the facility did not ensure suitable, nourishing alternative meals and snacks were provided to residents who preferred to eat at non-traditional times or outside of scheduled meal service times for two (2) of three (3) nursing units (Units B and C). Specifically, residents did not have snack items available on nursing units B or C and were not offered anything to eat or drink when meal trays were not available at the scheduled and posted times. Additionally, meals were not served according to the posted mealtimes for all units. Findings include: The facility policy Dining Experience, revised [DATE], documented the facility would make all efforts in providing a comfortable homelike meal experience for the residents. The facility would make all efforts to honor residents' meal preferences and choices. The facility policy Supplemental Nutritional Support and Snacks, revised [DATE] documented all residents were offered a beverage in between meals and a nourishment in the afternoon and a snack at bedtime to promote adequate nutrition and hydration. The posted mealtimes documented breakfast was served at 7:30 AM, lunch at 11:30 AM, and dinner at 5:30 PM. The Always Available Menu included cold options (assorted sandwiches), hot options (Italian sausage and grilled cheese sandwiches), chef salad, and tomato soup. Snacks: During an observation on [DATE] at 5:27 PM, the Unit B resident refrigerator contained 2 diet Pepsi's, 2 individual nutritional supplements, 2 opened cartons of lemon flavored water, 2 opened cartons of lemon flavored water that expired [DATE], one opened and unlabeled carton of orange water, thickened liquids, and vanilla ice cream in the freezer. In the locked kitchenette area, there was one individual cereal in the cabinet and resident specific labeled items in the refrigerator and freezer. During an interview on [DATE] at 5:30 PM, Certified Nurse Aide #21 stated there were no snacks on Unit B and they were not sure who was responsible for stocking the kitchenette. During an observation on [DATE] at 1:36 PM, the Unit C kitchenette refrigerator contained 8 individual puddings, 4 individual applesauce, 1 packet of saltine crackers, 1 individual cereal, and 3 containers of juice, and nutritional supplements. During an observation on [DATE] at 10:42 AM, an unidentified resident playing a game asked Activities Aide #28 for a snack. Activities Aide #28 told the resident they could not have another snack as they already had one. During an interview on [DATE] at 11:24 AM, Activities Aide #28 stated they assisted with activities which included coffee hour every day. They stated if the kitchen brought up snacks, they did a snack pass around 2:30 PM every day and residents were only allowed one snack because residents had to be on a budget at home so they should be on a budget in the facility. They were not sure who determined residents could have only one snack. Snacks included a choice of a small bag of chips, a cookie, a granola bar, or pudding. Snacks were limited allowing each resident to have one snack as there was not enough for the residents to receive more than one. If the kitchen did not bring up snacks the snack pass did not occur. Residents could also purchase snacks from the candy cart that sold items like soda, chips, and juice and the prices were determined by the Activities Director. A small bag of chips could be purchased for $1.50. They were not sure why residents had to pay for snacks from the candy cart or who determined residents could only have one snack. During an interview on [DATE] at 12:56 PM, Registered Dietitian #3 stated snacks like pudding, granola bars, and ice cream were available on all units for residents to have between meals. The kitchen staff was responsible for stocking the kitchenettes and the Director of Food Services ordered the snacks. Residents did complain the food did not taste good and was sometimes tough to chew and might not eat the meal and wanted a snack later in the day. They stated if residents did not eat, they could have weight loss, depression, and lack of interest in meals. Late meals: During a kitchen observation and interview on [DATE] at 12:01 PM, the kitchen ran out of the main entree of beef stew. Staff was overheard saying they prepared 6 cans (#10 cans, approximately 110 ounces per can equaling approximately 82, 8-ounce servings) of the beef stew and meal tickets called for 8 ounce servings. The District Food Services Manager #36 stated they miscalculated the portion with the meal serving. They did not have a system that communicated with the menu so ordering and portioning was done separately from the menus and recipes. At 12:08 PM, lunch service paused while staff made more stew. Lunch service resumed at 12:46 PM. Unit A During an observation on [DATE] at 5:36 PM residents were waiting in the dining room for their trays and stated they were hungry. The first cart of trays arrived at 5:57 PM and staff began passing meals to residents who ate in their rooms. During an observation on [DATE] at 6:09 PM all residents sitting in the dining room had not received their meals. One resident was given hot tea, and no other residents were offered a snack or beverage while waiting for their meal. The meal trays arrived at 6:20 PM, almost an hour after the posted mealtimes. During an observation on [DATE] at 12:04 PM passed the hall trays while residents in the dining room waited for their trays. No residents were provided snacks or drinks when they were waiting for their lunch and one resident stated they were hungry and asked where their lunch was. The last tray was served at 12:28 PM, almost an hour after the posted mealtimes. Unit B During an observation on [DATE] at 6:02 PM, 15 residents were sitting in the dining room since before 5:30 PM. Some of the residents stated they were hungry. No residents were offered a snack, and most residents did not have anything to drink while waiting. At 6:02 PM the first set of carts arrived, and staff started serving trays. At 6:21 PM the last tray from the first cart was passed. There were 11 residents in the dining room without trays, all sitting with at least one resident that was served a tray. At 6:30 PM, the second cart arrived on Unit B and the last tray was delivered at 6:43 PM. During an observation in the dining room on [DATE] 12:40 PM, Resident #90's visitor asked Licensed Practical Nurse #27 for ginger ale and was told we do not have enough on the unit and it had to be on their meal ticket. They stated they could add it to their ticket, but they would not get it today. At 12:54 PM, Resident #90's visitor asked Licensed Practical Nurse #27 for a cup of coffee and was told to wait for the trays to come up. At 1:05 PM the first cart of lunch trays arrived. During an interview on [DATE] at 9:26 AM, Certified Nurse Aide #18 stated residents complained they did not get enough food, received meals late, and did not get snacks. Lunch arrived daily at 11:45 AM however could be served as late as 1:00 PM and residents were in the dining room by 11:30. Lunch was served late today, and residents were in the dining room at 11:30 AM. There used to be drinks and soda on the unit to offer residents when they were waiting, however for the last few months there was no fluid or soda to offer residents. Dinner was normally served at 5:00 PM-5:30 PM. Sometimes residents were offered coffee, but they were not offered any fluids today. There were never snacks in the pantry to offer residents when they were waiting for late trays or to offer residents that wanted a snack. They were not sure who was responsible for stocking the kitchenette. Kitchen staff used to stock the kitchenette and that stopped abruptly. When residents asked for snacks, they had to tell them there were no snacks and they could not have snacks. During an interview on [DATE] at 11:48 AM, Licensed Practical Nurse #20 stated breakfast was scheduled to come at 7:45 AM and could arrive as late as 9:00 AM. Lunch was scheduled to arrive at 12:30 but often came after 1:00 and on [DATE] it arrived just before 2:00 PM. Trays were late when the kitchen was short staffed. There were times nursing was called to the kitchen to get the carts because there was not enough kitchen staff to deliver food. During an interview on [DATE] at 12:19 PM, Licensed Practical Nurse #20 there was never snacks or soda for residents that requested them. The kitchenettes used to have a supply of snacks and soda but that ended several months ago, and they were not sure why. During an interview on [DATE] at 12:56 PM, Registered Dietitian #3 stated residents could have coffee at any time but were only allowed to have soda with meals if it was listed on their meal ticket. They were not sure why residents were not allowed to have soda between meals or who made that decision. The units should have snacks available between meals and the kitchen staff was responsible for restocking the kitchenettes. During an interview on [DATE] at 2:23 PM, District Food Services Director #36 stated they had snacks and soda in the building, but the facility did not want them released to the units for the residents. They stocked the kitchenettes ,d+[DATE] times a week with milk, juice, ice cream, and Magic Cups (nutritional supplement). They used to supply soda, cereal, and chips but were told by Administration they were not allowed to stock them anymore because residents had to be on a budget. They did provide snacks to residents for purchase through activities on a cart that went from unit to unit. The did not stock the units on [DATE] because they were undergoing the recertification survey. During an interview on [DATE] at 11:57 AM, the Director of Nursing stated the kitchen was responsible for restocking the kitchenettes on Mondays, Wednesdays, and Fridays. Snacks may not offer nutritional value, but they did offer calories. The facility cut out soda because Administration said there was no nutritional value in soda. Lunch was scheduled to be served at 11:30 AM but was usually delivered to the units closer to 12:00 PM. 10NYCRR 415.14(f)(3)(4)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00327240) surveys conducted 4/28/2025-5/2/2025, the facility did not ensure residents were treated with respect and dignity in a manner and in an environment that promoted maintenance or enhancement of quality of life for three (3) of three (3) residents (Residents #31, #52, and #88) reviewed. Specifically, staff stood over Residents #52 and #88 while assisting them to eat; and Resident #31 was placed at a table that was above the level of their chin. Additionally, residents were referred to as feeders, and staff assisted residents with feeding while conversing amongst themselves and not including the residents. Findings include: The facility policy Resident Rights-Dignity and Respect, revised 3/18/2024, documented each resident was treated with dignity and respect, focusing on maintaining and enhancing their self-esteem and self-worth and incorporated the residents' preferences and choices. Staff should avoid standing over residents when assisting them to eat, conversing only with each other rather than with the residents while assisting residents with eating, or using labels like feeders. The facility policy Dining Experience, revised 6/5/2024, documented residents should be positioned appropriately to eat safely, sitting in an upright position, comfortable, and with all the necessary adaptive equipment per care plan. The following observations were made of staff standing over residents while assisting them to eat: - on 4/29/2025 at 9:05 AM, Certified Nurse Aide #5 was standing over Resident #88 while feeding them breakfast. - on 4/30/2025 at 8:47 AM, Certified Nurse Aide #4 was standing over Resident #88 while feeding them breakfast. - on 5/1/2025 at 9:24 AM, Certified Nurse Aide #4 was feeding Resident #52 in their room in bed while standing over the resident. During an interview on 5/1/2025 at 2:09 PM, Certified Nurse Aide #4 stated they could feed residents while sitting or standing, however residents might feel more comfortable if they sat. The following observations were made of staff referring to residents as feeders: - on 4/28/2025 at 6:42 PM, Certified Nurse Aide #16 was in the hallway across from the dining room and stated, the last three trays that needed to be passed were for feeders. - on 4/29/2025 at 12:35 PM, Certified Nurse Aide #5 stated to a coworker to wheel the resident to the feeders table. During an interview on 4/30/2025 at 9:26 AM, Certified Nurse Aide #18 stated the unit had a feeders table and they were allowed to call residents feeders. If a resident was called a feeder and did not want to be identified as a feeder it could embarrass the resident. The following observations were made of staff conversing at meals without including residents: - on 5/1/2025 at 9:37 AM, Certified Nurse Aide #5 and Certified Nurse Aide #17 were sitting at the dining room table assisting residents with eating. They were not engaged with the residents and were talking about their children, their birth weights, and other personal conversations. Inappropriate positioning during meals: The 11/15/2024 Registered Dietitian #3 nutritional assessment documented Resident #31 was 55 inches tall (4 foot 7 inches). During an observation on 4/28/2025 at 6:40 PM, Resident #31 was positioned at the dining table with their chin several inches below the table edge and was attempting to reach their food on their tray. During an observation and interview on 5/1/2025 at 12:06 PM, Resident #31 was sitting in their wheelchair across the dining room with an over the bed table in the lowest position waiting for lunch. Certified Nurse Aide #19 stated Resident #31 was not able to sit at the dining table as they were too short for the table. If they sat at the table, they would not be able to see their food or feed themself. During an interview on 5/2/2025 at 11:31 AM, Licensed Practical Nurse #20 stated the dining experience was supposed to be a good experience. Staff should engage in conversation with residents when feeding them, residents should be fed with staff sitting down, residents should be seated at the appropriate heights to see their tray and feed themselves, and they should not be addressed as feeders. If staff was standing and feeding residents it could make residents feel like they were being looked down on. If staff were having personal conversations during meals and excluding residents it could make residents feel left out. It was important for Resident #31 to sit in their wheelchair with a lower table so they could see their food and feed themself. During an interview on 5/1/2025 at 12:56 PM, Registered Dietitian #3 stated it was important for all residents to get the nutrients necessary to prevent weight loss, disinterest in meals, and depression. They expected all residents to be properly positioned to see their meals and feed themselves if possible. If a resident was not positioned properly, they may not see or smell the meal possibly impacting hunger cues, it could make a resident feel frustrated, be disinterested in meals, lose weight, and become depressed. During an interview on 5/2/2025 at 11:57 AM, the Director of Nursing stated residents should not be fed while staff was standing up, be identified as feeders, served a meal that was too high for them to reach, or be excluded from conversations as it was not dignified. 10 NYCRR 415.5(d)(1)(i) 52766

Based on observations, record review, and interviews during the recertification and abbreviated (NY00365859) surveys conducted 4/28/2025-5/2/2025, 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 four (4) of six (6) residents (Residents #24, #37, #60, and #68) reviewed. Specifically, Residents #24 and #60 did not receive toileting assistance when they were wet; Resident #37 was not provided with oral hygiene or shaving: and Resident #68 was not provided with oral hygiene. Findings include: The facility policy Oral Hygiene, revised 7/5/2024, documented the facility was committed to providing comprehensive oral hygiene to all residents ensuring their dental and overall health was maintained to the highest standard. The facility policy Activities of Daily Living Services, revised 1/19/2024, documented residents would receive assistance with activities of daily living every shift per the residents' care plan as appropriate. Help was provided to residents with toileting needs including assisting with use of the toilet or commode and maintaining continence. 1) Resident #68 had diagnoses including need for assistance with personal care, muscle weakness, and gastro-esophageal reflux (stomach contents flow backward into the esophagus). The 4/3/2025 Minimum Data Set assessment documented the resident had intact cognition, no behavioral symptoms, did not reject care, required substantial/maximum assistance for bathing, and supervision or touching assistance for oral hygiene. The section for oral/dental status was not completed. The Comprehensive Care Plan initiated 1/19/2023 and revised 4/11/2024, documented the resident had alterations in activities of daily living function related to deconditioning, gait imbalance, and incontinence. Interventions included oral care with supervision on the day and evening shifts. 5/29/2024 dental progress note documented the resident had a brief scaling (removal of plaque and tartar from the teeth) and staff should continue to assist with oral care. The resident's care instructions (Kardex) documented the resident required supervision assistance with oral hygiene. Resident #68 was observed: - on 4/28/2025 at 3:40 PM with foul smelling breath. - on 4/30/2025 at 12:12 PM with foul smelling breath. The resident stated their teeth were not brushed and they would like them brushed. - on 5/1/2025 at 10:18 AM with foul smelling breath. The resident stated their teeth were not brushed and they would like them brushed. During an interview on 5/1/2025 at 11:48 AM, Certified Nurse Aide #5 stated they were responsible for brushing residents' teeth every day. They were behind on completion of care for their assigned residents because they were helping a coworker. Certified Nurse Aide #5 stated they completed care for Resident #68 and forgot to brush their teeth and they should have. If residents did not have their teeth brushed, they could have bad breath and lose their teeth. 2) Resident #37 had diagnoses including dementia, depression, and muscle weakness. The 4/9/2025 Minimum Data Set assessment documented the resident had intact cognition, had no physical behavioral symptoms, had verbal behaviors 1 to three 3 days, did not reject care, and required substantial/maximum assistance of 1 for most activities of daily living. The section for oral/dental status was not completed. The Comprehensive Care Plan, initiated 10/13/2023 and revised 11/15/2024, documented the resident had an alteration in activities of daily living function related to activity intolerance, confusion, and impaired balance. Interventions included showers every Tuesday evening shift. The resident required maximum assistance for oral care and partial assistance for showering. The resident's care instructions (Kardex) documented the resident required partial/moderate assistance of one for showers, the resident had their own upper and lower teeth and required maximum assistance of one for oral hygiene. Resident #37 was observed: - on 4/28/2025 at 3:21 PM in their bedroom with stubble on their face. The resident stated they wanted to be shaved, and they were unsure of their shower day. - on 4/29/2025 at 3:27 PM in a chair being wheeled down the hallway. The staff member told the resident they were going to the shower for a shower and shave. - on 4/30/2025 at 9:21 AM in their room with stubble on their face and a foul breath odor. The resident stated they had their shower the previous evening but was not shaved. The aide told them they were going to come back later to shave them and never did. The resident stated they wanted assistance with brushing their teeth but never had help with that. - on 5/1/2025 at 8:37 AM in their room clean shaven with a foul breath odor. At 9:14 AM the resident stated Certified Nurse Aide #37 shaved them earlier in the morning but did not brush their teeth and they wanted them brushed. During an interview on 5/1/2025 at 2:09 PM Certified Nurse Aide #4 stated morning care consisted of washing residents, brushing hair, shaving, and oral care. All their care was completed, and no one refused care. They were assigned to Resident #37, however did not complete any care with them as Certified Nurse Aide #37 came from a different unit and shaved the resident. They assumed certified nurse aide completed all hygiene care. They were not sure why that staff came from another unit to complete the resident's care. During an interview on 5/2/2025 at 9:16 AM, Certified Nurse Aide #37 stated they were assigned to the day shift on Unit C and worked on Unit B previously. They heard Resident #37 was having a tough day, so they went over to say hello. They offered to assist in completing morning care for the resident, washed the resident and shaved them because the resident really needed to be shaved. If a resident wanted to be shaved and was not it was a dignity issue. They did not assist the resident with oral care as they were not the assigned certified nurse aide for the resident. They thought the assigned staff took over the care after they shaved the resident. If oral care was not provided residents could get gingivitis (gum disease). 3) Resident #60 had diagnoses including need for assistance with personal care, muscle weakness, and left sided hemiparesis (partial paralysis) following subarachnoid hemorrhage (brain bleed). The 4/18/2025 Minimum Data Set assessment documented the resident had intact cognition, no behavioral symptoms, did not reject care, was incontinent of urine, required substantial/maximal assistance for toileting hygiene, and was dependent for toilet transfers. The Comprehensive Care Plan initiated 8/3/2022 and revised 4/11/2024, documented the resident had a self-care performance deficit related to hemiplegia (partial paralysis), weakness, need for assistance with personal care, and abnormalities of gait and mobility. Interventions included maximum assistance for toileting and dependence for toilet transfers. The resident's care instructions (Kardex) documented the resident was dependent on staff for toilet transfers, required maximal assistance with toileting hygiene, was incontinent of bladder, and had incontinence checks/care every 2-4 hours. During an interview on 4/28/2025 at 3:49 PM, Resident #60 stated they wore an incontinent brief, and staff left them wet for hours. They rang their call bell when they were wet, and most days was not changed timely. They stated many times, staff said they would come back and change them and did not return. They stated they had a sore in their groin from sitting in a wet brief so long. During an observation and interview on 4/29/2025 at 1:42 PM, Resident #60 was sitting in their wheelchair in their room and stated they were waiting to be changed as they were wet and had a bowel movement. They stated their call bell was previously on and staff they were not able to identify turned off the light and said they were not able to change them as it was lunch time and trays were late. They were still waiting to be changed out of their urine and feces soaked incontinent brief. The certified nurse aide documentation documented incontinent care was provided on 4/29/2025 at 10:27 AM and 2:41 PM. There was no documented incontinent care after 2:41 PM on 4/29/2025. During an observation and interview on 5/1/2025 at 11:20 AM, Resident #60 was self-propelling their wheelchair to the nursing station. The resident stated they put their call bell on four times before 10:00 AM that day. Staff answered their call bell, turned their call bell off, and left their room telling the resident they needed assistance to change them and never came back. A short time after 10:00 AM Certified Nurse Aide #19 answered their call bell, turned off the call bell, and changed them, cleaned them, and dressed them for the day. Their breath had a foul odor. The resident stated their teeth were not brushed and they were embarrassed having bad breath, sitting in urine, and not getting help when they rang for assistance. During an observation and interview on 5/1/2025 at 1:47 PM, Resident #60 was observed in the hallway with their call bell on. They stated they were wet and had their call bell on since 1:00 PM. They stated they eventually self-propelled into the hallway to call for help as they were uncomfortable and wanted to be changed. During an interview on 5/1/2025 at 11:28 AM, Certified Nurse Aide #19 stated they arrived on the unit today at 10:00 AM. Shortly thereafter they noticed Resident #60's call bell on, so they answered it. They asked the resident who their assigned certified nurse aide was, and the resident stated it was Certified Nurse Aide #4. Certified Nurse Aide #19 stated the resident was soaked with urine, so they cleaned, changed, and dressed the resident. The resident usually only put their bell on when they were wet and needed changing. They did not assist with oral care as they completely forgot. During an interview on 5/2/2025 at 11:31 AM, Licensed Practical Nurse #20 stated hygiene care was completed by the certified nurse aides. Incontinent residents were supposed to be checked every two hours to make sure they were not wet. If they were left in a urine or feces soaked incontinent briefs it could make the resident feel embarrassed. Residents should have their teeth brushed every shift to promote eating, self-confidence, and smiling. Sometimes care was not completed because there was no regular staff on Unit B, many of the staff were from agencies. Residents should also be shaved because it was a self-esteem issue when they were not shaved. Call bells should be answered in less than five minutes and if the request was not met, the bell should be left on. Sometimes unit helpers answered bells, and the resident requested personal care, which unit helpers were not able to perform. Resident #60 was cognitively intact and only used their call bell when they needed to be changed. During an interview on 5/2/2025 at 11:57 AM the Director of Nursing stated the care plan drove the certified nurse aide care card for the individual care for each resident. Certified nurse aides were responsible for performing activities of daily living for residents that needed assistance. The units were staffed with both unit helpers and certified nurse aides. Unit helpers were able to answer call bells, however not able to assist in any resident care. They could drop off trays, deliver linens, make beds, talk with residents, deliver fluids, and other activities that did not require touching the resident. There was no way for residents to differentiate between a unit helper and a certified nurse aide. If a unit helper answered a call bell and was not able to perform the request, they should leave the bell on and get a certified nurse aide. Residents should never sit in soiled incontinent briefs. Resident #60 should be changed when they were soiled because they had frequent urinary tract infections and was currently on an antibiotic for a urinary tract infection. They expected residents to be shaven and have their teeth brushed because they might not feel clean, have decreased self-esteem, and unable to eat if they had mouth pain from not brushing their teeth. 10 NYCRR 415.12(a)(3) 52766

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure residents received respiratory care consistent with professional standards of practice for one (1) of one (1) resident (Resident #88) reviewed. Specifically, Resident #88 did not receive oxygen therapy as ordered, their portable oxygen tank was not replaced when it was empty, and their care plan did not include the need for oxygen therapy. Findings include: The facility policy Oxygen Administration, last reviewed 6/28/2022, documented oxygen therapy was delivered by way of an oxygen mask or nasal canula using a portable oxygen cylinder or oxygen concentrator and must be verified by a physician order. Once the appropriate setup was placed on a resident, observe the resident periodically thereafter for flow of oxygen and to be sure oxygen was being tolerated. Resident #88 had diagnoses including pneumonia due to COVID-19 and acute respiratory failure with hypoxia (low levels of oxygen in body tissues). The 3/13/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for all activities of daily living, and did not receive oxygen therapy. Physician orders documented: - on 4/9/2025 oxygen at 2 Liters/minute continuously by nasal canula to keep oxygen saturations 90% or greater. - on 4/10/2025 check oxygen tank to ensure adequate supply before meals and at bedtime for preventative replacement. The Comprehensive Care Plan did not include an individualized respiratory care plan with the use of oxygen. During a continuous observation on 4/29/2025 from 1:53 PM until 3:05 PM, Resident #88 was lying in their reclining chair in the dining room with a nasal canula in their nose. The portable oxygen tank was set to 3 Liters/minute and the gauge on the oxygen tank was in the red indicating the tank was empty. The resident had no obvious signs of respiratory distress. At 3:05 PM, an unidentified certified nurse aide approached Resident #88, unlocked the wheels on their reclining chair and pushed the chair back to the resident's room without checking the portable oxygen tank. The certified nurse aide stated the resident always used oxygen and the nursing staff should have checked the portable oxygen tank when the resident was put into their chair. They were unsure when the tank was last checked, and they were just transferring the resident back to bed. During observations on 4/30/2025 at 8:56 AM, 10:17 AM, and 11:53 AM, Resident #88 was lying in their reclining chair in the dining room without oxygen in place. The resident had no obvious signs of respiratory distress. During an interview on 5/2/2025 at 12:08 PM, Licensed Practical Nurse #20 stated oxygen should have been listed on the resident's care plan because all staff should look at the care plan to tell them everything about the resident's care. They were unsure if they could update a care plan but if they had noticed the care plan was wrong, they would notify the resident care coordinator to update it. Resident #88 had an order for oxygen at 2 Liters/minutes continuously. All nursing staff was responsible for monitoring portable oxygen tanks to ensure they were not empty and were set correctly. They were not aware the resident did not have their oxygen on, or the portable oxygen tank was set to 3 Liters/minute and was empty. They stated it was important for Resident #88 not to have an empty portable oxygen tank and to wear their oxygen as ordered because they could have become short of breath or confused from the lack of oxygen perfusion. During an interview on 5/2/2025 at 12:30 PM, Licensed Practical Nurse/Resident Care Coordinator #23 stated staff should look at the resident's care plan and certified nurse aide care instructions to know how to care for a resident. If a resident was on oxygen, they required a physician order. Resident #88's oxygen use, and instructions should be listed on their care plan. Nursing staff was responsible for checking the portable oxygen tanks to ensure they were working and not empty. Resident #88's physician order was for continuous oxygen at 2 Liters/minute and should not have been set to 3 Liters/minute. It was important for Resident #88 to wear their oxygen as ordered and for staff to ensure their portable oxygen tank was not empty so the resident could breathe easier and not become short of breath. During an interview on 5/2/2025 at 1:24 PM, Certified Nurse Aide #22 stated they looked at the care plan for instructions on how to care for Resident #88. Oxygen should have been listed on the care plan, so all staff knew how to properly care for them. Resident #88 was required to wear oxygen continuously that was a physician order. Nursing should check the oxygen tank to make sure it was not empty. It was important to have oxygen listed on the care plan, so all staff knew the resident required oxygen at 2 Liters/min at all times. Not receiving oxygen or too much oxygen put the resident in danger. During an interview on 5/2/2025 at 1:39 PM, the Director of Nursing stated staff looked at the resident's care plan or certified nurse aide instructions to know what care to provide. The certified nurse aide care instructions were generated from the care plan so they both had the same information. If a resident was on oxygen, it should be included in their care plan so they received proper care, and all staff would know they required oxygen. The nurses should check throughout the day to ensure Resident #88's portable oxygen tank was not empty and was set correctly to match the physicians order of 2 Liter/minute. It could put Resident #88 at risk to not have adequate oxygen. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure that a resident who required dialysis (a process that filters blood when kidneys do not function normally) received services consistent with professional standards of practice for one (1) of one (1) resident (Resident #77) reviewed. Specifically, Resident #77 received hemodialysis and there was no documented evidence of ongoing communication and collaboration with the dialysis facility. Findings include: The facility policy Care of the Hemodialysis Resident, revised 3/30/2024, documented, prior to each hemodialysis treatment a report book would be completed and sent with the resident to the dialysis center. The report should include relevant information such as the resident's vital signs, lab results and any significant change in their condition. Resident #77 had diagnoses including, end-stage renal disease (kidney disease) and dependence on renal hemodialysis. The 4/25/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment and received dialysis. The Comprehensive Care Plan initiated 4/21/2025, documented the resident had renal failure and had a goal of maintaining their continuity of care by regular communication with the outside dialysis provider. The resident was provided transportation to their appointments and the resident's attendance was encouraged on Mondays, Wednesdays, and Fridays. The 4/21/2025 physician order documented ensure dialysis communication book was filled out and sent with the resident to dialysis and reviewed upon return from dialysis on dialysis days Monday, Wednesday, and Friday. Call the dialysis provider for report if communication book was not present on return. During an interview on 4/29/2025 at 10:00 AM, Licensed Practical Nurse #7 was unable to provide the dialysis communication book for Resident #77. They stated the book had been misplaced by the dialysis center. They stated when the communication book was not returned with a report after the resident's dialysis, they should have called the dialysis facility to obtain a verbal report. Licensed Practical Nurse #7 stated they did not make notation in the electronic medical record indicating a verbal report with the dialysis center occurred. During an interview and observation on 4/30/2025 at 11:00 AM, Licensed Practical Nurse #7 stated the resident was at their dialysis appointment. The resident's dialysis communication book was observed at the desk. Licensed Practical Nurse #7 stated the book should have been with the resident at dialysis. The book on the desk was a new book because the last one was lost. Nursing progress notes dated 4/21/2025 through 5/2/2025 did not document phone communication with the dialysis center regarding the missing communication book or subsequent report of the resident's condition as ordered. The 4/2025 Medication Administration Record documented ensure dialysis communication book was filled out and sent with the resident to dialysis and reviewed upon return from dialysis on dialysis days Monday, Wednesday, and Friday, and was signed as completed on 4/30/2025 morning by Licensed Practical Nurse #7 and at 4:00 PM by Licensed Practical Nurse #41. During an interview on 5/1/2025 at 9:23 AM, Licensed Practical Nurse #7 stated there was no report sheet in the communication book from 4/30/2025. They stated the dialysis center failed to return the lost communication book. They had made a call to the dialysis center and received a verbal report. The report was not documented however there were vital signs entered in the Electronic Medical Record. During a telephone interview on 5/2/2025 at 10:52 AM dialysis center Registered Nurse #42 stated the communication book was often in the pocket of the wheelchair the resident arrived in. The transport company often picked the resident up after dialysis in a different wheelchair. If the dialysis center was unable to locate a communication book for the resident, a report would be sent on a dialysis center form and given to the resident to return to the facility. It was not their practice to call the facility to give report unless a significant event occurred during dialysis. It was important to communicate with the facility to ensure quality of care, continuity and to alert the facility of any specific areas to monitor regarding the resident's care. During an interview on 5/2/2025 at 12:17 PM Licensed Practical Nurse Unit Manager #6 stated the communication book was lost at dialysis however the dialysis center reached out with a telephone call whenever this occurred to report anything pertinent. They had no knowledge of the dialysis center ever having sent their own communication sheet apart from the original communication book. Having good ongoing communication ensured optimal care. During an interview on 05/02/2025 at 2:00 PM, the Director of Nursing stated the licensed practical nurse in charge during the shift was responsible for filling out the dialysis communication book and making sure the book had accompanied the resident to dialysis every time they went. The communication book contained the resident's vital signs, medications, and anything else that was pertinent to their care. The licensed practical nurse should review communication report upon the resident's return. Consistent communication was important for prevention of problems related to a change in a resident's condition. 10NYCRR 415.12(k)

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not review risks and benefits of bed rails, obtain informed consent, or remove enabler bars after physical therapy deemed them contraindicated for use for one (1) of one (1) resident (Resident #31) reviewed. Specifically, Resident #31 had enabler bars (used to assist with bed mobility) on both sides of their bed after a physical therapy assessment documented enabler bars were contraindicated for the resident; there was no documented evidence that risks and benefits were reviewed with the resident or resident representative or consents were obtained prior to bed rail use. Findings include: The facility policy Bed Rails, dated 11/20/2024, documented the facility would ensure bed rails, when provided, were used in compliance with federal and state guidelines to prevent and or reduce any risk of entrapment, restraint, or other injury. Informed consent was obtained from the resident or if applicable, the resident representative. Resident #31 had diagnoses including cancer of the large intestine and rectum, fracture of sacrum (shield shaped bone at base of spine), and muscle weakness. The 2/10/2025 Minimum Data Set documented the resident had severe cognitive impairment, required substantial/maximal assistance for chair/bed-to-chair transfers, toilet transfers, and tub/shower transfers. The Comprehensive Care Plan initiated on 12/01/2024 and last updated on 2/27/2025 documented the resident had an activities of daily living self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited mobility and limited range of motion. Interventions included full body mechanical lift for transfers. The resident was at risk for falls related to deconditioning. Interventions included the use of side rails as ordered and to evaluate for appropriate adaptive equipment as needed. The 3/29/2025 by Physical Therapist #31 assessment documented Resident #31 was no longer a candidate for enabler bars and was dependent with rolling maneuvers and scooting to the head of the bed. The 5/2/2025 Care Card (Kardex) documented the resident required use of a full body mechanical lift device from chair/bed to chair transfer, partial assistance of one for rolling left to right, and partial assistance of one for lying to sitting on edge of the bed. There was no documented evidence of enabler bar use. The following observations of enabler bars on both sides of Resident #31's bed were made: - on 4/28/2025 at 2:25 PM. The resident was grabbing and shaking the rails on the left side of the bed saying, get me out. - on 4/30/2025 at 11:28 AM. The resident stated no one every showed them how to use the rails or reviewed the risks and benefits of the bed rails. - on 5/1/2025 at 11:25 AM. During an observation and interview on 4/30/2025 at 11:31 AM, Certified Nurse Aides #22 and # 39 were observed entering Resident #31'a room with a lifting device and stated they were going to get the resident out of bed. They rolled the resident side to side to place the lifting device pad under the resident. The resident rolled side without using the enabler bars. Certified Nurse Aide #22 stated enabler bars were used to keep residents from falling out of bed, they did not know how to use them and was never taught how to. They stated they did not know who placed the enabler bars on Resident #31's bed, and did not know if a physician order was required. Certified Nurse Aide #39 stated they were not aware of how Resident #31 used the enabler bars and was never told what the risks associated with them were. During an interview on 4/30/2025 at 12:19 PM, Licensed Practical Nurse #20 stated enabler bars required a physician order and a physical therapy evaluation. Resident #31 was initially working with physical therapy for bed to chair transfers and may have used the enabler bars at that time. A couple months ago the resident started requiring a mechanical lift and the enabler bars were no longer used to assist in transferring. Enabler bars were installed by maintenance. They were unsure if enabler bars required a consent. If physical therapy recommended enabler bars not to be used, they should have been discontinued by maintenance. During an interview on 5/1/2025 at 8:48 AM, Rehabilitation Director #30 stated there were enabler bars in the facility. Every resident was screened by physical therapy on admission for appropriateness of any mobility assisting device, including over the bed trapeze and enabler bars. They required physician orders, and they were not sure if they required consents. If physical therapy found enabler bars to be helpful for mobility, physical therapy placed a clarification order for the physician's standing order for enabler bars and a work order was placed with maintenance electronically for enabler bars to be installed on the bed. Nursing was made aware by the clarification order. Every couple of months physical therapy would reassess the resident for the appropriateness of enabler bars, and if no longer appropriate a work order was placed with maintenance and the enabler bars were removed from the bed within 24 hours. Physical Therapist #31 performed an assessment on 3/29/2025 and recommended enabler bars be removed as Resident #31 was pushing against them and was no longer using them as a mobility device. During an interview on 5/1/2025 at 10:22 AM, Maintenance Worker #32 stated maintenance was responsible for installing and removing enabler bars from resident beds. They were never told about entrapment zones. There were no current workorders to remove enabler bars for any residents. During an interview on 5/2/2024 at 11:57 AM, the Director of Nursing stated physical therapy completed an assessment and consent for risk/benefits for any resident who required enabler bars. The enabler bars for Resident #31 should have been removed as physical therapy documented they were no longer appropriate for the resident because the resident could get injured or entrapped. Without access to the electronic record, they were not able to confirm if this was completed with the resident or representative. 10NYCRR 415.12(h)(1)(2)

52766 Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure each resident received food that accommodated resident preferences for two (2) of two (2) residents (Residents #60 and #31) reviewed. Specifically, Resident #31 was missing food items at meals; Resident #60 was missing soda listed on their meal ticket and received hot chocolate instead. Findings include: The facility policy Menus, revised 9/2017, documented that a Registered Dietitian/Nutritionist or other clinically qualified nutrition professional would adjust individual meal plans to meet the individual requests of residents. Menus would be served as written, unless a substitution was provided in response to preferences. The facility policy Dining Experience, revised 6/5/2024, documented the facility would make all efforts to honor the residents' meal preferences and choices. 1) Resident #31 had diagnoses including cancer of the large intestine and rectum, fracture of sacrum (shield shaped bone at base of spine), and muscle weakness. The 2/10/2025 Minimum Data Set documented the resident had severe cognitive impairment, weighed 83 pounds, and unplanned weight loss of 5% or more in the last month and/or 10% percent or more in the last 6 months. The Comprehensive Care Plan initiated 12/01/2024 and updated on 2/27/2025 documented the resident had a nutritional problem or potential problem related to medical diagnosis. Interventions included, provide and serve supplements as ordered, provide and serve diet as ordered, and provide snacks and fluids. The resident had an unplanned/unexpected weight loss related to poor food intake. Interventions included offer substitutes as requested or indicated, ice cream with chocolate syrup with meals, or snack and potato chips with meals. The 12/4/2024 Registered Dietitian #3 progress note documented the resident had significant weight loss and they made activities staff aware to offer snacks more often. Registered Dietitian #3 nutritional assessments on 1/6/2025, 1/12/2025, 2/9/2025, 3/20/2025, 3/31/2025, and 4/4/2025 documented the resident was to receive fruit at every meal and potato chips at lunch. During an interview on 4/28/2025 at 2:28 PM, Resident #31 stated the food lacked flavor, so they did not eat it and only ate food their family brought in. The 5/2/2025 Kardex (care instructions) documented to offer substitutes as requested and to offer ice cream and chocolate syrup with meals or for snack, and potato chips with meals; and provide with supplements as ordered. During an interview and lunch meal observation on 4/29/2025 at 1:10 PM the resident stated they never get fruit or chips. They stated they would eat chips and fruit if they were on the tray. They had no problem with their appetite, the food was just bad. There was no fruit or potato chips on the resident's lunch tray. During observations on 5/1/2025 at 9:09 AM Resident #31's breakfast tray was missing fruit and peanut butter, and at 12:06 PM their lunch tray was missing fruit and chips. 2) Resident #60 had diagnoses including diabetes and left sided hemiparesis (partial paralysis) following subarachnoid hemorrhage (brain bleed). The 4/18/2025 Minimum Data Set assessment documented the resident had intact cognition and snacks between meals were important to them. The Comprehensive Care Plan initiated 8/3/2022 and revised 4/11/2024, documented the resident had potential nutritional and fluid deficit problems related to medications and medical diagnosis. Interventions included to encourage the resident to drink fluids of choice. During an interview on 4/28/2025 at 3:53 PM, Resident #60 stated they hated the food, and it did not taste good. Their family member brought them microwave dinner meals to eat. During an observation and interview on 4/30/2025 at 12:12 PM, Resident #60 stated their soda, ice cream, and pizza casserole was missing from their tray and their soda was always missing. They stated hot chocolate was always on their tray, they did not want hot chocolate, and wanted it removed because they had diabetes. The resident's meal tray did not include soda, ice cream, or pizza casserole. During an interview on 4/30/2025 at 12:15 PM, Certified Nurse Aide #18 stated tray items had been missing and the kitchen was responsible for putting everything on the trays. When something was missing, they called the kitchen. Resident #60 did not like what was on their tray and usually only wanted salad. They stated the kitchen was not able to provide Resident #60 with soda because there was not enough. During an Interview on 5/1/2025 at 11:35, Certified Nurse Aide #19, stated when items were missing on trays, they called down to the kitchen to have the missing items brought up. Sometimes the kitchen would be too busy to bring up missing items. Resident #31 did not like the food. They had not seen Resident #31 receive fruit on their tray or chips at lunch and they did not have chips to hand out to residents on the unit. They stated soda was not available to residents and they did not know why. During an interview on 4/30/2025 at 12:19 PM, Licensed Practical Nurse #20 stated Items were often missing on trays. The kitchen put the trays together and staff who delivered the trays double checked the trays were correct. The residents never received fresh fruit, and staff were not able to give out potato chips to residents when they wanted them. Resident #31 had not received fruit with meals or potato chips at lunch. They stated residents could not get soda between meals. Soda was only available at meals if it was listed on meal ticket. Resident #60's soda should have been on their tray, they did not know why it was missing. They were told there was not enough soda. During an interview on 5/1/2025 at 12:56 PM, Registered Dietitian #3 stated when they ordered fortified meals or other recommendations for residents, they emailed the kitchen to communicate the change. They believed if residents asked for snacks they were given snacks between meals. The kitchen staff was responsible for stocking unit kitchenettes. They stated they did not understand why residents were not able to get soda, or soda between meals. Soda was still a way residents, like Resident #60 would receive hydration. They stated they expected Resident #31 to be provided the food items they recommended, and it was likely adding to the resident's decreased food intake. During an interview on 5/1/2025 at 2:23 PM, District Food Services Manager #36 stated they oversaw all food service operations. They used to stock snacks (chips, cookies, cereal) but no longer did. The unit kitchenettes were stocked with supplies for coffee, juice, and milk. They did not stock soda on units, soda only came on meal trays. Residents did not get soda between meals if they wanted it. They were told administration did not want residents drinking soda. One snack was provided to residents at 2:00 PM daily. Residents could buy extra snacks. They worked with the dietitian for individual requests and recommendations for residents. The dietitian emailed them with resident preferences or recommendations. They stated they did not receive an email for Resident #31 and their meal ticket was not changed to include fruit at every meal and chips at lunch. Resident #31 recommendations should have been provided. During an interview on 5/2/2024 at 11:57 AM, the Director of Nursing stated residents had a budget at home, the facility had a budget, and snacks must fit within that budget. Residents were provided with a snack at 2:00 PM daily. They stated residents were upset they did not get the snacks or drinks they wanted. The food situation at the facility was not right and residents' preferences should be respected and reflected on their meal tickets. 10NYCRR 415.14(d)(3)(4)

Based on observations, record review, and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen and one (1) of three (3) dining room refrigerators and ice machines (B-wing) reviewed. Specifically, the B-Wing dining room refrigerator was not clean; the B-Wing dining room ice machine was not working; the main kitchen dry storage room floor was not cleanable; the main kitchen hand wash sink was leaking onto the floor; and the main kitchen walk-in freezer door did not close properly due to ice buildup. Findings include: There was no documented policy referencing kitchen cleaning, maintenance, or food storage. The main kitchen's Monthly Cleaning List completed from 4/27/2025 to 4/30/2025 documented the following: - the walk-in cooler floors were swept and mopped weekly. - the dry storage room was swept and mopped weekly. - the walk-in freezer was cleaned and sanitized monthly. The following observations were made in the main kitchen: - on 4/28/2025 at 1:18 PM, the floor in the dry storage room had chipped floor tiles, stains from spilled food, and debris. - on 4/28/2025 at 1:20 PM, the walk-in freezer door would not close due to ice buildup on the door frame. - on 4/29/2025 at 11:50 AM, the hand wash sink was leaking onto the floor, and the walk-in cooler had a buildup of black grime on the diamond plate flooring. - on 4/29/2025 at 11:51 AM, the walk-in freezer had packaging debris on the floor and under the shelving, and the door would not close due to ice buildup on the door frame. The facility work orders from the kitchen documented the hand washing sink was leaking on 11/12/2024 and repaired on 5/2/2025. During observations on 4/28/2025 at 2:29 PM and on 5/1/2025 at 12:38 PM the B-wing dining room refrigerator had a dried on red liquid substance on the inside of the refrigerator. During observations on 4/28/2025 at 5:26 PM and 4/29/2025 at 12:49 PM the B-wing dining room ice machine was not working. During an interview on 5/1/2025 at 11:35 AM, Certified Nurse Aide #19 stated when equipment was broken, they completed a work order and maintenance repaired items within the day. The ice machine was broken for 2 months, and staff had to leave the unit to get ice for residents. During an interview on 5/1/2025 at 12:40 PM, Certified Nurse Aide #35 stated they thought everyone was responsible for cleaning and maintaining the dining room refrigerator and they had not cleaned it because they did not have time. During an interview on 5/1/2025 at 12:54 PM, Director of Maintenance/Laundry/Housekeeping #15 stated they were responsible for cleaning the outside of the dining room refrigerator, but nursing staff was responsible for cleaning the inside. They were unsure how often it was supposed to be cleaned. During an interview on 5/1/2025 at 1:12 PM, District Manager #36 stated the kitchen floors were cleaned nightly, the floors in the walk-in cooler and freezer were cleaned weekly, and they had plans to replace the flooring in the dry storage room and walk-in coolers. Staff should document the cleaning of those areas on the kitchen cleaning list. When something was broken in the kitchen staff should put in work orders which were reviewed weekly by Administration and maintenance. The hand wash sink was leaking for a while, but it was fixed yesterday. Dietary was no longer responsible for cleaning the refrigerators on the units. They were not being maintained so it was assigned to housekeeping or nursing. It was important for the kitchen and kitchenettes to be maintained and kept clean for food safety. During an interview on 5/2/2025 at 9:33 AM, Maintenance Worker #32 stated they used an outside vendor to fix the ice machines. They were not sure how long the ice machine on B-Wing was broken or when the vendor last came to repair the machine. During an interview on 5/2/2025 at 9:35 AM, Maintenance Director #15 stated they used a local heating and cooling company to repair their ice machines. The company was last in the facility a few months ago. During an interview on 5/2/2025 at 11:57 AM, the Director of Nursing stated they were not exactly sure how long the ice machine had been broken on the B-Wing, but it was at least a week. The believed maintenance was working on repairing the ice machine. 10NYCRR 415.14(h)

Based on record review and interviews during the recertification survey conducted 4/28/2025-5/2/2025, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility. Specifically, the facility did not provide the Facility Assessment, Medicare/Medicaid Application (CMS-671), Facility Survey Report (DOH-1550), New York State (NYS) Social Services Medicaid Provider Agreement (DOH-2325), Equipment Inventory Form, Legionella policies and procedures, and a list of employees whose date of hire was 4 months or less that was requested by the New York State Department of Health (NYS DOH) surveillance team in a timely manner as required. Findings include: The Centers for Medicare and Medicaid Services survey form Entrance Conference Worksheet provided to the Administrator/designee upon survey entrance documented the following items were required during the recertification survey: - Facility Assessment within four hours of entrance. - completed Medicare/Medicaid Application (CMS-671) within 24 hours of entrance. The New York State Addendum form Entrance Conference Worksheet provided to the Administrator/designee upon survey entrance documented the following items were required during the recertification survey: - a list of employees whose date of hire was four months or less within one hour of entrance. - Facility Survey Report (DOH-1550) within 24 hours of entrance. - New York State (NYS) Social Services Medicaid Provider Agreement (DOH-2325) within 24 hours of entrance. - Equipment Inventory Form within 24 hours of entrance. - Legionella policies and procedures within 24 hours of entrance. The New York State Department of Health surveillance team entered the facility on 4/28/2025 at 12:30 PM. The Team Coordinator met with the facility's Administrator and Director of Nursing at 1:20 PM to review the documents required for the survey as outlined on the entrance conference worksheets. The Administrator was provided with a hard copy of the entrance conference worksheets. The worksheets included the time frame for providing the Facility Assessment, Medicare/Medicaid Application (CMS-671), Facility Survey Report (DOH-1550), New York State (NYS) Social Services Medicaid Provider Agreement (DOH-2325), Equipment Inventory Form, Legionella policies and procedures, and a list of employees whose date of hire was four months or less. On 4/29/2025 at 9:16 AM, the Team Coordinator sent an email to the Director of Medical Records requesting the list of employees whose date of hire was four months or less that was required within one hour of entrance. On 4/29/2025 at 12:15 PM, the Director of Medical Records sent the list of employees whose date of hire was four months or less. This was 23 hours after the entrance conference meeting. On 4/29/2025 at 4:00 PM, the Team Coordinator met with the Administrator to review the missing entrance conference documents including the Facility Assessment that was required within 4 hours of entrance, the Medicare/Medicaid Application (CMS-671), Facility Survey Report (DOH-1550), New York State (NYS) Social Services Medicaid Provider Agreement (DOH-2325), Equipment Inventory Form, and Legionella policies and procedures that were required within 24 hours of entrance. They stated they thought they had sent them; they would check with the Director of Medical Records, and they would make sure they were sent by the end of the day. On 4/29/2025 at 5:57 PM, the Team Coordinator sent an email to the Director of Medical Records requesting the Facility Assessment that was required within 4 hours of entrance, Medicare/Medicaid Application (CMS-671), Facility Survey Report (DOH-1550), New York State (NYS) Social Services Medicaid Provider Agreement (DOH-2325), Equipment Inventory Form, and Legionella policies and procedures that were required within 24 hours of entrance and attached a blank copy of the Medicare/Medicaid Application (CMS-671), Facility Survey Report (DOH-1550), New York State (NYS) Social Services Medicaid Provider Agreement (DOH-2325), and Equipment Inventory Form. On 4/30/2025 at 8:20 AM, the Team Coordinator notified the Administrator they had not received the requested entrance conference documents. The Administrator stated they would follow up with the Director of Medical Records and have the documents sent. On 4/30/2025 at 8:25 AM, the Director of Medical Records sent an email stating their internet was acting up and they would start sending the requested documents. They attached the Facility Assessment and the New York State (NYS) Social Services Medicaid Provider Agreement (DOH-2325). On 4/30/2025 at 8:42 AM, the Director of Medical Records sent the Legionella policies and procedures. On 4/30/2025 at 9:58 AM, the Director of Medical Records sent the Medicare/Medicaid Application (CMS-671) and Facility Survey Report (DOH-1550). On 4/30/2025 at 4:55 PM, the Director of Medical Records sent the Equipment Inventory Form. 10 NYCRR 483.70(i)

Based on observation, record review and interview during the abbreviated survey (NY00347901), the facility did not ensure residents with pressure ulcers or at risk of pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 3 residents (Residents #1 and 3) reviewed. Specifically: -Resident #1 developed new pressure ulcers and there was no documented evidence that recommended treatment orders obtained or implemented timely and no documented evidence diagnostic tests were ordered or obtained timely. -Resident #2 developed a Stage 3 pressure ulcer on their coccyx and there was no documented evidence the registered dietitian reassessed the resident's nutritional needs. Additionally, the resident had a significant weight loss and there was no documented evidence the registered dietitian was made aware to reassess. Findings include: The facility's policy Weights, effective ,d+[DATE] documented residents were weighed upon admission, weekly for 4 weeks after admission, readmission and monthly thereafter to establish a weight patter and monitor for changes. Re-weights were to be obtained for any discrepancies, the Interdisciplinary Team reviewed possible causes of weight change and initiated appropriate interventions, and weight loss or gain of 5% in one month and/or 10% in 6 months must be reported to the registered dietitian, physician, and Minimum Data Set coordinators to review for possible significant change in status. The facility's policy Medication: Physicians Orders Management, revised [DATE] documented outside consultants wrote their orders and details of their visit on a consultation form or in their company documentation format. Outside consultants' documentation and orders would be scanned or uploaded into the resident's medical record. The orders and visit description would be reviewed by the resident's primary care provider, orders would be implemented and written by an in-house provider as deemed appropriate. 1) Resident #1 had diagnoses including dementia. The [DATE] Minimum Data Set Assessment documented the resident's cognition was moderately impaired, they required substantial/maximal assistance with rolling left to right, they were dependent for chair/bed-to-chair transfers, and they had no unhealed pressure ulcers. The [DATE] Comprehensive Care Plan documented the resident was at risk for skin breakdown related to immobility, deconditioning and incontinence. Interventions included keep skin clean and dry, pressure relieving device in wheelchair and on bed, and skin team to monitor weekly. The [DATE] at 5:24 PM Licensed Practical Nurse #4 Manager note documented the resident had a wound to the left buttocks that was 4 centimeters x 4.3 centimeters and the resident also had multiple unmeasurable sores to the right side of buttocks. The registered nurse assessed, and orders were obtained. The [DATE] physician orders documented to cleanse left side of buttock with normal saline, apply normal saline to wound bed and cover with Allevyn (silicone dressing). To the right side of buttocks, apply Desitin (protective barrier cream) three times daily for wound. The [DATE] Wound Physician #2 note documented the resident had left buttock moisture associated skin damage (skin problem that occurs from repeated exposure to bodily fluids) that was 4 centimeters x 11 centimeters by 0.2 centimeters. The plan was to use calcium alginate (wound treatment) with a bordered dressing daily. The [DATE] physician order documented to left side of buttock, cleanse with normal saline, apply calcium alginate to wound bed and cover with a 4 x 4 bordered dressing daily. The [DATE] updated Comprehensive Care Plan documented the resident had a wound to the left buttock. Interventions included treatments as ordered, monitor that dressing was intact, and obtain and monitor lab work and diagnostics as needed. The [DATE] Wound Physician #2 note documented the resident had a Stage 3 (full thickness loss of tissue) sacral (triangular bone in the lower back between two hipbones of the pelvis) ulcer that was 4 centimeters x 5 centimeters x 0.2 centimeters and was 30% necrotic (non-viable tissue). The plan was to use calcium alginate and Medihoney (wound treatment) covered with a foam silicone bordered dressing daily. The [DATE] physician order documented to left buttock, apply Medihoney and calcium alginate to wound bed and cover with a foam dressing daily. There was no documented evidence the treatment order was updated to apply to the sacral ulcer as documented in the wound physician note. The [DATE] at 1:35 PM Wound Physician #2 note documented the resident had: -an Unstageable sacral ulcer that was 4 centimeters x 2.5 centimeters x 0.2 centimeters. The plan was to continue calcium alginate and Medihoney covered with a foam silicone bordered dressing daily. -a Deep Tissue Injury (injury of underlying soft tissue from pressure or shear) on the left ischium (lower bone of the pelvis) that was 4 centimeters x 4 centimeters and was intact with purple discoloration. The plan was for hydrocolloidal paste (wound treatment) every shift. -a Deep Tissue Injury of the right ischium that was 6 centimeters x 2 centimeters and was intact with purple discoloration. The plan was to use hydrocolloid paste every shift. The [DATE] physician orders documented to left buttock, apply Medihoney and calcium alginate to wound bed and cover with a foam dressing daily. There was no documented evidence of an order for hydrocolloid paste every shift to left and right ischiums as recommended by the wound physician. The resident's previous order for Desitin to the right side of the buttocks continued three times daily as ordered on [DATE]. The [DATE] Attending Physician #3 note documented the resident's white blood cell count (potential indicator of infection) was up a bit. The resident was followed by wound care for a very significant sacral ulcer. No changes were made today. The [DATE] at 1:35 PM Wound Physician #2 note documented the resident had: -an Unstageable sacral ulcer that was 4 centimeters x 2 centimeters x 0.2 centimeters. The wound had 100% slough (non-viable tissue). The plan was to change the treatment to Santyl (wound treatment used to remove damaged skin), use a gauze sponge dressing moistened with saline and cover with a foam silicone bordered dressing daily. -an Unstageable left ischium ulcer that was 5 centimeters x 7 centimeters x 0.2 centimeters. The wound was 50% necrotic, 50% slough. The plan was to change to Santyl, use a gauze sponge soaked in saline and cover with a bordered dressing daily. -an Unstageable right ischium ulcer that was 3 centimeters x 6 centimeters x 0.2 centimeters. The wound was 100% necrotic. The plan was to continue hydrocolloid paste every shift, and add Santyl with saline soaked gauze pad daily, There was no documented evidence the resident's sacral ulcer treatment was changed from Medihoney/calcium alginate to Santyl as recommended by the wound physician and there was no documented evidence of a treatment order for the right and left ischium's as recommended. The [DATE] at 7:22 PM Registered Nurse #5 note documented they spoke with the on-call provider as the resident had a temperature of 101.6 and were lethargic. They observed the resident's sacral wound with purulent (pus) drainage. New orders were obtained for doxycycline (antibiotic) 100 milligrams twice daily for 7 days. Wound culture and labs ordered. The [DATE] physician order documented doxycycline 100 milligrams twice daily for 7 days and obtain wound culture from sacral wound bed. There was no corresponding provider note. There was no documented evidence a wound culture was obtained. The [DATE] Wound Physician #2 note documented the resident had: -an Unstageable sacral ulcer that was 2.6 centimeters x 2.7 centimeters x 0.2 centimeters. The plan was to continue Santyl. -an Unstageable left ischium ulcer that was 4.5 centimeters x 9.3 centimeters x 0.2 centimeters. Continue Santyl. -an Unstageable right ischium ulcer that was 8 centimeters x 4.6 centimeters x 0.2 centimeters. The wound was 100% necrotic with undermining (tissue beneath the visible edges of ulcer erodes, creating pockets between skin and underlying tissue) of 2.4 centimeters at 5 o'clock. The plan was to continue hydrocolloid paste every shift along with Santyl. The ,d+[DATE] to [DATE] Medication Administration Record documented calcium alginate and Medihoney were applied to the resident's left buttock daily. The Treatment Administration Record did not document a treatment to the resident's left and right ischium's. The [DATE] Nurse Practitioner #6 note documented both resident's buttocks ulcers and the coccyx (tailbone) ulcer continued to worsen, and their wounds were noted with tunneling (a wound that had progressed to form passageways underneath the skin surface), black eschar (non-viable tissue) and foul odor (potential indicator of infection). The resident was moaning in pain anytime they were positioned, and they only had Tylenol as needed for pain. The [DATE] physician order documented Tramadol (narcotic pain medications) 50 milligrams two times daily. The [DATE] at 10:22 AM Wound Physician #2 note documented the resident had: -an Unstageable sacral ulcer that was 4 centimeters x 2 centimeters x 0.2 centimeters. Continue Santyl. -a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) to left ischium ulcer that was 5 centimeters x 10 centimeters x 3 centimeters. The wound was previously Unstageable and after debridement, revealed itself to be Stage 4. Continue Santyl. -a Stage 4 right ischium ulcer that was 9 centimeters x 5 centimeters x 2 centimeters. The wound was previously unstageable and after debridement, revealed itself to be a Stage 4. Continue hydrocolloid paste every shift and continue Santyl. The note documented they recommended a complete blood count (blood test, provides information about blood cells including infection), erythrocyte sedimentation rate (blood test, shows inflammation or cell damage), C-reactive protein (blood test, shows inflammation or infection), x-ray both ischial wounds to assess osteomyelitis (serious bone infection) due to depth of wounds and significant short-term worsening of wounds. The [DATE] physician order documented to both buttock wounds, apply Santyl, wet to dry dressing with normal saline, pack kerlix (dressing) in wounds and cover with a bordered dressing daily. There was no documented evidence of a treatment order for the resident's sacral ulcer and no documented evidence the lab tests or x-rays recommended by the wound physician were ordered or obtained. The [DATE] Nurse Practitioner #6 note documented resident had increased pain when moving and when wound care was done to wounds on buttocks. Pain was not controlled on tramadol. The resident was started on Hydrocodone (strong narcotic pain reliever) with better results. The [DATE] Medical Records Clerk #10 note documented the resident was sent to the hospital. The [DATE] hospital discharge instructions documented the resident had osteomyelitis in both ischium's and sepsis (life-threatening complication of infection). The resident's family initially wanted a feeding tube (tube that delivers nutrition) but decided to make them comfort measures. To both buttock wounds, apply Santyl to bed of wounds then apply Amerigel (barrier ointment) and loosely pack wounds with Aquacel AG (wound treatment). To sacral wound, apply Amerigel and loosely pack with Aquacel AG. For superficial sacral wounds cleanse then apply Amerigel. Cover all 4 wounds with Allevyn. Zinc (protective ointment) to skin surrounding wounds. The [DATE] at 9:45 PM note documented comfort care continued, the resident was restless and displaying air hunger. Roxanol (strong narcotic medication) given with effect. The [DATE] at 10:54 AM Licensed Practical Nurse #7 documented the resident expired at 9:45 AM. During a telephone interview on [DATE] at 9:58 AM, Wound Physician #2 stated during wound rounds, staff knew what recommendation they made because they discussed the recommendations during wound rounds with the wound team including Licensed Practical Nurse Manager #4. They could not write their own orders. On [DATE], the resident's orders should have been changed to the sacrum because the location of the wound changed. They were not aware orders were not updated. The ischium's were located near the folds under the buttock cheeks and were not near the sacrum. When they recommended hydrocolloid paste on [DATE], they were not aware an order was not obtained and should have been. Treatments were implemented to slow or delay the deterioration of the resident's skin. The resident was not eating or drinking, their body was breaking down and the resident was actively dying. On [DATE], they ordered Santyl which was usually used to improve a wound. The resident's family was not on the same page about end-of-life care and why they went ahead and ordered Santyl. They changed the treatment order for the ischium ulcers to Santyl because hydrocolloid paste was for intact skin and those wounds were no longer intact. They were not aware calcium alginate/Medihoney continued to the sacrum and not aware there continued to be no treatment to the resident's ischium's. On [DATE], they documented the resident had undermining of skin which was like a cave formation where the under tissue had died and fallen away. It was a marker of a wound worsening. On [DATE], when the facility ordered treatment to the right and left buttocks, those dressings would not have covered the sacral wound and expected a separate order for the sacrum. They were not aware there was no treatment order to the sacrum. It was not timely when it took 3 weeks for an ordered treatment to be obtained to the resident's ischial wounds. When they documented recommended labs and x-rays for the resident, they were aware they were not obtained because to their understanding, the family wanted comfort care and end of life goals. When the resident was hospitalized and diagnosed with sepsis and osteomyelitis, they stated the resident's wounds would not have been the cause of sepsis because the wounds were open and draining. The resident was in such a state of decline and treatments would have slowed the progression but would not have cured them. During a telephone interview on [DATE] at 11:21 AM, Licensed Practical Nurse Manager #4 stated themself and the Interdisciplinary Team were responsible to review consultant recommendations. Wound Physician #2 gave them orders during wound rounds, and they entered them into the resident's electronic record. They were not required to confirm the order with a facility provider. The wound physician communicated with providers and if they disagreed with the order, the provider would change it. During the interview, Licensed Practical Nurse #4 verified the order on the Treatment Administration Record was to the left buttock and not the sacrum as Wound Physician #2 documented on [DATE]. A treatment order should have been obtained for the resident's right and left ischium ulcers and if an order was not obtained then ulcers could possibly worsen. It was not timely when the resident went 3 weeks without orders to their ischium's. On [DATE], there was a shortage of Santyl, it was not available, and they thought they discussed that with Wound Physician #2. That was why the resident's calcium alginate and Medihoney order continued. On [DATE], they recalled the on-call provider ordered a wound culture and another provider (could not recall who) discontinued the order. They stated if the wound culture was obtained, the results would have been in the record. On [DATE], they were not sure why labs and x-rays were not obtained as recommended by Wound Physician #2. They also were not sure why there was no ordered treatment to the resident's sacrum on [DATE]. During a telephone interview on [DATE] at 1:37 PM, the Director of Nursing stated the manager for the unit was usually responsible to review consult recommendations and communicate the recommendations to the provider to get them implemented. Wound Physician #2's recommendations should be communicated to the providers however they had providers who said Wound Physician #2's orders should be implemented without contacting them. On [DATE], they expected a treatment order to have been obtained to the resident's ischium's. On [DATE], treatment orders should have been changed to Santyl per Wound Physician #2's recommendations. On [DATE], there should have been documentation because the resident's wound culture was not obtained. On [DATE], the labs and diagnostic tests recommended by Wound Physician #2 should have been obtained. Additionally, there should have been treatment orders on [DATE] for all 3 of the resident's wounds. It was not timely when it took 3 weeks to obtain orders to the resident's ischium wounds. 2) Resident #3 had diagnoses including dementia and protein calorie malnutrition. The [DATE] Admission Minimum Data Set assessment documented the resident's cognition was severely impaired, they required partial/moderate assistance with rolling left and right and they required substantial/maximal assistance with transfers. The resident had no unhealed pressure ulcers. The [DATE] Comprehensive Care Plan documented the resident had a nutritional problem related to need for a therapeutic diet and mechanically altered diet, and the resident was at risk for skin breakdown. Interventions included to monitor, document, and report to provider the signs and symptoms of emaciation (muscle wasting, significant weight loss 3 pounds in 1 week, over 5% in 1 month, over 7.5 % in 3 months, or over 10% in 6 months), keep skin clean and dry, monitor for skin discoloration, open areas, and report to nurse. The [DATE] physician order documented Calmoseptine (protective skin treatment) ointment to buttocks every shift for prevention. The [DATE] at 11:35 AM nutritional assessment completed by Registered Dietitian #9 documented the resident's diet was no added salt, ground consistency, and nectar thickened fluids. Supplements included Boost 120 milliliters three times daily, fortified mashed potatoes at lunch, and chocolate milk at all meals. Intakes averaged ,d+[DATE]%. No significant weight changes noted. The registered dietitian remained available and would follow up. The [DATE] Wound Physician #2 note documented the resident had a new Stage 3 pressure ulcer on their sacrum that was 3 centimeters x 2.5 centimeters x 0.2 centimeters with moderate serous drainage and 100% granulation tissue. The plan was to use calcium alginate and Medihoney covered with bordered dressing daily. The [DATE] physician order documented cleanse coccyx with wound cleanser, apply Medihoney and calcium alginate to wound and cover with Allevyn (dressing). The [DATE] Weight and Vitals Summary documented the resident weighed 111.8 pounds (5.4% loss, previously 118.2 pounds on [DATE]). There was no documented evidence the resident's nutritional needs were reassessed timely after they developed a Stage 3 pressure ulcer and after they had a 5.4% weight loss. The [DATE] Comprehensive Care Plan documented the resident had impaired skin integrity related to a Stage 3 pressure ulcer. Interventions included monitor nutritional status, diet as ordered, monitor intake and record. Dietary consults as needed. During a wound observation on [DATE] at 11:48 AM with Wound Physician #2 and Licensed Practical Nurse Manager #1, the resident was lying on their back in bed and the alternating air mattress was on and functioning. The resident was rolled to the left, no dressing was in place on the sacrum. The wound was approximately 1 centimeter x 1 centimeter x 0.1 centimeters with granulation tissue. Per Licensed Practical Nurse Manager #1, the dressing was removed just prior to the wound physician evaluation. Licensed Practical Nurse Manager #1 cleansed the wound, placed Medihoney and calcium alginate cut to size into the wound bed and covered with a bordered dressing. During a telephone interview on [DATE] at 10:16 AM, Licensed Practical Nurse Manager #1 stated when a resident had weight loss, nursing was responsible to update the registered dietitian. The registered dietitian also had access to weights in the medical records. When a resident developed a new pressure ulcer, the registered dietitian would be notified. For weight loss and pressure ulcers, the registered dietitian typically assessed within 1 week. They were not sure if the registered dietitian was notified of the resident's weight loss or new pressure ulcer, and they should have been notified and it was not done timely. During a telephone interview on [DATE] at 12:57 PM, Registered Dietitian #9 they stated if a resident lost weight they became notified during the high-risk meeting held every week. If a resident had a significant weight loss of 5 or more pounds, the unit Manager notified them. They would then assess the resident, write a note, and possibly add more calories and protein. They typically assessed weight loss as soon as they were notified. The unit Manager was also responsible to notify them of new wounds. They would assess as soon as they were notified, write a note, and possibly add interventions. They first became aware the resident had a new pressure ulcer around [DATE] when they did their assessment. The resident was already on several supplements however they switched one of the supplements for 2 Cal which was higher in protein and calories. They stated they should have been notified sooner for assessment and their assessment was not timely. They stated they addressed the resident's weight loss in their [DATE] note, they could not recall if they were notified, and the assessment was not done timely. During a telephone interview on [DATE] at 1:37 PM, the Director of Nursing stated nursing should be looking at weights when they were obtained and if significant loss was noted, nursing should notify the registered dietitian. Nursing should also notify the registered dietitian for new pressure ulcers. They expected the registered dietitian to assess weight loss in 2 weeks and new pressure ulcers within a couple of days. They were not aware Registered Dietitian #9's assessment for weight loss took 11 days and that was not timely. When it took Registered Dietitian #9 two and a half weeks to reassess the resident's nutritional needs after they developed a new pressure ulcer, it was not done timely. 10NYCRR 415.12(c)(1)

Based on record reviews and interviews during the abbreviated survey (NY00341925) the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical and nursing needs for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 exhibited frequent exit-seeking behaviors, there were no documented interventions to address their behaviors, the resident exited the building and was found in the parking lot. Findings include: The facility policy, Comprehensive Care Plans, reviewed 3/24/2022 documented: - the facility would provide an individualized, interdisciplinary plan of care for all residents that was appropriate to the residents' needs, strengths, results of diagnostic testing, limitations, and goals. - The plan of care shall be individualized, based on diagnosis, resident assessment, and personal goals of the resident and their family. - The planning of care, treatment, and services shall include care planning based on data collected from assessments with integration of those findings into the care planning process. The facility policy, Elopement/Wandering Risk, revised 3/20/2024 documented: - An assessment will be completed by the Charge Nurse/designee and elopement/unsafe wandering risk will be determined. - Upon completion of the Elopement/Wandering Risk Assessment, the Charge Nurse/designee will initiate/update the Elopement/Wandering Risk Care Plan based upon information/risk factors identified and interventions will be implemented as appropriate. - If a resident is considered high risk for elopement/unsafe wandering, initially and upon change in physical status, a care plan must be initiated with documented interventions. Resident #1 had diagnoses including dementia, psychotic disorder with delusions (false beliefs), and history of falls. The 4/4/2024 Admission Minimum Data Set assessment documented the resident had moderate cognitive impairment and did not exhibit wandering behaviors. The Comprehensive Care Plan initiated 3/31/2024 documented: - the resident had impaired cognitive function related to the disease process, schizophrenia, and impaired decision making. Interventions included: simple, structured activities; consistent routine; monitor, document, and report changes in cognition, decision-making, and general awareness; and the resident required supervision with decision-making. - the resident had an activities of daily living self-care performance deficit related to confusion, dementia, and impaired balance. Interventions included supervision for walking with a 4-wheeled walker, walking 5 feet with two turns, supervision and contact guard assistance. - the resident was at risk for falls related to confusion, gait/balance problems, and lack of safety awareness. The resident had falls on 4/5/2024, 4/25/2024, 5/7/2024, and 5/9/2024. Interventions included: safety reminders, anticipate needs, encouragement to participate in activities, and appropriate footwear. The 4/1/2024 Wandering Risk Evaluation completed by Registered Nurse #5 documented the resident was forgetful/had a short attention span, was admitted within the last month, had a caregiver or staff change, was independent with mobility and use of a cane/walker, and took antidepressants and narcotics. The last section Elopement Risk (known wandering, history of wandering, follows visitors out, opens exit doors, exit seeking, potential to learn door codes, or resident is not at risk for unsafe wandering) had no options checked. The risk score was documented as 6 and moderate risk for wandering. The evaluation did not include parameters for interventions based on the score. There were no documented interventions in the Comprehensive Care Plan related to wandering or exit-seeking from 4/1/2024-5/11/2024. The 5/11/2024 Incident Report completed by Licensed Practical Nurse Supervisor #1 documented: - at approximately 5:50 PM, an alarm indicated a door was opened. The alarm panel indicated one of the side doors on the C-wing was opened. - Registered Nurse Supervisor #1 went to Resident #1's room, the resident's wheeled walker was in the room, the resident was not in the room. - The Predisposing Situation Factors included use of a walker and wandering. - A certified nurse aide (unnamed) alerted Licensed Practical Nurse Supervisor #1 that Resident #1 was in the visitor parking lot, leaning against a car. During a telephone interview on 8/19/2024 at 6:30 PM Certified Nurse Aide #2 stated since the resident was admitted (end of 3/2024), they frequently exhibited exit-seeking behaviors. Their behaviors included getting their coat, saying they were leaving, and going to the front and side doors. They were unaware of any specific interventions and was instructed to redirect the resident. During an interview on 8/20/2024 at 10:35 AM Licensed Practical Nurse #18 stated since the resident was admitted they wandered in and out of rooms, the halls, and sometimes went to doors, and the reception area. The resident verbalized all the time they wanted to get their truck, go to work, or go see their brother. The resident would approach the emergency exit doors and looked like they were reading the signs on the door (which says if door held for 15 seconds, it would release). The resident had triggered the door alarm by pushing the bar before 5/11/2024. The exit-seeking behaviors were discussed multiple times at shift reports. They were not certain if the resident had a wander alert device in place prior to 5/11/2024. During an interview on 8/20/2024 at 10:47 AM the Activities Director stated since the resident was admitted , they exhibited exit-seeking behaviors. The resident said things such as they had to get out of there, had to get their truck, go to work, they had to get their brother, and would ask where to get out. The resident went to the doors, sometimes saying they were looking for their spouse. Staff redirected them by offering walks, snacks, or distracting them with conversation. At times it was not difficult to redirect the resident, other times, it required more persuasion. Prior to the resident's elopement on 5/11/2024, they had participated in meetings where the resident's exit-seeking was discussed as related to their confusion. They were unaware of any specific interventions or if the resident had a wander alert device at the time. During an interview on 8/30/2024 at 11:31 AM, Licensed Practical Nurse Unit Manager #17 stated they were responsible for care plans. The interdisciplinary team reviewed them to ensure needed areas were addressed. Updates and revisions were done based on changes in status and new interventions needed. A Wandering Risk Evaluation result of moderate risk meant the resident was actively wandering the building without active attempts to leave and the resident should be care planned for the behavior. Specific interventions would be discussed with the interdisciplinary team. The resident began exit-seeking and wandering close to their admission. The resident wandered about the facility and made verbal statements about leaving. They stated they were unsure of the reason there was no care plan for the resident's wandering behaviors. 10NYCRR 415.11(c)(1)

Based on record reviews and interviews during the abbreviated survey (NY00341925) the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 exhibited frequent exit-seeking behaviors, was not supervised, had no care planned interventions in place, and exited the building to the parking lot. Findings include: The facility policy, Elopement/Wandering Risk, revised 3/20/2024 documented: - Assessment would be completed by the Charge Nurse/designee and elopement/unsafe wandering risk would be determined. - Upon completion of the Elopement/Wandering Risk Assessment, the Charge Nurse/designee would initiate/update the Elopement/Wandering Risk Care Plan based upon information/risk factors identified and interventions would be implemented as appropriate. - If a resident was considered high risk for elopement/unsafe wandering, initially and upon change in physical status, a care plan must be initiated with documented interventions. Resident #1 had diagnoses including dementia, psychotic disorder with delusions (false beliefs), and history of falls. The 4/4/2024 Admission Minimum Data Set assessment documented the resident had moderate cognitive impairment, did not exhibit wandering behaviors, required supervision/touching assistance for walking up to 150 feet in a corridor or similar space, partial/moderate assistance for walking 10 feet on uneven surfaces, was dependent for walking 1 step (curb) or multiple steps, and had no falls since admission. The 4/1/2024 Wandering Risk Evaluation completed by Registered Nurse #5 documented the resident was at moderate risk for wandering. The evaluation did not include parameters for interventions to address the risk. Nursing and social work progress notes from 4/1/2024 through 5/10/2024 did not include documentation related to the resident's wandering or exit-seeking. The 5/11/2024 Incident Report completed by Licensed Practical Nurse Supervisor #1 documented: - at approximately 5:50 PM, an alarm indicated a door was opened. The alarm panel indicated one of the side doors on the C-wing was opened. - Licensed Practical Nurse Supervisor #1 went to Resident #1's room, the resident's wheeled walker was in the room, and the resident was not in the room. - The Predisposing Situation Factors included use of a walker and wandering. - A certified nurse aide (unnamed) alerted Licensed Practical Nurse Supervisor #1 that Resident #1 was in the visitor parking lot, leaning against a car. - The resident was confused and stated it was their vehicle and they were going to their brother's. The resident was walked back into the facility and had no noted injuries. - Certified Nurse Aide #2's statement documented they last saw the resident at 5:15 PM walking to their room with another aide. The resident had been more confused and was exit-seeking at the front entrance earlier in the shift. - Certified Nurse Aide #3's statement documented they were with a resident when the alarm went off. They went to the nurse's station and was told Resident #1 had left. They knew it was Resident #1 as Certified Nurse Aide #2 stated they saw the resident out in the parking lot. - Certified Nurse Aide #4's statement documented they were in another room assisting a resident with dinner. The resident's roommate had visitors and the aide did not hear the alarm. The undated, unsigned Investigation Summary documented: - according to statements and video footage reviewed, Resident #1 exited the building from the unit's side exit door to the visitor parking area at 5:54 PM. - The resident was located by staff 2 minutes and 35 seconds following their exit. - The resident was found without their wheeled walker, leaning against a vehicle. - Orders for a urinalysis (a urine test used to detect and monitor health conditions) were obtained and results indicated infection. - The resident was placed on 15-minute visual checks for safety. During an observation on 8/19/2024 at 11:30 AM, Resident #1 was lying on their bed. There was no visible wander alert device on the resident, and they had a walker in their room. During an observation on 8/20/2024 a 2:00 PM, the resident's prior room (where they resided from admission to 8/5/2024) and exit door were observed. The resident's room was located toward the end of the corridor to the left of the main dining room and nurse's station. Their room was 2 doors away from the emergency exit door at the end of the corridor. The door was labeled with signs documenting if the bar on the door was held for 15 seconds, it would release. The door opened to a sidewalk in the front of the building. The visitor parking lot was located approximately 20 to 25 feet to the right. During an observation on 8/20/2024 at 11:46 AM Resident #1 was in the dining area. They were seated in a chair with their walker next to them. There was a wander alert device on their right ankle. The resident stated the device was to make sure they did not go anywhere. During a telephone interview on 8/19/2024 at 6:30 PM Certified Nurse Aide #2 stated on 5/11/2024, Resident #1 wandered and exit-seeked most of the second shift (2:00 PM-10:00 PM). Staff redirected the resident throughout the shift. During dinner, they heard one of the door alarms sound. Licensed Practical Nurse #1 checked the side door that led to the courtyard and checked the resident's room and did not see the resident. Certified Nurse Aide #2 went to the window in the dining room and saw the resident outside leaning against a car. They immediately went out to get the resident. Staff had to frequently redirect the resident, and on 5/11/2024, they got busy with dinner and the resident must have taken that opportunity to leave. Licensed Practical Nurse #1 was made aware on 5/11/2024. Certified Nurse Aide #2 stated they were not aware who the supervisor was and did not report to a supervisor about the resident's exit-seeking. During a telephone interview on 8/20/2024 at 9:37 AM Licensed Practical Nurse #1 stated the resident had ongoing exit-seeking behaviors prior to 5/11/2024. Their room was near the emergency exit door, which clearly showed if the handle was held, the door would release. The resident was known to attempt to elope all the time. 5/11/2024 was one of those days when the resident tried to get out and said they had to get to their brother. The nurse was the floor nurse on the unit and the Supervisor for the shift as well. The staff were all aware the resident had been exit-seeking that shift and they all agreed to keep an eye on the resident. Licensed Practical Nurse #1 stated they were giving insulin before dinner and the aides were passing trays when they heard the alarm. They immediately checked the exits and at the same time, a certified nurse aide said they saw the resident outside. They immediately went outside to the resident and had to persuade them to return inside to the facility. During an interview on 8/20/2024 at 10:38 AM, Unit Clerk #19 stated there was no book or list on the unit that identified residents at risk of wandering or elopement. They stated the list was kept only at the reception desk. During an interview on 8/20/2024 at 11:32 AM Certified Nurse Aide #4 stated the resident was always exit-seeking. The resident often went to the doors, saying they had to go to work on their truck, asked for help to get out there, pushed on the doors, and often went to the reception area and front door. Staff redirected the resident with conversation, distraction, asking them to stay for dinner, or offering coffee. On 5/11/2024, the resident was redirected frequently, and was very adamant about leaving. Staff continued to try and distract or redirect them. Licensed Practical Nurse #1 told staff to keep an eye on the resident when exit-seeking was reported. The resident's room was very close to the emergency exit door and the aide did not think that was the best idea. If the resident had been moved away from that door, they may have not noticed it so much. During an interview on 8/30/2024 at 11:31 AM, Licensed Practical Nurse Unit Manager #17 stated the resident began exit-seeking and wandering close to their admission. The resident wandered about the facility and made verbal statements about leaving. The resident did not have a wander alert device prior to their 5/11/2024 elopement. When the resident exhibited active exit-seeking behaviors, the supervisor should be notified, staff should be aware of the resident's location, monitor them, and try to direct them to a common area to be monitored. 10NYCRR 415.12 (h)(2)

Based on record review, and interview during the abbreviated survey (NY00333772), the facility failed to administer cardiopulmonary resuscitation to 1 of 3 residents (Resident #1) who was found without a pulse and wished to be resuscitated. Specifically, on [DATE], Resident #1 was found without a pulse and without respirations, and staff did not initiate cardiopulmonary resuscitation (chest compressions) per the resident's wishes documented on their Medical Orders for Life Sustaining Treatment. Staff asked the resident's spouse (who was not the resident's decision maker ) if they wanted staff to initiate cardiopulmonary resuscitation and the spouse declined. The facility's failure to administer cardiopulmonary resuscitation, per the resident's wishes, placed all 108 residents in the facility who had Advance Directives in place at risk. This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to resident's health and safety. Findings include: The facility's Cardio-Pulmonary Resuscitation Basic Life Support Policy, dated [DATE], documented the facility's nurses shall assure that cardiopulmonary resuscitation was provided to residents unless their advance directives indicated otherwise. The purpose of the policy was to institute resuscitation measures as soon as possible to increase the likelihood of survival. The policy further documented the Medical Orders for Life Sustaining Treatment was the only reference to ensure resident wishes. In the event of an unresponsive person, cardiopulmonary resuscitation certified staff were to verify orders on the Medical Orders for Life-Sustaining Treatment, check for breathing, circulation (pulse), call a Code Blue (life threatening medical emergency), and initiate cardiopulmonary resuscitation. Resident #1 had diagnoses including end stage renal (kidney) disease and congestive heart failure. The [DATE] Minimum Data Set assessment documented the resident's cognition was moderately impaired. The [DATE] attending physician #7's order documented refer to the Medical Orders for Life Saving Treatment; no directions specified for order. The [DATE] nurse practitioner #1's progress note documented they discussed the resident's current condition, prognosis, and options of treatment with the resident. The resident fully understood, had decision making capacity, and expressed and reiterated they wanted a Full Code order (cardiopulmonary resuscitation, perform chest compressions, in the event their heart stopped). The resident's Medical Orders for Life-Sustaining Treatment (signed by the resident and nurse practitioner #1) documented the resident wished for cardiopulmonary resuscitation. The review and renewal section of the Medical Orders for Life-Sustaining Treatment was signed by nurse practitioner #1 on [DATE]. The [DATE] comprehensive care plan documented the resident wished to have Advance Directives in place and to refer to the Medical Orders for Life-Sustaining Treatment. Interventions included to review Advance Directives with significant changes and/or upon annual review, and review changes with the physician at time of changes. The [DATE] at 9:11 AM, licensed practical nurse #2's progress note documented they were alerted by the Charge Nurse that Resident #1 was found by their spouse, in bed unresponsive and not breathing. The resident had jaundice-like skin (yellowed appearance), pupils were fixed and dilated, and they had no apical (pulse point on the left side of chest over heart) pulse. The resident had a cardiopulmonary resuscitation order, however the spouse requested not to initiate the order. The Director of Nursing was notified and was aware. Time of death was 8:04 AM. The [DATE] at 8:04 AM, Investigative Summary completed by the Director of Nursing, documented the resident was found unresponsive and without respirations by their spouse. Certified nurse aide #5 alerted licensed practical nurse #3 who found the resident with prolonged signs of death. Licensed practical nurse #3 notified Licensed Practical Nurse Supervisor #2 and obtained the Medical Order for Life Sustaining Treatment which documented a Full Code order. The resident's spouse requested that cardiopulmonary resuscitation not be initiated. During an interview on [DATE] at 1:13 PM, licensed practical nurse #3 stated they were required to follow the Medical Orders for Life Sustaining Treatment and to initiate cardiopulmonary resuscitation after calling a Code Blue. On [DATE] at around 8:00 AM , they heard certified nurse aide #5 call out. They ran down the hall to the resident's room where certified nurse aide #5 reported the resident was not breathing. The resident had no pulse. They checked the Medical Orders for Life Sustaining Treatment and did not initiate cardiopulmonary resuscitation because they had a lot of things going on and they could not handle it. They ran to get Licensed Practical Nurse Supervisor #2, and they both arrived back to the resident's room within a minute or so. Licensed Practical Nurse Supervisor #2 checked the resident's pulse, listened to their lungs, and determined the resident had no signs of life. Licensed Practical Nurse Supervisor #2 asked the resident's spouse if they wanted them to initiate cardiopulmonary resuscitation and the spouse stated no. During a telephone interview on [DATE] at 1:34 PM, Licensed Practical Nurse Supervisor #2 stated when a resident had no signs of life, they checked the Medical Orders for Life Sustaining Treatment. Licensed practical nurses or registered nurses could initiate cardiopulmonary resuscitation at the facility. When a registered nurse was not on duty, they needed to gather information and call the Director of Nursing. On [DATE], they were in the Supervisor's office when licensed practical nurse #3 came and said Resident #1's spouse found Resident #1 expired. They asked licensed practical nurse #3 what the resident's code status was, and they did not know. When they arrived on the unit, licensed practical nurse #3 checked the resident's Medical Orders for Life-Sustaining Treatment while Licensed Practical Nurse Supervisor #2 confirmed the resident had no pulse, no respirations, with fixed and dilated pupils. Licensed practical nurse #3 had not come back to the room yet with the resident's code status information, so they went to the nursing station where licensed practical nurse #3 said the resident wanted cardiopulmonary resuscitation. The Medical Orders for Life Sustaining Treatment was not signed by a medical provider and there were no other interventions listed on the form. They called the Director of Nursing, explained the situation and the Director of Nursing told them that with all the information provided, it would be inhumane to start compressions because the resident had advanced signs of death. The Director of Nursing directed them to ask the resident's spouse if they preferred to initiate cardiopulmonary resuscitation and the spouse said no. During an interview with the Director of Nursing on [DATE] at 2:25 PM and [DATE] at 11:00 AM, they stated on [DATE], they were called around 8:00 AM by Licensed Practical Nurse Supervisor #2, who reported the resident was not breathing, had no pulse, and their eyes were fixed and dilated. Licensed Practical Nurse Supervisor #2 reported the resident's Medical Orders for Life Sustaining Treatment documented cardiopulmonary resuscitation. The Director of Nursing asked why cardiopulmonary resuscitation had not been started, and Licensed Practical Nurse Supervisor #2 stated they did not know what to do because the resident had advanced signs of death, and the resident's spouse was in the room and did not want cardiopulmonary resuscitation started. There was no documentation found that the resident's spouse was their Healthcare Proxy (medical decision maker). Licensed Practical Nurse Supervisor #2 reported the resident's Medical Orders for Life Sustaining Treatment was not signed by the medical provider. They did not tell Licensed Practical Nurse Supervisor #2 to not start cardiopulmonary resuscitation; however, that was what was understood. When licensed practical nurse #3 found the resident without signs of life, they should have called a Code Blue and started cardiopulmonary resuscitation. During an interview on [DATE] at 11:50 AM, certified nurse aide #4 stated on [DATE] between 6:25 AM to 6:30 AM, they completed rounds and observed the resident asleep in bed. They looked at the resident for a few seconds to be sure their chest was rising, and it was. They were providing care in another resident's room when certified nurse aide #5 told them the resident's spouse did not think the resident was breathing. It took them around 2 minutes to leave the resident they were working with in a safe place and proceed to Resident #1's room. Resident #1 was not breathing and certified nurse aide #4 t old, certified nurse aide #5 to get licensed practical nurse #3, who arrived about a minute later. Licensed practical nurse #3 evaluated the resident and said to get Licensed Practical Nurse Supervisor #2 who arrived around 2 to 3 minutes later. During a telephone interview on [DATE] at 1:35 PM, Nurse Practitioner #1 stated they discussed Advance Directives at the initial visit with residents, and if they determined a resident did not have mental capacity, they discussed it with the resident's Healthcare Proxy to determine Advance Directives. The Medical Orders for Life Sustaining Treatment form was signed by the medical provider during the initial visit. Nurse practitioner #1 signed the resident's Medical orders for Life Sustaining Treatment when they completed the form but instead of signing on the front page which is what was normally done, they signed in the renewal section and stated signing in the renewal section was an oversight on their part. When they assessed the resident on [DATE], they determined the resident had the capacity to make decisions, determine their wishes for cardiopulmonary resuscitation, and even if the resident had a Healthcare Proxy in place, they would defer to the resident's decision because the resident had capacity to make those decisions. If staff called them and stated a resident had cool skin, no apical pulse, no respirations, and they had not started cardiopulmonary resuscitation in a resident who elected cardiopulmonary resuscitation, they would have instructed staff to begin cardiopulmonary resuscitation and call 911. Even with signs of death, including advanced signs of death, they would still do cardiopulmonary resuscitation. During a telephone interview on [DATE] at 1:32 PM, the Medical Director stated resident capacity was determined at the time the Medical Orders for Life Saving Treatment were discussed and if the resident had decision making capacity, a family member or Healthcare Proxy could not change their determination. The resident or the resident's Healthcare Proxy could make the determination if the resident did not have capacity to make the decision. The Medical Orders for Life Saving Treatment was a legal document that determined residents' wishes for life saving treatment in the event a resident was not able to make the decision. If a resident was found unresponsive and without signs of life, they expected staff to look at the Medical Orders for Life Saving Treatment, begin cardiopulmonary resuscitation if indicated, and call 911. Even if a resident was last seen 5 hours prior to being found unresponsive and they were cold and blue, staff were expected to begin cardiopulmonary resuscitation if that was what the Medical Orders for Life Sustaining Treatment indicated. They were notified about the incident on [DATE] by the Administrator and the Director of Nursing after it occurred. 10 NYCRR 415.3(e)(2)(iii) -------------------------------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was removed on [DATE] at 11:43 AM prior to survey exit based on the following corrective actions taken: - The facility's Cardio-Pulmonary Resuscitation-Basic Life Support Policy was updated on [DATE] following the incident. - On [DATE], the facility reviewed their Medical Record Documentation-Advance Directives Policy and made no changes. - Three staff were immediately re-educated on [DATE] on the facility's Cardio-Pulmonary Resuscitation- Basic Life Support Policy, which included the Medical Orders for Life Sustaining Treatment needed to be followed and was the only identifier of resident wishes. - On [DATE], the facility reviewed their Cardio-Pulmonary Resuscitation-Basic Life Support and Medical Records Documentation-Advance Directives Policy, and no changes were made. - Mock Code Blue drills began [DATE] and were to continue on different shifts on a weekly basis. - All staff identified for education received education on [DATE] and [DATE], with the exception of 15 staff who were not available. The staff that did not receive education were to complete education upon their return, prior to the start of their shift. - Interviews were completed on [DATE] to determine compliance with staff training and education including the Director of Medical Records, 3 certified nurse aides, 3 licensed practical nurses, the Director of Nursing, 1 janitor and 1 housekeeper.

Based on observation, record review, and interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 3 resident units (B Unit and C unit). Specifically, B Unit and C Unit had damaged walls and floors. Findings include: C Unit: During observations on 8/10/2023 at 10:40 AM, the tub room had peeling paint on the wall and the ceiling near the sink; and at 11:10 AM the shower room wall tiles had a black substance on them. During an interview on 8/16/2023 at 2:51 PM, the Environmental Services Director stated that they were not aware of the black substance on the tiled walls in the C unit shower room. They stated this shower area was actively used for residents. They expected staff entering the room to see the black substance and submit a work order through the computerized work order system. The Environmental Services Director stated that all staff had access to the work order system, and there were no work orders for the identified issues within the C unit. During an interview on 8/16/2023 at 3:36 PM, licensed practical nurse (LPN) #6 stated they were not aware of the black substance on the C Unit shower room walls, or the peeling paint in the C Unit tub room. They stated enough staff entered both rooms and the identified issues should have been reported to them. LPN #6 stated all staff could enter work orders in the computers. They stated that the unknown black substance on the C unit shower room walls could cause breathing issues for residents and staff entering the room. B Unit: During observations on 8/10/2023 at 11:25 AM, the nursing station wall had a 1 foot x 1 inch gouge; and at 11:41 AM, the floor at the end of hall near resident room [ROOM NUMBER] had one missing 1 foot x 1 foot floor tile, and three damaged 1 foot x 1 foot floor tiles. During an interview on 8/15/2023 at 12:15 PM, LPN Resident Care Coordinator (RCC) #1 stated they were not sure if a work order had been submitted for the damaged wall at the nursing station. The wall had been damaged for a couple of months. They stated the wall had previously been repaired before the current damage. LPN RCC #1 stated that they were not aware of the damaged hall floor near resident room [ROOM NUMBER]. During an interview on 8/16/2023 at 3:00 PM, the Environmental Services Director stated they were not aware of the gouge in the B Unit nursing station wall, or the damaged floor in the hallway outside resident room [ROOM NUMBER]. They stated that the B Unit nursing station wall was previously damaged and fixed. They stated they could not find any work orders for the identified issues on the B Unit. The was no documented evidence of work order submissions for the peeling paint in the C Unit tub room, the black substance on the C Unit shower room wall tiles, the gouge in the B Unit nursing station wall, and the damaged floor in the B Unit hallway near resident room [ROOM NUMBER]. 10 NYCRR 415.29(j)(1)

Based on observation, record review, and interview during the recertification survey conducted 8/10/2023-8/18/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 7 residents (Residents #38, 51, 69, 75, and 105) reviewed. Specifically, Resident #38 was not ambulated or assisted with toileting as planned; Resident #75 was observed wearing a hospital gown and was exposed and visible from the hallway, their ADLs were not completed timely, and they did not have a hand splint and heel booties applied as ordered; Resident #105 was not provided oral care as planned; Resident #51 was not assisted with shaving; and Resident #69 was not turned and positioned or provided incontinence care as care planned. Findings include: The facility policy Activities of Daily Living (ADLs) revised 11/2022, documented residents should be provided care and treatment every shift to include bathing, grooming, dressing, eating, oral care, ambulation, and toileting services with safety of resident utilized while performing ADL's. The facility policy Increasing Resident Independence revised 10/2022 documented that healthcare providers shall encourage resident independence to increase resident self-esteem and self-confidence. ADLs shall be performed by health care providers for those residents who are unable to perform the activity. The facility policy Oral Hygiene policy revised 6/28/2023 documented residents received oral care daily to provide cleanliness of mouth and teeth. Care would be documented on the task record. 1)Resident #38 was admitted to the facility with diagnoses including unspecified dementia without behavioral disturbances, urinary tract infection, and was a fall risk. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, required extensive assistance of 1 with transfers, walking in their room and in the corridor, dressing, and hygiene, and had 2 falls without injury. The 7/13/2023 physical therapist (PT) #11 progress report documented Resident #38 was ambulating on level surfaces 50 feet using a front wheeled walker (FWW) with moderate assistance of 1. Ambulation ability would enhance the resident's quality of life by requiring a decreased level of assistance from caregivers, and performance of functional mobility with less risk for falls The comprehensive care plan (CCP) initiated 7/21/2023 documented the resident's activity was dependent on staff related to dementia. The resident had a self-care performance deficit related to confusion and dementia. Interventions included walking with extensive assistance of 1 with rolling walker on the unit, wheelchair was self-propelled or assistance of 1 off the unit, and assistance of 1 with toileting and hygiene as needed. The Kardex (care instructions) documented Resident #38 required extensive assistance of 1 for dressing, bed mobility, toileting, walking with wheeled walker on the unit, wheelchair self-propel or assistance of 1 off the unit, and walking in and out of room. During a continuous observation on 8/11/2023 from 8:29 AM through 11:10 AM Resident #38's pants were wet. The resident was not checked, changed, or offered toileting during the observation. During a continuous observation on 8/14/2023 from 9:45 AM through 1:07 PM Resident #38 was not offered or assisted with toileting or ambulation. During an observation on 8/14/2023 at 12:30 PM Resident #38 was transferred into a dining chair for lunch by certified nurse aide (CNA) #9 and the resident ate their lunch in wet pants. During an observation in the soiled utility room on 8/14/2023 at 1:06 PM with CNA #9, Resident #38's incontinence pad was observed to be wet and soiled with a strong urine odor. At 1:07 PM CNAs #25 and #9 transferred the resident from the dining chair into their wheelchair. The dining chair seat the resident had been sitting in was wet. During an interview on 8/14/2023 at 1:06 PM CNA #9 stated Resident #38's incontinence pad was wet, soiled and smelled of urine and they removed the pad from the chair because of this. CNA #9 stated the resident should have been changed before lunch and should not have eaten lunch in wet pants. During an interview on 8/15/2023 at 12:26 PM CNA #10 stated that residents that cannot request or toilet themselves should be checked, changed, or assisted with toileting every two hours. CNA #10 stated Resident #38 should be checked every two hours. They stated the Kardex gave individual ADL instructions for each resident. Resident #38 required extensive assistance of 1 with transfers, ambulation, and toileting. CNA #10 stated they did not know why the resident was not ambulated on Thursday 8/10/2023 and the resident was able to walk 30-50 feet. During an interview on 8/15/2023 at 1:05 PM CNA #9 stated that Resident #38 could not walk and only pivoted. During an interview on 8/17/2023 at 11:35 AM the Director of Nursing (DON) stated that each resident's ADL level was identified in the Kardex. Staff were expected to know their residents and have access to the Kardex to check if needed. The DON stated locomotion provided exercise for the resident and they could lose their abilities and independence. Residents that were not independent with toileting should be toileted after breakfast and after lunch. They stated if staff were aware that a resident was incontinent, they should be toileted and cleaned up immediately. If residents were left in wet clothing, they were at risk for moisture associated skin damage or fungal rashes, and it could also have a negative effect on their mood. During an interview on 8/18/2023 at10:24 AM licensed practical nurse (LPN) Resident Care Coordinator (RCC) #5 stated that ambulation distances were determined by therapy and were re-evaluated as needed. The distance from the resident's bed to their bathroom would be about 10 feet. If a resident was not ambulated as planned, it could result in loss of strength and less independence. Resident #38's goal for ADLs was to maintain their status. LPN RCC #5 stated Resident #38 should be checked and or toileted every 2-3 hours. The resident could sometimes say they needed to be toileted and was not always incontinent. During an interview on 8/18/2023 at 10:51 AM physical therapist (PT) #11 stated they encouraged ambulation on the unit, but they could not enforce it as the facility did not have restorative services. PT #11 stated they and occupational therapist (OT) #12 discussed Resident #38's ambulation and a safe distance was from the bed to the bathroom. 2) Resident #75 was admitted to the facility with diagnoses including hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) affecting the right dominant side, contractures (rigidity) of the right and left knees, and muscle wasting and atrophy. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive assistance of 2 for bed mobility, transfers, dressing, toilet use, and personal hygiene, and was always incontinent of bladder and bowel. The comprehensive care plan (CCP) initiated on 10/11/2022 documented Resident #75 had bowel and bladder care plan needs. Interventions included the resident was to be checked every 2 hours and as needed for incontinence; wash, rinse, and dry the area, and change clothing as needed after incontinence episodes. The CCP initiated on 11/29/2022 documented the resident had a history of contractures. Intervention included use of splints and adaptive equipment as tolerated and encouraged good hygiene especially in areas of contractures for skin integrity. The CCP initiated 1/30/2023 documented the resident had an ADL deficit related to activity intolerance. Interventions initiated on 9/20/2022 included total assistance of 1 for toilet use, full mechanical lift with assistance of 2 for transfers, extensive assistance of 1 for bathing, dressing, and personal hygiene, total assistance of 2 for bed mobility, and the resident was incontinent of bladder. Physician orders documented: - on 5/1/2023 apply an ACE wrap to the right knee in the morning and remove at bedtime for swelling. - on 9/23/2023 ensure splint is in place as tolerated on right hand, every shift for contracture. - on 4/17/2023 protective heel booties on while in bed as tolerated every shift for preventative measures. Resident #75 was observed: - on 8/10/2023 at 11:20 AM, in bed, leaning slightly right, wearing only a brief and visible from the hallway, without hand splints or protective heel booties; - on 8/10/2023 at 12:04 PM, in bed, leaning to the right, wearing only a brief and visible from the hallway. The resident was attempting to use their remote with hand contractures. The resident was not wearing hand splints or protective heel booties. - on 8/10/2023 at 1:13 PM, in bed, leaning to the right, wearing only a brief and visible from the hallway, without hand splints or protective heel booties; - on 8/10/2023 at 2:26 PM, in bed, sliding down below the height of over bed table, eating lunch, without hand splints or protective heel booties; - on 8/11/2023 at 10:44 AM, positioned in bed with the head of bed less than 45 degrees, wearing a hospital gown, without hand splints or protective heel booties; - on 8/14/2023 at 9:59 AM and 1:00 PM, positioned in bed lying on their back wearing a hospital gown, without hand splints or protective heel booties; - on 8/15/2023 at 12:40 PM, positioned in bed with head of bed slightly elevated, leaning to the right, wearing a hospital gown, without hand splints or protective heel booties; - on 8/16/2023 at 9:20 AM, in bed wearing a hospital gown, attempting to operate their bed controls, without hand splints or protective heel booties; and - on 8/17/2023 at 9:26 AM, positioned in bed laying supine with head of bed slightly elevated, wearing a hospital gown, without hand splints or protective heel booties. The 8/2023 Treatment Administration Record (TAR) documented ensure splint was in place as tolerated on the right hand every shift for contracture; and protective heel booties while in bed as tolerated every shift for preventative measures. The TAR documented the splints were in place and heel booties were in use on 8/10/2023, 8/16/2023, and 8/17/2023 for the day shift. During an interview on 8/10/2023 at 6:47 PM Resident #75 stated they sometimes like to get dressed. They stated they wanted to be cleaned up, but that only happened sometimes. During a continuous observation on 8/14/2023 from 10:14 AM through 1:00 PM, no staff entered Resident #75's room to provide care. Unidentified staff were observed entering and exiting the room for less than 1 minute. The resident did not have heel booties or splints in place. During an interview on 8/14/2023 at 10:41 AM, Resident #75 stated they were changed with staff assistance. They stated they had clothes in the closet and that clothing was more comfortable than the gown they were wearing. They did not always like the treatments of splints and wraps, because they could be too hot. During an interview on 8/16/2023 at 10:58 AM, certified nurse aide (CNA) #14 stated they knew what resident's needs were based on the Kardex in the computer. When assigned to Resident #75's care they look for ADL status changes every shift, as they were not always updated timely or at all for some residents. They were unsure who changed the ADL status, but several residents required more assistance than what was listed on the Kardex. CNA #14 had been assigned to Resident #75's care a few times and the resident never refused ADL care. Resident #75 required assistance of 2 to bath, dress, and turn in bed, and they needed assistance rolling from side to side. During an interview on 8/17/2023 at 10:47 AM, CNA #15 stated that Resident #75 only got out of bed for appointments. They required total assistance for all ADL care and had never refused ADL care. The resident was willing to let staff check their brief and clean them, as needed. Resident #75 had a history of removing their clothing if they were hot, so the staff used a gown to ensure they were covered. During an interview on 8/17/2023 at 11:08 AM, LPN #1 stated CNAs were responsible for providing ADL assistance to residents. This included turning, positioning, and toileting. If the CNAs were unable to complete the required tasks for a resident, they should advise the medication nurse and LPN #1, and they would complete the required tasks. They stated if a resident refused care, the medication nurse and Unit Manager should be made aware to provide education. If a resident routinely refused care and treatments, the medical provider and social services should be notified. Residents may want a different time of day for care and treatments. LPN #1 stated once a pattern of refusal was identified, they researched to identify the problem areas. The resident's care plan reflected their preferences and needs. They stated ADL status changes came after evaluation from therapy. LPN #1 was responsible for updating the resident's care plans. Therapy had not indicated to LPN #1 the need to advise the providers of Resident #75 refusal of splints, wraps, and heel booties, so they had not discussed a plan of care for Resident #75. During an interview on 8/17/2023 at 1:04 PM, CNA #16 stated residents were changed every 2 hours, and documentation of the resident's ADLs was completed by 1:30 PM daily. They stated when it came to documentation of ADLs and toileting, only 1 documented occurrence was required in the system. If a resident had 3 bladder incontinence occurrences, the CNAs documented incontinence care was completed. If a resident had 3 bowel incontinence occurrences, the CNAs charted each one. The difference was that the number of or change in bowel movements can indicate a problem, where wet was wet for bladder incontinence. CNA #16 stated that even though there was no further documentation of incontinence checks for Resident #75 after 8/14/2023 at 7:42 AM, that the resident was checked multiple times that day, and changed at least twice that shift. During an interview on 8/17/2023 at 2:15 PM, occupational therapist (OT) #12 stated they were responsible for initiating the ADL status on the care plan for new admissions. If a resident was on a therapy program the assigned therapist updated the care plan as needed. The OT stated If a resident was not on a therapy program, the therapist evaluated the resident and provided the resident care coordinator (RCC) with recommended changes. They stated previously, there was a paper document that was provided to the RCC, but they were not updated timely or consistently. OT #12 stated Resident #75 was on a therapy program recently, but not since the new policy had been in place. Residents were screened every 3 to 4 months for changes if they were not on a therapy program. During an interview on 8/18/23 at 12:51 PM, the Director of Nursing (DON) stated therapy was responsible to make sure level of assistance for ADLs was updated and accurate in the Kardex while the resident was in therapy. The DON stated when a resident was not on a therapy program, therapy notified nursing and nursing updated it. The care plan and the Kardex information should match. Care plans were reviewed annually, quarterly, significant change, and as needed. It was important for the care plan to be updated to ensure the resident received the proper care. 3) Resident #105 was admitted to the facility with diagnoses including major depressive disorder, gastrointestinal hemorrhage (bleeding), and septic shock (a widespread infection causing organ failure). The 8/9/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact; required extensive assistance of one with bed mobility, transferring, toileting, personal hygiene, and dressing. The comprehensive care plan (CCP) initiated on 2/22/2023 and updated 8/9/2023 documented the resident had an ADL deficit related to activity intolerance. Interventions included grooming every morning and evening, oral care, toileting and shaving as needed. The 3/8/2023 dental progress note documented the resident had obvious or likely cavities and/or broken natural teeth. Recommendations included staff should assist with daily oral care. The 8/17/2023 Kardex (care instructions) documented the resident required extensive assistance of one person for showering and dressing. Personal hygiene included oral care, grooming in the morning and afternoon, and shaving as needed. The following observations were made of Resident #105: - on 8/11/2023 at 9:42 AM the resident was hard of hearing and answered by shaking their head yes or no. The resident's bottom teeth were black and missing part of the lower front teeth. When asked if their teeth had been brushed, they shook their head no, and when asked if they wanted their teeth brushed, they shook their head yes. - on 8/15/2023 at 12:34 PM sitting in bed for lunch. When asked if their teeth were brushed, they shook their head no. When asked if they wanted their teeth brushed, they shook their head yes. The resident opened the drawer of the bedside nightstand, and the drawer contained a tan basin with two bottles of shampoo/body wash. There was no toothpaste or toothbrush in the bin. During an interview on 8/15/2023 at 11:21 AM, CNA #39 stated they always provided oral care, shaved, washed, dressed, and applied deodorant to residents every morning. Oral care was an important part of morning care because residents could get tooth pain, cavities, and infections in their mouth which could cause them to not eat and lose weight. They stated they just completed oral care for Resident #105, and they did not notice anything wrong with their mouth or teeth. They stated supplies were at the bedside and they used toothpaste, toothbrush, and mouthwash for oral care. During an observation and interview on 8/15/2023 at 12:45 PM CNA #39 was in Resident #105's room. CNA #39 left the room and stated they would be back shortly to show the surveyor the resident's oral hygiene supplies. At 1:00 PM the surveyor left the room and went to the adjoining room. CNA #39 walked past the surveyor into Resident #105's room and came back to the surveyor asking to show them the resident's oral hygiene supplies. The CNA opened the drawer of the bedside nightstand and took out the tan basin the resident had removed on 8/15/2023 at 12:34 PM. There was a dry toothbrush in the bin with completely straight bristles. There was no toothpaste in the basin. CNA #39 stated they had finished the tube of toothpaste and mouthwash and had thrown it in the trash and did not know why the toothbrush appeared dry and brand new. They stated they did not replace the toothbrush recently. There were no supplies in the bathroom. During an observation on 8/16/2023 at 10:32 AM the resident was in bed. When asked if their teeth were brushed, they shook their head no. When asked if they wanted their teeth brushed, they shook their head yes. They opened the drawer to the bedside nightstand. The contents of the drawer included a tan basin with two bottles of shampoo/body wash, a toothbrush, toothpaste, a mouth swab, and a toothbrush case. The toothbrush was dry, and the toothpaste was unopened. The mouth swab was in unopened plastic wrap. During an interview on 8/16/2023 at 10:35 AM licensed practical nurse (LPN) Resident Care Coordinator (RCC) #31 stated oral care was an important part of ADLs and health. It prevented infection and was important for adequate nutrition. LPN RCC #31 expected CNAs to assist with or complete oral hygiene for all residents twice a day. They stated Resident #105 was seen by the dentist on 3/8/2023 and CNAs were to perform oral hygiene daily as recommended by the dentist. 10NYCRR 415.12(a)(3) 48632 48895

Based on record review, observation, and interview during the recertification and abbreviated (NY00311963) surveys conducted 8/10/2023-8/18/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, and at an appetizing temperature for 3 of 3 meals reviewed (8/10/2023 dinner meal, 8/10/2023 supper meal, and 8/11/2023 breakfast meal). Specifically, food was not served at palatable and appetizing temperatures. Findings include: The facility form Temperature Logs documented hot food should be held over 135 degrees Fahrenheit (F) and cold food should be held below 41 degrees F. A 2/19/2023 anonymous complaint documented the food at the facility did not taste good and was frequently cold. During an interview on 8/10/2023 at 10:27 AM, Resident #18 stated the food was not always served hot. During an interview on 8/10/2023 at 1:53 PM, Resident #41 stated the food was not appealing to look at. During an observation on 8/10/2023 at 2:30 PM, after all residents were served on B unit, a test tray was requested and included every item left in the steam table. At 2:32 PM, the food temperatures were measured, and the ravioli measured at 109 degrees F and the pizza was 99 degrees F. The ravioli and pizza were not served at palatable temperatures. The pizza was located next to the steam table and was left uncovered during the entire meal service. The water in the steam table had drained or evaporated prior to all residents being served. During an interview on 8/10/2023 at 4:35 PM, Resident #13's family member stated the resident had complained that the food was always cold. During an interview on 8/10/2023 at 5:30 PM, Resident #51 stated the food was always cold and was not cooked properly. During an interview on 8/10/2023 at 6:02 PM, Resident #77 stated the food did not taste good and was cold. During an observation on 8/10/2023 between 6:00 PM and 7:00 PM the main kitchen refrigerator holding the milk and other cold items to being plated was observed to be held open. At 7:25 PM, a test tray from the main kitchen (where dinner trays were plated) was requested to be brought to the C Unit. At 7:30 PM, the test tray arrived on the C Unit and was kept covered until the last resident was served at 7:39 PM. At 7:40 PM, the food temperatures of the test tray were measured with the following results: milk was 53 degrees F, chicken tenders were 92 degrees F, macaroni and cheese was 90 degrees F, and carrots were 92 degrees F. The milk, chicken tenders, macaroni and cheese, and carrots were not served at palatable temperatures. The test tray did not have a hot plate under it and was wrapped in clear plastic. During an observation on 8/11/2023, at 9:01 AM, after the last food tray was served, a test tray was obtained. The food temperatures were measured with the following results: the pureed oatmeal was 90 degrees F, and the toast was cool to the touch. Dietary aide #34 stated the pureed oatmeal was not at a palatable temperature and should be served at 135 degrees F or higher, and the toast was not good. During an interview on 8/16/2023 at 3:24 PM, the Environmental Services Director stated there had been no reported steam table issues in the last three months, and staff had not mentioned that the water was draining from any of the steam tables during food service. They stated that food would not stay hot in the steam table if there was no water or steam in the reservoir. The Environmental Services Director stated they could not find any work orders regarding the steam tables. During an interview on 8/16/2023 at 4:06 PM, dietary aide #3 stated that hot foods should be held at 135 degrees F, and cold food should be held at 37 degrees F or lower. They stated that depending on the kitchen staff in the main kitchen, food might arrive to the B Unit kitchenette at less than 135 degrees F. Dietary aide #3 stated that the ravioli at 109 degrees F, pizza at 99 degrees F, chicken tenders at 92 degrees F, macaroni and cheese at 90 degrees F, carrots at 92 degrees F, and milk at 53 degrees F were not palatable temperatures. They stated that pizza had been served two to three times a month on a sheet pan, the sheet pan had to be placed next to the steam table and would not fit within the steam tables located in the kitchenettes. Dietary aide #3 stated that if time allowed, they would cut the pizza in half and place it inside a hot rolling cart to ensure that the pizza temperature was held. They stated that the water in the steam table had never drained during a meal service before, and without water there would be no steam to heat up the food. Dietary aide #3 stated that during some dinner services the staff would run out of hot plates and food would be plated and served without one. They stated that the tray line refrigerator would stay open the entire meal service and that could affect the products inside getting too warm. During an interview on 8/16/2023 at 4:39 PM, dietary aide #20 stated that hot food items should be held at 135 degrees F or higher and cold food items should be held between 35 degrees F and 41 degrees F. They stated that that the ravioli at 109 F, pizza at 99 F, chicken tenders at 92 F, macaroni and cheese at 90 F, carrots at 92 F, and milk at 53 F were not palatable temperatures. Dietary aide #20 stated that if there was a call down for another food tray, they would write a ticket and the cook would then plate it from the steam table. They stated that the main kitchen frequently would run out of hot plates during the supper meal as there would be some hot plates not returned to the main kitchen after the breakfast and dinner meals. Dietary aide #20 stated that the test tray they had brought up to the C unit for the 8/10/2023 dinner meal did not have a hot plate under it. During an interview on 8/17/2023 at 11:32 AM, the District Food Service Manager stated hot food should be held at 135 degrees F or higher, and cold food should be held at 35 degrees F to 41 degrees F. They stated that pizza at 99 F, ravioli at 109 F, chicken tenders at 92 F, macaroni and cheese at 90 F, carrots at 92 F, pureed oatmeal at 90 F, and milk at 53 F was not palatable. The District Food Service Manager stated that the sheet pan for the pizza did not fit on the unit kitchenette steam tables, dietary staff would place the sheet pans over the steam table [NAME] and/or put the pizza into the kitchenette hotbox. They stated that if the lunch food had been delivered to the unit timely, then temperatures of the pizza probably would have been acceptable. The District Food Service Manager stated that the dinner test tray food was taken from the main kitchen steam table after the steam table had been turned off for 9 minutes, was then wrapped with a plastic film, and there were no pellet bases available to put under the test tray plate. They stated that the dinner test tray should have been microwaved or placed back in the oven to warm prior to bringing it to the resident unit. The District Food Service Manager stated if a steam table had no water in it, it could keep food heated in the short term but in the long term would overheat the heating elements in the steam table. 10NYCRR 415.14(d)(2) 40803 48446 48511 48675

Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 13 residents (Resident #10) were free of significant medication errors. Specifically, Resident #10's anti-[MEDICAL CONDITION] medication was discontinued without a physician's order and the resident had a [MEDICAL CONDITION] requiring hospitalization . Findings include: The Policy Telephone and written orders for medication revised 5/2014 documented the procedure for verbal and telephone orders for medications to include, a nurse checks the order from the chart, verifies that the order is in the computer correctly, if the order is correct the nurse approves the order, if the order is not correct the order is either corrected or rejected. If the order is rejected, pharmacy is notified of the error and then pharmacy corrects the error and sent back to facility for approval. Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired and he required extensive assistance with activities of daily living. The resident had a [MEDICAL CONDITION] disorder and a feeding tube. The comprehensive care plan (CCP) updated 8/26/2017, did not document the resident's [MEDICAL CONDITION] disorder. The physician's orders dated 6/12/2017, documented to administer [MEDICATION NAME] [MEDICATION]) 600 milligrams twice a day for the resident's [MEDICAL CONDITION] disorder. The Medication Administration Record [REDACTED]. The record documented the medication was given at 8:00 AM from 7/1 to 7/11/2017, and at 8:00 PM from 7/1 to 7/10/2017. The MAR indicated [REDACTED]. There was no physician order to discontinue the medication. A nursing progress note dated 7/26/2017 at 12:34 PM, documented the resident was convulsing, frothing at the mouth, and unresponsive with very heavy labored breathing. The resident's blood pressure was 240/100, his heart rate was 96 and irregular, a non-rebreather oxygen mask was applied and the resident was sent to the hospital. The nurse practitioner's (NP) note dated 7/26/2017, documented the resident had a grand mal [MEDICAL CONDITION], became unresponsive and was transferred to the hospital. She documented he had been controlled with [MEDICATION NAME] and followed by neurology. The hospital discharge summary dated 8/2/2017, documented the resident was admitted to the hospital after a [MEDICAL CONDITION] and not getting his [MEDICAL CONDITION] medication. When interviewed on 9/22/2017 at 11:30 AM, the registered nurse (RN) Manager #7 stated the resident was on [MEDICATION NAME] and it was discontinued in the computer system by a nurse that no longer worked at the facility. She stated the medication should not have been discontinued and no one saw the mistake until after the resident returned from the hospital. When interviewed on 9/22/2017 at 11:50 AM, the Director of Nursing (DON) stated the [MEDICATION NAME] was discontinued by a nurse without an order. The error was found by RN Manager #7 after the resident's hospitalization . When interviewed on 9/22/2017 at 2:50 PM, the resident's physician stated he was unaware the resident was taken off his [MEDICAL CONDITION] medication until the resident returned from the hospital. When the resident went to the hospital he thought the order for [MEDICATION NAME] was active. The resident's [MEDICAL CONDITIONS] (low blood sodium), and an infected [MEDICATION NAME] (antispasmotic) pump (delivers medication directly into spinal fluid, removed 3/2017) put the resident at risk for [MEDICAL CONDITION], and the risk for [MEDICAL CONDITION] increased without anti-[MEDICAL CONDITION] medication. 10NYCRR 415.12(m)(2)