Every finding on record at North Country Nursing & Rehabilitation Center

Based on record review, observations, and interview during the recertification and abbreviated surveys (NY00351103) conducted 8/11/2025-8/15/2025, the facility did not ensure facility menus reflected input received from residents and resident groups for 7 of 7 anonymous residents present at the resident group meeting. Specifically, generic menus were provided to the residents without specific fruits and vegetables to be served and had repetitive starches daily resulting in complaints about the lack of variety in food options. Findings included:The facility policy Resident Food Preferences, revised 7/2024 documented the dietitian, or designee would identify a resident's food preferences. Those preferences were documented in the resident's care plan. The Food Service Department would offer a variety of foods at each scheduled meal with alternates available, as well as access to snacks throughout the day and night.The facility policy Dietary Menu Development, last reviewed 11/2024, documented all residents received meals that were nutritionally adequate, appealing, and tailored to their preferences. All menus were reviewed and approved by a registered dietitian at least annually and with significant changes. Menus were planned 4 weeks in advance using a minimum 4-week cycle. There were three meals per day plus snacks as appropriate. The menus were to have variety in color, flavor, texture, and food group presentation. Resident council feedback would be reviewed and incorporated. Seasonal fruits and vegetables were included into the menu. The final menu was signed and dated by the registered dietitian.The 5/2025 monthly Resident Council minutes documented residents voiced they were not receiving condiments on a regular basis with their meals.During a resident group meeting on 8/12/2025 at 1:30 PM, seven anonymous residents stated meal portions were shrinking, and there was no variety to the menus.The 8/12/2025 Week at a Glance, documented the following lunch meals:- Monday 8/12/2025 fruit mix, rice, and assorted vegetable.- Tuesday 8/13/2025 assorted dessert, mashed potatoes, and vegetable of the day.- Wednesday 8/14/2025 chilled fruit cup, mashed potatoes, and assorted vegetable.- Thursday 8/15/2025 fruit mix, mashed potatoes, and assorted vegetable.- Friday 8/16/2025 assorted dessert, mashed potatoes, and assorted vegetable. The 8/12/2025 Week at a Glance, documented the following dinner meals:- Monday 8/12/2025 fruit cup, a pasta, and assorted vegetable.- Tuesday 8/13/2025 canned fruit, French fries, and coleslaw.- Wednesday 8/14/2025 assorted dessert, a pasta, and assorted vegetable.- Thursday 8/15/2025 assorted dessert, a pasta, and assorted vegetable.- Friday 8/16/2025 assorted dessert, rice, and assorted vegetable.The weekly menu documented mashed potatoes were served on Sunday, Tuesday, Wednesday, and Thursday for lunch. Every lunch included a generic vegetable of the day and generic chilled fruit cup, assorted fruit or assorted dessert. Most dinners also documented generic vegetable of the day and generic chilled fruit cup, assorted fruit or assorted dessert. The menu did not specify what the vegetables, fruits, or desserts were. During an interview on 8/15/2025 at 9:49 AM, Registered Dietitian #5 stated the Regional Food Service Director gave the facility the menu. They stated they reviewed the menu for variety and did not know why the posted menu was generic. A specific menu was programmed in the facility's Meal Tracker (specific electronic dietary program). Residents had a right to know what they were going to be eating on a routine basis. The posted menu met all residents' nutritional needs. The facility provided starches via mashed potatoes or rice. Butter or margarine was sent on the meal carts if a resident wanted them.During an interview on 8/15/2025 at 9:54 AM, Certified Nurse Aide #9 stated many residents complained about getting the same type of foods over and over. They stated the residents were served mashed potatoes or rice every day.During an interview on 8/15/2025 at 10:15 AM, Certified Nurse Aide #10 stated the residents got a lot of the same types of foods. The residents complained that sometimes the food was cold, and staff had to heat it up or call the kitchen for a replacement. The staff ensured the food was not too hot, after reheating it, by taking the food temperature before giving it to the resident. Some families brought food in they knew the residents would eat. Staff offered snacks and cereals when a resident did not eat the food.During an interview on 8/15/2025 at 10:39 AM, Licensed Practical Nurse #11 stated the residents complained about frequently getting the same types of food. They stated they had personally eaten the food in the past and it was bland. The kitchen usually had sandwiches available if a resident did not like the main entree. During an interview on 8/15/2025 at 11:00 AM, Food Service Director #1 stated the registered dietitian set the menu and signed off on approval. When asked to view the menu, the Food Service Director stated it was not readily available. The menu was generic to make it appear neater. The menu was decided daily based on the available foods in the kitchen. If there were vegetables and desserts on hand, that was adequate. They stated the food being served during survey was not always the posted menu as it was a very simple process of cooking the vegetables on hand. They stated the residents had a right to know exactly what the menu for each day would be. At 11:26 AM, the Food Service Director stated the facility did not have menus signed by the dietitian but was having them signed and sent to the facility.During an interview on 8/15/2025 at 11:03 AM, Licensed Practical Nurse #12 stated the residents received a lot of chicken. Mashed potatoes and vegetables were usually the same daily, and usually an assorted vegetable mix or just carrots. Most of the residents complained about getting the same thing all the time. They were able to have sandwiches as an alternate. During an interview on 8/15/2025 at 11:18 AM, the Director of Nursing stated alternates were listed on the menu for every meal. The facility also offered soup and sandwiches. They stated they were aware of residents complaining of getting the same types of meals. 415.4(c)(1-3)

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety for one (1) of one (1) main kitchen reviewed. Specifically, the main kitchen dish machine did not reach the temperature required to sanitize soiled dishware; food in the freezer was not labeled or dated; the dish machine temperature log and three bay sink sanitizer testing logs were not completed every day; and appropriate hand hygiene was not performed. Findings include:The facility policy Dishwasher Policy & Procedure, revised 10/2024, documented high temperature sanitizing dish machines must reach a minimum rinse temperature of 180 degrees Fahrenheit to ensure dishware was safe to use; and monitor daily logs for temperatures and chemicals.The facility policy Kitchen Sanitation, revised 10/2024, documented no eating or drinking was allowed in the kitchen, all food was to be labeled and dated, and all dishes that touched food was to be cleaned and sanitized before and after each use.Food Storage:During an observation of the walk-in freezer on 8/13/2025 at 10:32 AM, there was an unlabeled and undated stack of sliced meat; an opened unlabeled and undated bag of a breaded product; and an unlabeled and undated bag of frozen round patties.During an interview on 8/13/2025 at 1:51 PM, Food Service Director #1 stated leftover food in the freezer should be labeled and dated. Food Preparation:During an observation during lunch preparation on 8/13/2025 at 10:32 AM, Food Service Director #1 was preparing chicken and there was a personal beverage cup sitting on the same counter. The Food Service Director used their phone as they walked away from the area near the ovens, picked up a pan of ground chicken and their ungloved thumb was in the pan. The Food Service Director put on gloves and did not perform hand hygiene. During an interview on 8/13/2025 at 1:51 PM, Food Service Director #1 stated the hand hygiene policy required hand washing upon arrival, when changing gloves, and when hands were soiled. They stated it was not acceptable to have their thumb inside a pan of food without gloves on or put gloves on without washing their hands first. They stated they did not receive hand hygiene training. Dishwashing:During an observation and interview on 8/13/2025 at 10:32 AM, the rinse portion of the dish machine read 150 to 155 degrees Fahrenheit. There was no documented evidence of the dish machine temperature log and three bay sink sanitizer recording forms for 8/13/2025. Dietary Aide #8 stated they usually tested the sanitizer in the three-bay sink and the dish machine temperatures first thing when they started work, but they forgot to today. They stated testing was important to make sure dishes were cleaned and sanitized.During an interview on 8/13/2025 at 12:10 PM, Food Service Director #1 stated the dish machine was a high temperature machine and needed to reach 180 degrees Fahrenheit on the rinse to sanitize safely. They stated the plates observed earlier were not properly sanitized and were used to serve lunch. They stated without proper sanitation it could cause food born illness and contamination.During an interview on 8/13/2025 at 1:35 PM, Dietary Aide #8 stated they logged the dish machine temperature readings and sanitizer results from the three-bay sink on the forms, both in the morning and afternoon. They stated they forgot to test the sanitizer and dish machine temperatures on 8/13/25 in the morning. They stated the dishes from breakfast were pushed through the dish machine, air dried, then stacked on a cart, and put over by the steamtable and used at lunch. They stated these dishes were used to plate up lunch and they did not have enough plates to serve two meals without using the same plates.During an interview on 8/13/2025 at 1:51 PM, Food Service Director #1 stated they only had enough dishes in house for one meal service and the same dishes that were cleaned during observation of the dish machine not sanitizing properly were also used at lunch. They stated they were aware of the temperature issues with the dish machine not sanitizing properly before lunch and should have sanitized the dishes in the three-bay sanitizer before using them. They stated dishes required sanitizing to get rid of bacteria. 10NYCRR 483.60(i)(2)

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of one (1) resident (Resident #11) reviewed. Specifically, Resident #11 had unplanned significant weight loss; nutritional interventions were not included in the care plan or implemented timely; staff assistance was not provided at meals; and there was no documented evidence the medical provider was notified of the weight loss.Findings includeThe facility policy Weight Assessment and Intervention, revised September 2008, documented the interdisciplinary team intervened for undesired weight loss and the physician identified factors that caused the weight loss. The threshold for significant weight loss was defined as five (5) % over 1 month, seven and half (7.5) % over three (3) months or ten (10) % over six (6) months. If the weight loss was deemed undesired, interventions would be implemented.The facility' policy Change in Resident Condition, revised 7/2024, documented the registered nurse would notify the physician if residents had a significant change in physical condition. Resident #11 had diagnoses including dementia, severe protein calorie malnutrition, and glaucoma (eye disease). The 5/29/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, significant visual impairment, required supervision with touching assistance at meals, weighed 140 pound, and had unplanned significant weight loss in 6 months. The Comprehensive Care Plan initiated 8/2021 documented the resident had cognitive loss with dementia, impaired vision, required assistance with meals, and had impaired nutritional status with a significant, unplanned weight loss. Nutritional interventions included regular pureed diet with nectar thick liquids and weight resident as ordered. The 3/10/2025 Registered Dietitian #5 progress note documented the resident weighed 172.6 pounds on 12/5/2024 and 157 pounds on 3/5/2025 (9% weight loss in 3 months). The resident's intake was mostly fair/good with 51-100% meal consumption. The resident fed themself after set-up assistance. The resident triggered for significant, unplanned, undesirable weight loss in three months. Recommendations included weight maintenance, monitor weekly weights, monitor/encourage intake, and meet food preferences. There were no documented updated interventions to the nutritional care plan. The resident weight record documented the following weights:-3/12/2025 157 pounds-3/18/2025 158 pounds-3/26/2025 155 pounds -4/1/2025 154.8 pounds-5/6/2025 153.2 pounds (17.8 pound/ 10.4 percent loss in six months).The 5/8/2025 (edited on 6/2/2025) Registered Dietitian #5 progress note documented the resident triggered significant, unplanned, undesirable weight loss related to variable intake and dementia. Intake at meals was 26-100 %. Recommendations included weight maintenance, and eight ounces of Boost Plus or Ensure Plus (nutritional supplements) twice a day. There was no documented evidence the care plan was updated to reflect nutritional interventions, or the medical provider was notified of the significant weight loss. Resident #11's documented weight on 6/6/2025 was 150.4 pounds (22.2 pound/ 12.8 percent loss in six months).The 6/12/2025 Registered Dietitian #5 progress note documented the resident triggered for significant, unplanned, undesirable weight loss related to variable intake and dementia. Intake at meals was 26-100 %. The plan was for weight maintenance and the current plan of care remained appropriate. There was no documented evidence the care plan was updated to reflect nutritional interventions, or the medical provider was notified of the significant weight loss. Resident #11's documented weight on 8/7/2025 was 142.6 pounds (7.7 pound/ 5.2 percent loss in one month).Physician progress notes from 3/8/2025, 3/28/2025, 3/31/2025, 4/5/2025, 5/3/2025, 6/6/2025, 7/3/2025, and 8/8/2025 did not document weight loss for Resident #11.The 8/11/2025 Registered Dietitian #5 progress note (edited on 8/13/2025) documented the resident triggered for significant, unplanned, undesirable weight loss related to variable intake and dementia. Intake at meals was 26-100 %. The plan was for weight maintenance, and eight ounces of Boost Plus or Ensure Plus was increased to three times per day at that time. There was no documented evidence the care plan was updated to reflect nutritional interventions, or the medical provider was notified of the significant weight loss. During a meal observation on 8/11/2025 at 12:47 PM, Resident #11 was trying to eat chopped broccoli and rice with their fork and got very little of it to their mouth. They felt their cups with their hands and tried to stab the food in an up and down motion. Resident #11 was not assisted with their meal. They consumed very little of their food and when the tray was removed at 1:06 PM, no substitutes were offered.During a meal observation on 8/12/2025 9:11 AM, Resident #11 was trying to eat a chopped muffin, scrambled eggs, and oatmeal with their fork. They were unable to get very little food into their mouth. They felt their cups with their hands and tried to stab the food in an up and down motion. Resident #11 was not assisted with their meal. They consumed very little of the food and when the tray was removed, no substitutes were offered.During an interview on 8/14/2025 at 11:34 AM, Registered Dietitian #5 stated if there was a significant weight loss, they requested a reweight. They stated they visited the resident and obtained food preferences and implemented interventions if the weight was confirmed accurate. They stated they had not seen Resident #11 struggling to feed themself. They would have recommended a therapy evaluation if they had noticed issues. They stated the nursing unit manager should have told the physician about the weight loss but if they saw the physician had not addressed weight loss they told them as well.During an interview on 8/14/2025 at 12:10 PM, Licensed Practical Nurse Unit Manager # 6 stated if a resident had significant weight loss, they completed a form with clinical information such as weights, intake, bowel status, behaviors, and medication changes and sent this to the physician. They stated they recommended an Occupational Therapy evaluation if a resident was having issues feeding themselves. They were not sure if past significant weight changes for Resident #11 were submitted to the physician because they were new to the floor.During a telephone interview on 8/15/2025 at 9:53 AM, Registered Dietitian #5 stated they initiated an intervention for unplanned weight loss within a week of a reweight confirming significant weight loss. They stated they care planned interventions for weight loss and thought they did in Resident #11's case but could not verify without their computer.During a telephone interview on 8/15/2025 at 10:13 AM, Physician #7 stated they were very familiar with Resident #11. They stated the Unit Manager sent weight loss forms to them. They stated being aware of weight loss was very important and increased the risk for infection. They stated they were not aware of documented weight loss for the resident. 10NYCRR 483.25(g)(1)

Based on observations and interviews during the recertification survey conducted 8/11/2025- 8/15/2025, the facility did not ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in one (1) of (3) three units (Unit 200). Specifically, Unit 200 hallway was unclean and had odors.Findings include: The undated facility Housekeeping Tasks documented hallways/nurse's station should be dust mopped and wet mopped. The following observations were made on Unit 200:- On 8/11/2025 at 4:12 PM, there was a brown, dried, odorous substance smeared on the floor going down the hallway from the elevators to the shower room.- On 8/12/2025 at 8:52 AM, there was a brown dried, odorous substance on the floor in the hallway near the elevators. During an interview on 8/14/2025 at 10:07 AM, Housekeeper #2 stated they were responsible for sweeping, mopping, cleaning windowsill, and wiping down everything. They stated they were responsible for mopping the hallways every day, but they did not always get to them. Feces on the floors should be cleaned up by nursing staff. They stated they saw a brown streak down the hallway near the elevator. During an interview on 8/14/2025 at 2:30 PM, the Infection Preventionist stated the certified nurse aides were responsible for cleaning up feces on the floor and housekeeping would sanitize the area afterward. During an interview on 8/14/2025 at 2:45 PM, Certified Nurse Aide #4 stated if they observed feces and urine on the floor, they were responsible for cleaning up the feces or urine.10NYCRR 415.29

Based on observations, record review, and interviews during the recertification survey conducted 8/11/2025-8/15/2025, the facility did not ensure garbage and refuse was disposed of properly. Specifically, facility garbage areas were not maintained to prevent attraction and harborage of pests. Findings include: The facility policy Pest Control, dated 9/1/2019, documented the facility would maintain an on-going pest control program to ensure the building was kept free of insects and rodents. Garbage and trash were not permitted to accumulate and were removed from the facility daily.During an observation on 8/13/2025 at 10:32 AM, there was a large amount of old food, old food containers, and trash on the ground under the metal grates next to the outside dumpster. There was old, dried food debris on the metal grates. There were flies swarming around the dumpster and the old food. During an interview on 8/13/2025 at 1:51 PM, the Food Service Director stated cooks took the garbage out the back door. They were not sure who was responsible for cleaning around the dumpster. The area around the dumpster should be free of food debris and garbage to prevent flies or other pests. During an interview on 8/15/2025 at 10:37 AM, the Maintenance Director stated they had a pest control company come in every month, and they treated for flies. They saw some flies around the dumpster. They stated the kitchen staff was supposed to clean and monitor the trash near and around the dumpster, but if the trash was in the parking lot the maintenance staff was responsible for cleaning it up. 10 NYCRR 415.14(h)

Based on observation, record review and interviews during the recertification survey conducted 12/11/2023 -12/15/2023, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases and infections for 10 of 10 staff members (certified nurse aides #1, 2, 6,10, 11,17 and 21 and licensed practical nurse unit managers #3, 9 and13) observed entering droplet precaution or COVID-19 resident rooms for 7 of 7 residents (Residents #27, 72, 31, 120, 121 and 382), 2 of 2 residents (#101 and 121) who were COVID-19 positive observed in common areas with non-positive residents and for 1 of 1 (Resident #63) residents with a urinary catheter reviewed. Specifically: - Certified nurse aides #6, 10, #11 and #21 were not wearing an N95 mask, gown and gloves as required in rooms with COVID-19 positive residents or residents on droplet precautions. - Certified nurse aides #1,2 and #17 did not sanitize equipment after exiting a droplet precaution room. - Licensed practical nurse unit managers #3, 9 and #13 were not wearing an N95 mask, gown and gloves prior to entering COVID-19 rooms. - Resident #101 was observed eating in the main dining room and Resident #121 was in common areas with non-COVID-19 positive residents. Staff did not separate COVID-19 exposed vs. non-COVID-19 exposed residents - Infection control standards during indwelling urinary catheter care for Resident #63 were not maintained. Findings include: The facility policy Personal Protective Equipment - COVID-19, revised 5/2020, documented all personal protective equipment must be worn by all staff when interacting with COVID-19 suspected or confirmed residents (droplet precautions). Specialty masks should be worn when caring for residents with respiratory illnesses; nurse aides should always change their masks when moving between residents and the same mask should not be worn when moving between residents. The facility policy Infection Prevention and Control Program, reviewed 1/2023, documented outbreak management was a process that determined the presence of an outbreak, managing the affected residents, preventing the spread to other residents, and educating the staff and the public. Prevention of infection included educating the staff on using proper techniques and procedures. The facility policy Cleaning and Disinfection of Non-Critical Resident Care Equipment, revised 8/2023, documented shared equipment, including transport equipment, would be cleaned and disinfected after use by each patient/resident and as needed. 1) PERSONAL PROTECTIVE EQUIPMENT with COVID-19 POSITIVE RESIDENTS AND CONTACT PRECAUTIONS The following staff observations were made on Unit 100 with COVID-19 positive residents: - On 12/11/2023 at 10:06 AM, certified nurse aide #11 was observed entering Resident #72 and #121's room that had signage indicating it was a COVID-19 positive room with a blue surgical mask on and no other personal protective equipment. At 10:07 AM, licensed practical nurse #13 entered the same room with a blue surgical mask on and told the aide they needed a gown on and exited the room wearing the same blue surgical mask. Certified nurse aide #11 donned a gown inside of the room with their blue surgical mask on, completed their task, washed their hands, exited the room, and walked down the hall to another resident's room with the same blue surgical mask on. Certified nurse aide #11 did not have an N95 mask on or face shield. - On 12/11/2023 at 11:22 AM, a family representative of Resident #64 was in their room marked as COVID-19 positive wearing a blue surgical mask and no other personal protective equipment. They were observed wiping down the bedside tables of the resident and their roommate. - On 12/11/2023 at 12:49 PM, residents from Unit 100, with COVID-19 positive residents residing on it, were sitting in the main floor dining room eating lunch. A resident from the 3rd floor (Resident #101) was also eating in the dining room. Staff did not separate COVID-19 exposed vs. non-COVID-19 exposed residents or direct Resident #101 to leave the unit. - On 12/11/2023 at 2:17 PM, certified nurse aide #11, who had earlier (12/11/2023 at 10:06 AM) been observed wearing personal protective equipment inappropriately, was instructing the 2nd shift certified nurse aides on how to don/doff personal protective equipment outside of Resident #121's COVID-19 positive room. The following resident observations on Unit 100 were as follows: - On 12/11/2023 at 9:52 AM, Resident #121 walked out of their COVID-19 positive room and sat in a chair near the nurse's station where other residents were sitting. - On 12/11/2023 at 1:04 PM Resident #121 was pushing Resident #72 in their wheelchair down the hall without a mask on. Resident #72 was their roommate. - On 12/11/2023 at 1:47 PM Resident #121 was walking out of their room without a mask on touching the personal protective equipment cart outside of their door, the box of masks and hand sanitizer. - On 12/11/2023 at 2:26 PM, Resident #121 was in the hall without a mask on touching the personal protective equipment cart outside of their room. The 12/12/2023 at 10:45 AM, facility line list for COVID-19 positive residents included Residents # 64,72,121 and 382.During an interview on 12/12/2023 at 1:41 PM, certified nurse aide #27 stated they did not know why they were placing clear plastic bags around the lunch trays and would ask their supervisor. During an interview on 12/12/2023 at 1:41 PM, certified nurse aide #28 stated staff were told to place bags around the COVID-19 positive room trays so kitchen staff would know they came from COVID-19 positive rooms due to not having disposable dishes. The following staff observations were made on Unit 200 with droplet precaution rooms: - On 12/13/2023 at 8:48 AM, Resident #27 was moved to a room with a stop sign and a droplet precaution sign on the door. - On 12/13/2023 at 9:23 AM, certified nurse aide #6 exited Resident #27's room with a blue surgical mask on; they were not wearing an N95 mask. - On 12/13/2023 at 9:32 AM, registered nurse #24 placed a red isolation trash bin and linen bin inside Resident #27's room, and a personal protective equipment cart outside of the room door. - On 12/13/2023 at 10:49 AM, certified nurse aides #1, 2, and 17 were observed exiting Resident #120's room (COVID-19 positive) with a mechanical lift and did not sanitize the equipment upon placing it in the hall. - On 12/13/2023 at 12:47 PM, certified nurse aide #21 entered Resident #120's room (Rhinovirus positive) wearing a blue surgical mask. They were not wearing an N95 mask or other personal protective equipment. - On 12/13/2023 at 12:53 PM, certified nurse aide #6 entered Resident #120's room (Rhinovirus positive) with a blue surgical mask, delivered a lunch tray, exited the room, donned personal protective equipment, and re-entered the room. During an interview on 1213/2023 at 10:47 AM with certified nurse aide #27, they stated the precaution signs on the COVID-19 positive rooms were so that staff knew what personal protective equipment to don, and the red arrows on the floors in front of the rooms were placed there in case staff missed the signs. During an interview on 12/13/2023 at 10:51 AM with certified nurse aide #32, they stated droplet precautions meant the resident had some type of disease in their spit and that the signs on the doors did not tell the specific disease but told staff what type of personal protective equipment wear before entering the rooms; staff should not enter the rooms without reading the signs on the doors. The following staff observations were made on Unit 300 with COVID-19 positive residents and residents on contact precautions: - On 12/13/2023 at 11:19 AM, licensed practical nurse #9 entered Resident #31's room with no personal protective equipment on.The signs on the door stated contact precautions, gown and gloves required. - On 12/13/2023 at 12:56 PM, certified nurse aide #10 entered Resident #382's room with a blue surgical mask on and no other personal protective equipment on. The signs on the door stated droplet precautions. At the time of the observation, certified nurse aide #10 stated they knew they needed to follow precautions to keep themselves and residents safe from germs; had not worked that side of the hall before and stated infection could spread if they did not follow precautions. The Infection Control staff education dated 12/2/2023 and 12/13/2023 documented education for donning/doffing (taking on/off) personal protective equipment for COVID-19 positive rooms. The staff sign-in sheet did not include certified nurse aide #11. During an interview on 12/14/2023 at 8:25 AM, certified nurse aide #11 stated the rooms with signs and red arrows signified COVID-19 positive rooms; staff were required to wear personal protective equipment including an N95 mask, gown, gloves, and face shield before they entered the room; they had several in-services and were educated on infection control last month. They should not enter COVID-19 positive rooms without an N95 mask as it could spread infection. During an interview on 12/14/2023 at 8:30 AM, licensed practical nurse #13 stated they were the unit manager for Unit 100 for the past 2 years. When a resident tested positive for COVID-19, they immediately cohorted positive residents together, placed signs on the doors and red arrows on the floors to prevent staff from entering without putting on personal protective equipment. They stated the facility missed the previous COVID-19 outbreak, had to re-educate their staff on how to properly put on personal protective equipment and usually assigned one staff member for the COVID-19 positive rooms. Licensed practical nurse #13 stated it would not be appropriate for staff to enter a COVID-19 positive room without an N95 mask and other personal protective equipment; it was important to prevent the spread of infection to either themselves or other residents. During an interview on 12/14/2023 at 9:43 PM, the Infection Control Nurse, who resumed the position in July 2023, stated they were also the Assistant Director of Nursing. During active COVID-19 outbreaks, they were responsible for calling the families of residents. The visitor policy included wearing a mask if they had symptoms, but they could not enforce it. Staff were expected to take off their surgical masks and put on an N95 mask, gown, gloves, and face shield prior to entering a COVID-19 positive room. Not doing so would result in the staff getting a written disciplinary notice. The Infection Control Nurse stated it would not be appropriate for a nurse manager to follow a staff member into a COVID-19 positive room without personal protective equipment on or they could risk the spread of infection to residents who were not COVID-19 positive. Residents should not eat in the main dining room with other residents who had been exposed to COVID-19. During active COVID-19 outbreaks, residents would be cohorted, staff would not float between units in the building and residents from other floors would not be allowed to eat in other dining rooms affected. 2) INFECTION PREVENTION FOR RESIDENT WITH URINARY CATHETER Resident #63 had diagnoses of urinary retention, urinary tract infection and nodular prostrate with lower urinary symptoms. The 11/20/2023 Minimum Data Set assessment documented the resident had intact cognition, had an indwelling urinary catheter, and required partial to moderate assistance of 1 with toileting. The 11/14/2023 physician #4 orders for Resident #63 were: - Foley catheter (a type of indwelling urinary catheter) size 16-French with a 10 cubic centimeter balloon. - The Foley catheter was related to urinary retention. - Change Foley catheter as needed for blockage/leakage. - Provide Foley catheter care every shift on days, evening, and nights. - Monitor and record Foley catheter output every shift on days, evenings, and nights. During an observation on 12/13/2023 at 9:37 AM, certified nurse aide #1 placed a paper towel on the floor underneath Resident #63's catheter bag and placed a measuring container on the paper towel. Certified nurse aide #1 emptied the catheter bag's urine into the container, wiped the catheter drainage spout with the same paper towel that was on the floor and placed the spout back in the holder on the bag. The measuring container was emptied and placed in the bathroom. During an interview on 12/13/2023 at 9:40 AM, certified nurse aide #1 stated they had worked as a certified nurse aide for 3 weeks; they looked up the resident's care instructions on the computer and had to perform catheter care once per shift. They stated they used the paper towel from the floor to wipe off the resident's catheter bag drain spout and should not have because this was unclean and it could cause the resident to get an infection. During an interview on 12/13/2023 at 1:02 PM, licensed practical nurse #3 stated certified nurse aides were taught how to do catheter care upon orientation and their certification process; resident care instructions would be found in the computer and were driven by the care plan. Licensed practical nurse #3 stated when emptying a catheter bag and before placing the drain spout back into the holder, staff should only use alcohol swabs to wipe off the spout; using a barrier such as a paper towel that had been on the floor could cause bacteria to enter the resident's urinary tract and cause an infection. During an interview on 12/14/2023 at 12:10 PM, the Registered Nurse Staff Educator stated they were new to the role of nurse educator, and had only been in the role for the last 6 weeks.They were responsible for yearly handwashing and fire safety education for the staff and putting on and taking off personal protective equipment. If they saw employees using the wrong technique, they would pull them aside and demonstrate how to properly don the personal protective equipment, which included an N95 mask, gown, gloves and a face shield. Also, they would show them how to properly doff the personal protective equipment and had staff do a return demonstration. Registered Nurse Staff Educator stated it was not appropriate for staff to enter COVID-19 positive rooms without wearing an N95 mask, gown, and gloves and the risk of doing so would spread the infection. 10 NYCRR 415.19(a)(b) 48632

Based on record review and interview conducted during the recertification survey on 12/11/2023 - 12/15/2023, the facility did not ensure sufficient staff with the appropriate competencies and skills to carry out the function of the food and nutrition service were in place at the facility. Specifically, the facility did not have a qualified person to serve as the Director of Food and Nutrition services or a qualified dietician onsite at the facility to carry out food and nutrition services. Findings include: The facility's Director of Food Services undated job description documented the primary purpose of the job was to assist the dietitian in planning, organizing, developing and directing the overall operation of the Dietary Department in accordance with federal, state, and local standards. The person must be registered as a food service director in this state, must be knowledgeable in dietary practices and procedures as well as the laws and regulations for long term care facility. The Employee Individual Mandatory In-Service Record for the Food Service Director dated 7/8/2022 included the following trainings: Infection Control/Hand Washing/COVID-19, bloodborne pathogens, personal protective equipment, tuberculosis, hazardous communications, fire safety, harassment, workplace violence, abuse, dietary services, telephone etiquette and performance improvement. The 8/18/2023 annual inservice training for the Food Service Director documented all the same trainings that were completed on 7/8/2022. These are the same general facility staff trainings required to be completed by all facility staff. The Food Service Director- Kitchen Manager job description/competency and evaluation form dated 7/9/2022, documented the primary purpose of the job position was to plan, organize, develop and direct the overall operation of the Food Service department in accordance with the established food services standard, policies, procedures and practices of the facility and requirements of current federal, state and local standards and be directed by the Administrator to assure that quality nutritional [NAME] were provided on a daily basis and that the dietary department was maintained in a clean, safe and sanitary manner. The Education and Qualifications listed on page 8 included the person to be a graduate of an accredited course in dietitic trainig approved by the American Dietetic Association and must provide documentation of registry/certificate upon application for position. Experience must include 2 years experience in a supervisory capacity in a health care setting. They must have training in cost control, food management, and diet therapy. The Food Services Director Acknowledgment on page 10 was not signed by the employee, the supervisor or Administrator. The Kitchen Manager responsibilities letter dated 7/9/2022, documented the following responsibilities: 1. Meal planning, 2. Food Preparation, 3. Dietary Compliance, 4. Inventory Management, 5. Staff Supervision, 6. Budgeting and Cost Control, 7. Quality Assurance, 8. Resident Satisfaction, 9. Compliance with Regulations, and 10. Collaborating with Healthcare Professionals. The Quality Assurance Audit Tool for survey finding of 7/2/2021 dated 11/7/2023 was signed by the kitchen manager #33 as the Food Service Director. The facility's Key Personnel list updated 12/1/223 listed the kitchen manager #33. There was no registered dietitian or Food Service Director listed. During an interview on 12/11/2023 at 11:28 AM, the Food Service Director/kitchen manager #33 stated they were put into their position without any formal training on the kitchen or how to be a Food Service Director. They stated they had started approximately July 2022. They stated the percentages of work duties listed were as follows: 15% on Administrative functions, 5% committee function, 10% Personnel Function, 25% Job specific functions, 10% staff development, 10% Competency, 5% Safety, 5% equipment and supply, 5% financial responsibilities, and 10% customer service. The undated and unsigned job requirements for the Food Service Director documented experience must be at least 2 years in a supervisory capacity and they must have been trained in cost control, food management and diet therapy. The Food Service Director/kitchen manager #33's resume documented working at the facility from 7/2022 to present, prior work experience was a retail store manager from 9/2021 - 7/2022 and prior to that was a babysitter from 1/2020 - 9/2020.There was no kitchen supervisor or food service management experience. During an interview on 12/13/2023 at 2:39 PM, the Administrator stated the Food Service Director/kitchen manager #33 was sick last week and then were called in and trying their best. They further stated the Corporate Food Service Director was not really involved and had been stuck downstate. During an interview on 12/14/2023 at 12:18 PM, the Food Service Director/Kitchen Manager #33 stated they were never trained for kitchen supervision when they were asked to be the Food Service Director. They only got a four hour training. They further stated the Registered Dietician #30 had access to the computer to get into the electronic medical records system and can call family's and residents. The Registered Dietitian #30 was not in the facility and may be out of state. The position had been a telecommuting service. During an additional interview on 12/14/2023 at 1:03 PM, the Food Service Director/kitchen manager #33 stated they had not recevied training or inservices related to kitchen basics like placement of hand wash signs, probe calibration and processes in the kitchen. When they got the position they were shown how to use the meal ticket system with limited access, the Material Data Safety sheets and the office area and computer. There was no food service or food safety training given. They further stated they were not Serve- Safe certified and had nothing in their file for food service safety and training at orientation or inservices. They tried to take a Serve-Safe training, but the course was not counted as they were given the resident public dining room space to take the course and test. The Serve-Safe moderator told them the coursework would not count with people coming and going in the room during the test. They asked during their interview to be trained and they were told by the Corporate Food Service Director that they would be given training for the position. They had not received any word or training since their hire in July 2022. The Corporate Food Service Director was never onsite to give guidance or training as they were always stuck downstate. They were not reachable a lot of the time. They had held previous positions at the facility as a dishwasher, dining room server and a night cook. During an interview on 12/14/2023 at 2:26 PM, registered dietician #30 stated they had been on staff approximately 2 years on and off. They started back at the facility in October 2023 and today had been their first physical visit to the building. They plan going forward to be onsite once every few months. They knew resident weights had fluctuated, with histories of refusing meals. They suspected some of the weights were not accurate. The biggest part of their job was weight monitoring and adding supplements as needed. They used video calls to meet with the residents regarding food preferences and food histories. They stated they relied on nursing staff to report concerns with residents and their nutritional status. They worked closely with the Food Service Director on menus and preferences. They relied on nursing and speech therapy to report observations of resident intakes/issues since they were not onsite. They had not attended care plan meetings, in person or by phone. They felt not being onsite would not impair their ability to perform all aspects of their job. There were no other clinical nutrition personnel on site or on staff. During an interview on 12/15/2023 at 11:21 AM, the Director of Nursing stated care plan meetings were held weekly. The Director of Nursing, Assistant Director of Nursing, Administrator, Social Worker, the Minimum Data Set Coordinator, wound care team, Rehab Director, Activities, and families and residents were invited to care plan meetings. The Registered Dietician #30 would join the meeting if necessary. The Registered Dietician would update the care plan if there was weight loss, dietary supplements, or change in diet for some reason. The Registered Dietician would send an email to department heads. 10 NYCRR 415.14(a)(1)

Based on observation, record review and interview during the recertification survey and abbreviated survey (NY00299190) 12/11/2023 - 12/15/2023, the facility did not ensure the main kitchen was maintained in accordance with professional standards for food service safety in the main kitchen. Specifically, the floors, ice machine and walk-in freezer were unclean with food debris and ice buildup. In addition, there was no hand wash sign adjacent to the dish machine and cartons of milk were stored past expiration date in the milk cooler. Findings include: The facility policy North Country Nursing and Rehabilitation Food Receiving and Storage, revised 10/2023, documented food would be received and stored in a manner that complied with safe food handling practices. The food services or other designated staff would always maintain clean food storage area and all food stored in the refrigerator or freezer would be labeled and dated with the use by date. The undated kitchen schedule and duties documented the kitchen staff was responsible to sweep and mop the kitchen every shift. The cook was responsible to remove outdated food from the coolers daily. The staff was to clean up food spilled immediately and to not leave food on the floor. Food Storage: During an observation on 12/13/2023 at 11:13 AM, three milk crates full of four-ounce milks were dated 12/11/2023. During an interview at the time of observation, kitchen manager #32 stated the milk would normally be discarded on the day of expiration. They were the only employee that did milk and food deliveries. They were short-staffed, so the milk had not been discarded yet. Cleanliness: During an observation on 12/11/2023 at 11:28 AM, the floor under the racks in the walk-in produce cooler were unclean and soiled with food debris at the wall and floor union. During an observation on 12/13/2023: - At 11:03 AM, the handwash sink adjacent to the dish machine did not have signage to indicate proper procedure for washing hands. - At 11:11 AM, the outside freezer had ice build-up in the inside corner of the freezer. - At 11:35 AM, the ice machine was unclean inside the sides of the machine with white residue and rust-colored material dripping down the side. There was food debris on the floors around and under the food prep and cooking area. During an interview on 12/11/2023 at 11:28 AM, kitchen manager #32 stated they cleaned every Friday under and behind the kitchen equipment, which included the walk-ins. During an interview on 12/13/2023 at 2:39 PM, the Administrator stated they had staffing issues related to staff being out with COVID-19 which had impacted the kitchen's efficiency and ability to complete tasks. During an interview on 12/14/2023 at 1:03 PM, kitchen manager #32 stated maintenance was supposed to clean the ice machine monthly. Maintenance cleaned the ice machine three weeks prior, but they did not feel the ice machine was clean. They had not had in-service trainings on where hand wash signs should be placed. There used to be a sign by the handwashing sink with the proper procedure, but they were not sure when it came down. The staff member who handled the ice build-up outside the walk-in freezer no longer worked for the facility. They had not been trained by the facility on the kitchen operation and protocols. 10NYCRR 415.14(h)

Based on observation, record review, and interview during the recertification survey conducted 12/11/2023 - 12/15/2023, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 1 residents (Resident #124) reviewed. Specifically, Resident #124 received oxygen at a flow rate that was not consistent with physician orders. Findings include: The facility policy Oxygen Therapy dated 5/2023 documented oxygen was delivered with a physician's order. The licensed nurse was responsible to consult the physician's order and turn the oxygen flow meter to the desired concentration. Resident #124 had diagnoses including Chronic Obstructive Pulmonary Disease, pulmonary fibrosis, and chronic respiratory failure with hypoxia (low oxygen in the blood). The 10/09/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, required moderate assistance for most activities of daily living, and received continuous oxygen therapy. The comprehensive care plan initiated 10/3/2023 documented the resident required oxygen therapy related to chronic obstructive pulmonary disease and respiratory failure. Interventions included to provide the supplemental oxygen per physician orders. The 10/3/2023 Physician #4 order documented apply supplemental oxygen at 4 liters per minute; always wear nasal cannula for oxygen due to diagnosis of respiratory failure. The December 2023 treatment administration record documented the resident's oxygen was ordered at 4 liters per minute and to always wear. The following observations of Resident #124 were made: - On 12/11/2023 at 2:32 PM, in bed with oxygen via nasal cannula set at 3.5 liter per minute.- On 12/12/2023 at 8:24 AM, in the dining room, connected to an oxygen concentrator via nasal cannula that was set at 3.5 liters per minute . - On 12/13/2023 at 8:32 AM, in the dining room, connected to an oxygen concentrator via nasal cannula that was set at 3.5 liters per minute. - On 12/13/2023 at 9:09 AM, the oxygen concentrator was shut off and the resident was moved out of the dining room with the oxygen tubing rolling under the wheelchair wheel. - On 12/13/2023 at 9:12 AM, the resident's oxygen tubing was re-attached to the oxygen concentrator in the common room at 3.5 liters per minute. - On 12/13/2023 at 9:17 AM, the resident was transported from the common area to their room by certified nurse aide #6 without their oxygen on; once in their room, the oxygen concentrator was not plugged in. - On 12/14/23 at 9:31 AM, in the common area, connected to an oxygen concentrator via nasal cannula that was set at 3.5 liters per minute. - On 12/14/2023 at 12:18 PM, they were in the dining room connected to an oxygen concentrator via nasal cannula that was set at 3.5 liters per minute. - On 12/14/2023 at 2:47 PM, they were in bed with oxygen via nasal cannula set at 3.5 liters per minute. During an interview on 12/14/2023 at 1:57 PM, certified nurse aide #6 stated they put oxygen tubing on the residents and were able to move the oxygen concentrators with the residents. They used the oxygen concentrators because they ran out of the portable oxygen tanks. The nurse was responsible for checking that oxygen settings were the correct liters per minute. During an interview on 12/14/2023 at 2:19 PM, licensed practical nurse #7 stated during the day shift they were responsible to checking oxygen tubing dates, oxygen flow rates and the oxygen saturation for the residents. The resident care plan documented what the liters per minute should be for the resident. Resident #124 was supposed to be on 4 liters per minute according to the treatment section of the care plan. If the resident did not receive the correct amount of oxygen, they could have trouble breathing and become hypoxic (oxygen deficient). Resident #124's order was for 4 liters per minute. The oxygen concentrator being set at 3.5 liters per minute was not correct. They could not recall if they had checked Resident #124's flow rate prior to the interview. During an interview on 12/14/2023 at 3:59 PM, licensed practical nurse unit manager #3 stated they expected the nurses to follow the orders in the electronic health record to ensure a residents' oxygen was on the correct liters per minute. Resident #124 was ordered 4 liters per minute, not 3.5 liter per minute. When a resident was not receiving the correct amount of oxygen, this could lead to respiratory distress. During an interview on 12/15/2023 at 9:58 AM, the Director of Nursing stated they expected the nursing staff to follow the physician order in the electronic health record. If the liters per minute were set lower than the order stated, they would expect the physician to be notified. If they were trying to titrate (decrease) the oxygen there would be an order for that, such as 2- 4 liters per minute. They confirmed Resident #124's order was 4 liters per minute and should be set as the order was written. The nurses should be checking the concentrator to make sure the oxygen was set to the correct rate. 10 NYCRR 415.12(k)(6)

Based on record review and interview during the recertification survey conducted 12/11/2023 -12/15/2023, the facility did not ensure a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet a resident's medical and nursing needs for 1 of 2 residents (Resident #22) reviewed. Specifically, Resident #22's wheelchair seat belt was not removed at meals as planned. Findings include: The facility policy Care Plans, revised 9/2023, documented the facility's care planning/interdisciplinary team were responsible for the development of an individualized comprehensive care plan for each resident. Resident #22 had diagnoses that included cerebrovascular accident (stroke), dysphagia (difficulty swallowing), and seizure disorder. The 10/1/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, required supervision to moderate assistance of one person for activities of daily living, and did not use physical restraints. The resident's comprehensive care plan, last reviewed on 10/12/2023, documented the resident had a seat belt to assist with positioning. The resident was able to unbuckle and buckle the seat belt themselves. The seat belt was to be put on when self-propelling in the wheelchair and removed during meals. The resident was observed during meals with their seat belt not removed: - On 12/11/2023 at 1:02 PM, brought into the dining room for lunch by a staff member. - On 12/13/2023 at 8:37 AM, in the dining room eating breakfast. - On 12/14/2023 at 8:41 AM, in the dining room eating breakfast. - On 12/14/2023 at 12:36 PM, in the dining room eating lunch. During an interview on 12/14/2023 at 2:19 PM, licensed practical nurse #7 stated Resident #22 was able to buckle and unbuckle the seat belt themselves and to their knowledge, there was no specific time the resident's seat belt was to be unbuckled. During an interview on 12/14/2023 at 3:59 PM, licensed practical nurse unit manager #3 stated Resident #22's seat belt should be undone at meals and when the resident was being toileted. Even though the resident was independent with buckling and unbuckling their seat belt, staff should be unbuckling it at meals. Staff were aware the resident's seat belt needed to be undone at meals as they had educated the unit staff. Therapy had educated the unit staff upon its initiation. During an interview on 12/15/2023 at 8:49 AM, physical therapy assistant #23 stated they just started working with Resident #22 again. The resident was able to buckle and unbuckle the seat belt and the resident felt more upright and secure with the seat belt on. The resident could take the seat belt off or ask staff to take it off. The resident could have the seat belt on at meals or remove it if they wanted to. They were unaware the care plan documented the seat belt should be removed at meals. During an interview on 12/15/2023 at 8:53 AM, the Director of Rehabilitation stated the resident released the seat belt when they wanted to and often did not allow staff to touch the seat belt. They did know the care plan documented the seat belt should be off at meals. A previous interim physical therapist likely put that on the resident's care plan previously as any device that could be considered a restraint, like a lap buddy or seat belt, was care planned to be off at meals. 10NYCRR 415.11(c)(2)(ii) 48511

Based on observation, record review, and interview during the recertification and abbreviated (NY00293414, NY00294008, NY00299190, NY00300100, and NY00308466) surveys conducted 12/11/2023 - 12/15/2023, 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 2 of 12 residents (Residents #27 and #124) reviewed. Specifically, Resident #27 and #124, were not provided with adaptive equipment during meals as ordered for multiple days of survey. Findings include: The facility policy Activities of Daily Living-North Country Nursing and Rehab, revised 3/2023, documented residents would be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who were unable to carry out their activities of daily living, would receive the services necessary to maintain good nutrition, grooming, and personal hygiene. The facility policy Adaptive Equipment With Meals. revised 07/2023, documented the residents would receive assistance with meals that met the individual needs of residents. Adaptive equipment (special eating equipment and utensils) would be provided to residents who needed or requested the items. Occupational or speech therapy would determine the need for adaptive equipment, update the care plan as needed, and the kitchen director would be notified. 1) Resident #27 had diagnoses which included dysphagia (a condition with difficulty in swallowing food or liquid), vision loss, and atherosclerotic heart disease of native coronary artery (a build-up of plaque in the arteries that minimizes blood flow). The Minimum Data Set assessment dated [DATE] documented the resident had severely impaired cognition, a swallowing disorder with coughing or choking with a mechanically altered diet, and required moderate to maximum assist for most activities of daily living. A physician's order dated 11/29/2023 by physician #4 documented the resident was to have a regular diet that was ground with a divided plate and thin liquids. The resident's undated care profile documented the resident was to have a regular diet, ground in texture, with a divided plate and thin liquids. The resident's meal ticket dated 12/14/2023 documented a divided, three-compartment plate at every meal. The following observations were made during mealtime of the resident: - On 12/11/2023 at 1:11 PM, the lunch meal was served on a regular, non-divided plate. - On 12/13/2023 at 1:05 PM, the lunch meal was served on a regular, non-divided plate. During an interview on 12/14/2023 at 1:52 PM, certified nurse aide #17 stated the certified nurse aides were to check the resident meal trays for accuracy, such as correct consistency and adaptive equipment prior to serving the tray to the resident. If the tray was incorrect in consistency or missing a piece of adaptive equipment, they would call the kitchen to get a replacement. If the resident's meal ticket documented a divided plate and they received a regular, non-divided plate, they would call down to the kitchen for a divided plate. If the resident did not have the right equipment, they would not be able to eat their meal independently. During an interview on 12/14/2023 at 1:57 PM, certified nurse aide #6 stated they verified everything that was on the meal ticket was on the tray, including adaptive equipment, before they set the tray up for the resident. If a resident did not have what was needed on the tray or something was incorrect, they would call the kitchen to get it fixed. The resident was supposed to get a divided plate per their meal ticket. If the resident got a regular plate instead of the divided plate, it would be incorrect. During an interview on 12/15/2023 at 8:49 AM, certified occupational therapy assistant #19 stated a divided plate was usually used related to impaired vision. The resident would be able to utilize the clock method to orient themselves to where different food groups were on their plate as they would be separated. If a resident did not have the correct adaptive equipment, staff should have called down to the kitchen to get the correct equipment. It was important that a resident received their ordered adaptive equipment at meals as that is what would make it easier for the resident to feed themselves and have independence during their meals. During an interview on 12/15/2023 at 8:53 AM, the Director of Rehabilitation stated it was important for Resident #27 to have their ordered, divided plate while eating as that was would give the resident more independence while eating. 2) Resident #124 had diagnoses including other lack of coordination, legal blindness, and chronic right heart failure. The Minimum Data Set assessment dated [DATE] documented the resident had moderately impaired cognition and required moderate assist for activities of daily living, including eating. Physician #4's order dated 10/5/2023 documented the resident was to have a no concentrated sweets, no added salt diet in chopped texture. Special instructions included food in bowls and thin liquids with no straws, in double-handled spouted cups. The comprehensive care plan, updated 12/8/2023, documented the resident would receive the appropriate level of assistance and be encouraged to perform activities of daily living to the best of their abilities. Interventions included the resident was limited assist of one for eating with no straws, double-handled spouted cups, and their food in bowls. The resident's undated care profile documented the resident had a diet of regular food, ground in texture, on a divided plate with thin liquids. The following observations were made during mealtime of the resident: - On 12/12/2023 at 8:24 AM, during the breakfast meal, they had one, double-handled spout cup filled with liquid and two, flexible, plastic cups filled with juice. - On 12/13/2023 at 8:32 AM, during the breakfast meal, they had a regular coffee cup. - On 12/14/2023 at 12:37 PM, during the lunch meal, they had one, double-handled spout cup filled with hot cocoa, two flexible plastic cups filled with juice, and one flexible plastic cup filled with milk from the carton. During an interview on 12/14/2023 at 1:52 PM, certified nurse aide #17 stated the resident was supposed to have a double-handled spout cup for all drinks but staff were educated to pour all drinks into the flexible plastic cups. The kitchen would usually send up two, double-handled spout cups and the certified nurse aides would rinse out the cups between each beverage for the resident after they were finished. During an interview on 12/14/2023 at 1:57 PM, certified nurse aide #6 stated they believed the resident's double-handled spout cup was only for hot drinks, but the ticket did not specify. It was important for a resident to have their ordered adaptive equipment during meals as it was for the resident's benefit. During an interview on 12/14/2023 at 2:19 PM, licensed practical nurse #7 stated they had oversight during tray pass and meals but were not actively involved in tray pass. It was important that a resident received their ordered adaptive equipment at mealtimes as those interventions were in place for their safety and ease of use to eat their meals. If a resident did not have the correct equipment, they would not be able to eat or drink effectively, which could lead to low nutrition and hydration issues. During an interview on 12/14/2023 at 3:59 PM, licensed practical nurse unit manager #3 stated they expected staff to have checked the resident meal tickets against the tray contents for accuracy. The adaptive equipment needed for each resident was listed on the meal ticket; if the ticket called for a divided plate or double-handled spout cup, the resident should have had that on their tray. In some instances, a resident may need a double-handled spout cup for only hot drinks, but the meal ticket would specify; if it was not specified, the cup should have been used for all drinks. 10NYCRR 415.12(a)(3)

Based on observation, record review and interview during the recertification survey conducted 12/11/2023 - 12/15/2023, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion and proper positioning for 2 of 6 residents (Residents #36 and #38 ) reviewed. Specifically, Resident #36 did not have a left hand splint as ordered and planned; Resident #38 did not have supportive devices for their wheelchair or frequent positioning as planned. Findings include: The facility policy Repositioning revised 5/2023 documented repositioning was a common, effective intervention for preventing skin break down, promoting circulation, and providing pressure relief. Repositioning was critical for a resident that was immobile or dependent on staff for repositioning. The facility policy Splint/Orthotics/Prosthetics revised 8/2023 documented to promote quality care, the facility used appropriate techniques and devices for splints, prosthetics, and orthotics. Therapy would perform a thorough evaluation and assessment of the resident for splints, prosthetics, and orthotics. Facilities would acquire the necessary equipment, the device would be distributed to the resident, and the plan of care would include the type of device, location, wearing schedule and the goal for the resident. 1) Resident #36 was admitted to the facility with diagnoses including cerebral infarction (stroke), left wrist contracture, and hemiplegia (paralysis of one side of the body).The Minimum Data Set assessment dated [DATE] documented the resident had moderately impaired cognition, did not reject care, had limited range of motion/impairment on one side of upper and lower extremity (left side), required moderate assist of 1 to supervision for dressing, toileting, and personal hygiene. The 8/14/2021 physician #5's order documented the resident was to have a left upper extremity resting splint applied when out of bed. On 12/13/2023 at 11:51 AM, Resident #36's comprehensive care plan documented they were to wear the left upper extremity resting hand splint when out of bed to increase proper positioning of the left upper extremity. The undated resident care instructions documented a left upper extremity resting splint when out of bed. The 11/6/2023 at 10:43 AM, occupational therapist #20's updated plan of treatment documented a short term goal that included the staff would demonstrate proper hand hygiene strategies and ability to don splint with good awareness of precaution and wearing schedule. On 10/30/2023, the goal was not met because nursing staff were not consistent with applying the hand splint and were consistently misplacing the splint.They would attempt to find the splint again and develop a system with the therapy aide. The 11/11/2023 at 9:52 AM, occupational therapist #20's progress note documented the resident received passive stretch to the left hand with moderate tightness; the splint was missing so a washcloth roll was placed. Resident #36 was observed without hand splints applied as ordered: - On 12/11/2023 at 10:58 AM, they were in their room, left side flaccid and fingers curled into the left hand. - On 12/12/2023 at 2:26 PM, in their room dialing their phone with left hand with fingers curled in. - On 12/13/2023 at 12:07 PM, they were in wheelchair, leaving their room and their left hand on their lap with fingers curled in and no splint. - On 12/14/2023 at 9:29 AM and 10:35 AM, not wearing a splint on their left hand. The resident stated they were not sure where their splint was. At 2:48 PM, the resident was sitting in their wheelchair without a splint on their left hand. During an interview on 12/14/2023 at 1:52 PM, certified nurse aide #17 stated Resident #36 should have been wearing a splint but did not wear it all the time. Physical therapy and occupational therapy had been working with the resident. They were not aware of the splint being misplaced. The care plan would document if the certified nurse aides were responsible to apply the splint. During an interview on 12/14/2023 at 3:59 PM, licensed practical nurse unit manager #3 stated the resident's splint should be applied as they were care planned. There was no place in the electronic record for the aides to document the splint was applied or if the resident refused to wear it. Therapy should be documenting the resident splint usage as well as nursing. They were not aware Resident #36 was not wearing their left hand splint. During an interview on 12/15/2023 at 8:49 AM, the certified occupational therapy aide #19 stated the resident had a splint to use, they were not usually the one to work with the resident, but the resident had a splint they should be wearing. During an interview on 12/15/2023 at 8:53 AM, the Director of Rehabilitation stated in July of 2023 the resident was assisted by inconsistent nursing staff and the resident kept losing the splint. The laundry staff would find the splint in the dirty laundry frequently. They issued the resident a new splint a couple of times and then they started to keep the splint in the therapy gym. The splint was applied during therapy but not every day, and they usually only tolerated it for 4 hours. The orders should have been updated around mid- November 2023 when the resident was building a tolerance back up to the splint. When the responsibility was placed on the nursing staff to put the splint on, it was not always applied consistently or appropriately, and the splint would go missing. That is why therapy added the resident to therapy again, to work on a splinting schedule. 2) Resident #38 was admitted to the facility with diagnoses including traumatic brain injury, functional quadriplegia, and generalized muscle weakness. The Minimum Data Set assessment dated [DATE] documented the resident had intact cognition, had no behaviors, required extensive assist of 2 for most of their activities of daily living, and normally used a wheelchair. The 9/1/2023 - 12/15/2023 physician orders did not include any ordered splinting devices or instructions or repositioning the resident. The 11/13/2023 at 3:17 PM, certified occupational therapy aide #19's treatment encounter note documented the resident tolerated stretching to the right hand and finger, stretching the neck and tolerated the neck and right hand rolls. The 12/14/2023 comprehensive care plan documented the resident had a neurological disease/damage related to traumatic brain injury with quadriplegia and generalized weakness/fatigue. The interventions included to provide assistive/adaptive/postural devices to help the resident do as much for themselves as possible. When in the wheelchair the resident should have footrest, pommel cushion, lateral supports at the trunk and head, padded back and soft head support between the left side of head and lateral support at the head, with frequent repositioning, when in the recliner the resident should be repositioned frequently to sit upright. During an observation on 12/12/2023 at 8:48 AM, while the resident was sitting in a lounge chair in their room, the resident's right arm and right elbow were contracted. The resident's head was leaning to the left side, and there were no braces, splints, rolls or pillows in place. During an observaton on 12/12/2023 at 9:05 AM, the resident's right hand appeared contracted, and the resident's neck was hyper-flexed to the left side. During an observation on 12/13/23 at 9:38 AM, the resident was awake in their room, sitting in a recliner chair. Their right hand was contracted at the elbow. The left arm was at their left side and straight out. There was no adaptive equipment in the room or on the resident (no splint, no brace, no booties). During an interview on 12/15/2023 at 8:32 AM, certified occupational therapy aide #19 stated they worked with the resident in the past, and they were discharged from therapy on 11/30/23. The resident should have had a towel roll at their neck with 2 towels rolled together and a hand roll which was one wash cloth folded in half rolled up and place in the right hand. These should have been placed when the resident was in their wheelchair. The purpose of the towel rolls were to prevent further contracture of the hand and the neck roll was to promote proper alignment for comfort and safety when the resident would eat. If the staff were not providing the resident the towel rolls the resident's hand would become more contracted and the contraction harder to reverse and the neck would become stiffer. The interventions were on the care plan and the staff should be following the care plan. They did not think staff were documenting their use of these adaptive items. During an interview on 12/15/23 at 9:01 AM, certified nurse aide #29 stated they were familiar with the resident. The resident was very contracted and needed to transfer to the chair using a platform walker. The resident required two people to assist with the transfer. Once the resident was sitting in the recliner, they would support the resident with a pillow on the side because their head and body leaned to the left. The resident did not require any splints and was not required to use any towel rolls. They knew how to care for the resident based on the care card in the computer. The only training they received was from other aides on the floor regarding the resident's preferred routines. During an interview on 12/15/23 at 9:17 AM, licensed practical nurse #9 stated the resident was unable to reposition or brace themselves. When the resident was in the recliner, they required a roll in their right hand and a neck roll. The certified nurse aides were required to give the resident the towel rolls. Those instructions were in the care plan. The hand roll was to protect the skin on the resident's hand from injury from their fingernails and to help prevent further contracture. The neck roll was to support the resident's neck because they tended to lean their neck to the left side. The certified nurse aides were not required to document the task anywhere. 10NYCRR415.12(e)(2)

Based on record review and interview during the recertification survey conducted 12/11/2023 - 12/15/2023, the facility did not ensure that a resident who required dialysis received such services consistent with professional standards of practice for 1 of 1 residents (Resident #34) reviewed. Specifically, Resident #34 did not receive a complete post-dialysis treatment assessment of their fistula (direct connection between an artery and a vein; dialyis access site) by a registered nurse. Findings include: The facility policy, Dialysis Residents - North Country Nursing and Rehab, revised 8/2023, documented residents receiving dialysis would have the following in effect: observe shunt for signs and symptoms of infection or inflammation; observe shunt for thrills (a vibration caused by blood flowing through the fistula) and bruits (a whooshing sound heard with a stethoscope near the fisula incision site) every shift and report any abnormal findings to physician and/or dialysis, and medications as ordered. Resident #34 had diagnoses of end-stage renal disease, respiratory failure, and diabetes mellitus. The 11/22/2023 Minimum Data Set assessment documented Resident #34 had intact cognition, end-stage renal disease, and attended dialysis as a resident. The 8/13/2022 physician #5 orders documented: - Check site every shift for complications: check bruit and thrill; check for bruising, bleeding (fistula or port) every shift on days, evening, and nights. - No blood pressures, blood work in right arm secondary to right arterio-venous shunt for all shifts; days, evenings and nights. - Weights and vital signs on Tuesdays, Thursdays and Saturdays pre-dialysis between 5:00 AM - 6:00 AM; post-dialysis between 2:00 PM-10:00 PM. The December 2023 Treatment Administration Record from 12/1/23 - 12/14/2023 documented the resident was to be monitored every shift for complications: check for bruit, thrill, bruising, and bleeding.This order was signed by the licensed practical nursing staff all three shifts with the exception of three times by registered nurses: 12/1/2023 night shift, 12/2/2023 day shift and 12/11/2023 evening shift. The comprehensive care plan, revised 12/4/2023, documented resident #34 was at risk for complications related to alteration in renal function and end-stage renal disease. Interventions included to assess resident for changes in mental status/general condition; administer medications as ordered and check for untoward effects; assess hemodialysis graft, i.e., arterio-venous graft for signs of bleeding, infection or any abnormality and notify medical doctor, check for thrill and bruit daily and monitor vital signs. During an observation on 12/11/2023 at 12:22 PM, Resident #34 was sitting in their wheelchair in their room working on a puzzle. Resident #34 then stated they went to dialysis three times a week on Tuesdays, Thursdays and Saturdays and had an arterio-venous fistula (a loop created from an artery and a vein for dialysis access) in their right arm. Their right arm did not have a bandage on it. Resident #34 stated whenever they returned from dialysis their arm was bandaged up and never not got looked at by a nurse. The fistula bled a couple of times upon return, but they just applied pressure and asked for a band-aid. They had learned how to apply pressure when they first attended dialysis, knew how to stop the bleeding and when it stopped they would remove their own bandage at bedtime. On 12/12/2023 at 8:50 AM, Resident #34 was out of the facility at dialysis. During an observation on 12/13/2023 at 8:36 AM, the resident was sitting in their wheelchair in their room eating breakfast. The resident's right arm dialysis fistula site did not have a bandage on it and was observed to be clean and dry. The resident stated they took their bandages off at bedtime after dialysis the day before. On 12/14/2023 at 9:00 AM Resident #34 was out of the facility at dialysis. On 12/14/2023 at 11:05 AM there were no documented registered nurse progress notes with an assessment of the resident and their right arm arterio-venous fistula post-dialysis treatement. During an interview on 12/15/2023 at 9:12 AM, certified nurse aide #1 stated they were familiar with Resident #34. The resident was picked up for dialysis in the early morning and returned around 11:00 AM. During an interview on 12/15/2023 at 9:17 AM, licensed practical nurse #12 stated they were familiar with Resident #34 and they would be picked up around 4:00 AM for dialysis and returned around 10:30 AM. The resident had a fistula in their right arm and no blood pressures or blood work could be obtained in that arm. They did not assess the resident's arm when they returned from dialysis as only a registered nurse could assess. During an interview on 12/15/2023 at 9:34 AM, licensed practical nurse Unit Manager #13 stated the resident attended dialysis three times a week and was picked up at 5:00 AM. The resident's vital signs were taken, and their communication book was checked when they returned. They thought dialysis staff took care of the resident's arm and the resident would notify the nursing staff if anything were wrong with the dialysis site. During an interview on 12/15/2023 at 9:54 AM, registered nurse #14, stated they primarily worked the overnight shift and were covering for day shift. Resident #34 had dialysis treatmetnts and a right arm fistula, but were unsure if their fistula was assessed by a registered nurse at the facility. They would have to find out more information as to whether the resident managed their own fistula, or if the fistula should be auscultated (listen with a stethoscope) to make sure it was functioning. A registered nurse assessment should be documented in a progress note. They had not assessed the resident's post-dialysis treatment. During an interview on 12/15/2023 at 11:36 AM, the Director of Nursing stated they were familiar with the resident and they attended dialysis. Only a registered nurse could do an assessment on a resident that received dialysis. It was important for a registered nurse to assess the resident's fistula to make sure it was functioning, and it would be a big problem for the resident if the fistula stopped working. Upon review of the resident's December 2023 treatment administration record, the Director of Nursing acknowledged that licensed practical nurses were signing the box for the resident's fistula assessment most of the time. This was wrong and only a registered nurse should be signing off on that task and that they would have the electronic record fixed. 10 NYCRR 415.12(K)

Based on observation, interview, and record review during the recertification survey and abbreviated survey (NY00299190) 12/11/2023 - 12/15/2023, the facility did not ensure food was served at palatable and appetizing temperatures in accordance with professional standards for food service safety in the main kitchen. Specifically, 4-ounce cartons of milk on the tray line (approximately 50) as well as on 1 of 2 test trays measured 63-64 degrees Fahrenheit on one day of survey. In addition, one lunch meal was burned and appeared over cooked at the steam table in the main kitchen, and, 1 of 2 test trays tasted over-cooked. Findings include: The facility policy, Food Receiving and Storage revised 10/2023 documented food should be received and stored in a manner that complied with safe food handling practices, refrigerated foods must be stored below 41 degrees Fahrenheit. The facility policy, Food Preparation and Service revised 10/2023 documented the 'danger zones' for food temperatures were between 41 degrees Fahrenheit and 135 degrees Fahrenheit. Those temperatures promoted the rapid growth of microorganisms (bacteria) that caused food borne illnesses. Potentially hazardous foods included meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese. During an interview on 12/11/2023 at 11:28 AM, Food Service Director #32 stated they were put into the position and had not been formally trained on how to be a Food Service Director. During an interview on 12/11/2023 at 3:11 PM, Resident #57 stated the food was terrible; it was always overcooked or mushy, and dietary staff had a hard time keeping it warm. During the lunch meal on 12/13/2023 the following were observed: - At 11:35 AM, the second lunch cart was leaving for Unit 100; there was a black, burned appearance to the tomato sauce inside of a six-inch pan all around the upper portion of the pan and multiple burned ends of ravioli. - At 12:13 PM, the lunch tray of an anonymous resident was tested , and a replacement was requested. The tray included ravioli that measured 138 degrees Fahrenheit; spinach at 136 degrees Fahrenheit, and milk at 64 degrees Fahrenheit. The ravioli texture was thick, pasty, and burned on the outer edges. - At 12:27 PM, a random milk was pulled from the kitchen and the temperature measured 63 degrees Fahrenheit. - At 1:18 PM on Unit 300, ravioli with burned edges was served. During an interview on 12/13/2023 at 12:27 PM, Food Service Director #32 stated the milk should not have been 63 degrees; they would replace the milk on the trays with refrigerated ones. During an interview on 12/13/2023 at 12:39 PM, cook #33 stated they did not serve hard or burned pieces of food. The ravioli could have been over-cooked. During a follow-up interview on 12/14/2023 at 12:45 PM, Food Service Director #32 stated the ravioli had been cooked too long, burned pieces should not be served and they would not like over-cooked or burned food served to them. 10NYCRR 415.14(d)(1)(2) 48511

Based on observation, record review and interview during the recertification survey conducted from 6/29-7/2/21, the facility did not ensure each resident had a right to a dignified existence for 2 of 9 residents (Residents #71 and 72) reviewed and for 1 of 2 units (Unit 200) reviewed. Specifically, Residents #71 and 72 were not served their meals and other residents were served and eating before them, and residents on Unit 200 were referred to in a manner that was not dignified. Findings include: 1) Resident #71 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/20/20 comprehensive care plan (CCP) documented the resident was at risk for nutritional decline related to dementia. The resident was on a regular diet and interventions included monitoring intake. During an observation on 6/29/21 at 1:04 PM, Resident #96 was eating lunch in the lounge area behind the nursing station with other residents nearby. At 1:14 PM, Resident #71 was in the lounge by the nursing station and yelling at the surveyor because they did not have their lunch. At 1:31 PM, Resident #71 was served lunch while most of the residents nearby had already finished their meals. On 7/1/21 at 12:17 PM, Resident #7 was served their meal in the lounge behind the nursing station with Resident #71 nearby. At 12:38 PM, Resident #71 was saying they had not had any lunch yet while Residents #7 and 48 were eating in the same area. At 12:40 PM Residents #71 and 37 were served their meals. Resident #72 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/29/21 CCP documented the resident was at risk for alteration in nutritional status. Interventions included obtaining food preferences. The following was observed on 7/2/21 in the lounge area located near the Unit 2 nursing station: - At 4:50 PM, Residents #51 and 26 were served their dinner meal in the lounge area near the nursing station and began eating their meals, that included pork chops. Resident #72 was seated between them. - At 4:52 PM, Resident #72 was yelling and stating, where is the pumpkin pie, anything here? - At 4:54 PM, Resident #72 yelled twice about not having food yet. - At 5:00 PM, Resident #72 yelled about not getting food yet saying, are we going to get any food here? We are getting nothing here. Resident #26 asked Resident #71 if they wanted a grilled cheese sandwich and Resident #72 stated they did not know what they were supposed to eat. - At 5:01 PM, Resident #26 asked an employee if they could call and get a grilled cheese sandwich. Resident #72 was asking where their meal was. A CNA asked Resident #26 if the grilled cheese was for them and then asked if Resident #72 if they wanted a grilled cheese. Resident #72 stated they wanted pork chops. - At 5:02 PM, Resident #72 asking if they were getting anything here. - At 5:05 PM, Resident #72 was upset they did not have a meal. - At 5:07 PM, Resident #72 stated I do not get anything every - [expletive]- time. The resident then asked staff who were nearby for food. - At 5:09 PM, Resident #72 was asking for food and the RN Unit Manager stated it was coming. - At 5:11 PM, Resident #72 was stating, anyone here got anything to eat. At that time Resident #72 stated, I am starving to death. The RN Unit Manager assured it was coming and asked CNAs if they located the resident's meal tray. - At 5:17 PM, Resident #72 was yelling out they had not received any food. - At 5:19 PM, the Corporate Food Service Director went to look for the resident's tray. - At 5:20 PM, Resident #72 was served their meal. During an interview with food service worker #30 on 7/2/21 at 9:58 AM, they stated the meal trays were set up and placed on the cart by room number and hall. When the dining area was fully open, they set up trays in a different order. The order of tickets did not change to dining room set up as the dining rooms were not open yet. During an interview with Corporate Food Service Director on 7/2/21 at 10:04 AM, they stated tray tickets were printed by room number and then go on the cart for delivery to specific wings. That system had been set up when residents ate in their room during COVID-19 precautions. If a resident ate in the dining room, their tickets were separated. If residents now ate out of their room the tickets/meal trays should be specific to the area the residents were eating in. During an interview with temporary nurse aide (TNA) #14 on 7/2/21 at 10:32 AM, they stated the trays were not set up on the carts in the order of the resident's current locations and it made it difficult to pass the trays. 2) During an observation on 6/29/21 at 1:04 PM, there was a posted sign near the Unit 200 nursing station that documented, feeders are now allowed to go to the dining room and be fed there. On 6/29/21 at 4:40 PM, meal trays were being delivered to Unit 2. Unidentified dietary staff and direct care staff were discussing amongst themselves, Do you need help with the feeders? Dietary staff then stated, You have the feeders all set? During an interview with certified nurse aide (CNA) #13 on 7/2/21 at 9:57 AM, they stated they felt the term feeders was rude and staff should say, a person that needs feeding assistance. During an interview with temporary nurse aide (TNA) #14 on 7/2/21 at 10:32 AM, they stated a resident that had an altered consistency such as puree or ground would be called a feeder. During an interview with CNA #1 on 7/2/21 at 10:59 AM, she stated their unit had 3 residents that were feeders and then named 1 specific resident that was a feeder. During an interview with licensed practical nurse (LPN) #15 on 7/2/21 at 11:04 AM, they stated the residents should not be called feeders. During an interview with registered nurse (RN) Unit Manager #16 on 7/2/21 at 11:31 AM, they stated calling residents, feeders, was a dignity issue and the term should not be used. During an interview with RN Unit Manager #2 on 7/2/21 at 1:23 PM, they stated that they did not like the term feeder and the term was not dignified. The RN was unsure who wrote feeder on the whiteboard sign and it should not be written there. 10NYCRR 415.3(c)(1)(i)

Based on observation, record review and interview during the recertification and abbreviated (NY 642 and NY 985) surveys conducted from 6/29/21-7/2/21, the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 12 residents (Residents #2, 18, 22, 36 and 54) reviewed. Specifically, Resident #18 was not assisted with showers as scheduled. Resident #22 was not provided facial hair grooming or nail care. Resident #54 was not toileted timely. Residents #2 and #36 were not dressed or assisted out of bed per their preference. Findings include: The facility policy Activities of Daily Living (ADLs), Supporting revised 3/2018 documented residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 1) Resident #18 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/10/21 Minimum Data Set (MDS) assessment documented that the resident had moderate cognitive impairment, required extensive assistance of 1 with dressing and personal hygiene and was totally dependent with bathing. The Resident Profile (care instructions) initiated 12/31/20 documented the resident required extensive assistance with bathing. The profile did not include the resident's preference for showering. The comprehensive care plan (CCP), dated 4/7/21, documented that the resident required extensive assistance with bathing and did not include a preference for showering. The Point of Care History (ADL documentation) dated 1/1/21-7/2/21 documented no showers were provided to the resident. The resident received partial bed baths or complete bed baths during this time. The Shower Roster updated 6/14/21 documented the resident was scheduled for showers on Monday and Thursday on the 3 PM-11 AM shift. During an interview on 6/29/21 at 1:08 PM, the resident stated they were not getting showers as often as they used to and would like to be showered. During an interview with TNA #14 on 7/2/21 at 10:32 AM, the TNA stated they had time to get to showers. A lot of residents had sponge baths instead of showers because they could not get in the showers. The CNAs usually say what residents get sponge baths and what residents get showers and the kiosk (profile) says what the residents need. During an interview with CNA #24 on 7/02/21 at 10:48 AM, they stated that Resident #18 required extensive care. The CNA stated they did not know the shower schedule and did a shower one evening a week. There is not time on days to do showers. Resident #18 was difficult to shower and that is why the resident's shower was scheduled for evening. During an interview with CNA #35 on 7/02/21 at 5:18 PM, they stated they cared for Resident #18 on evenings. The resident was dependent with bathing except for the face and hands. The resident received showers and it was recorded in the kiosk under bathing. The kiosk prompted to document a partial bath, a shower, or a complete bath. The CNA stated they had not given the resident a shower because the resident refused because they got cold at nighttime. The CNA stated they followed the resident's directions and did not give the resident a shower. 2) Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/16/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required limited assistance of two staff for personal hygiene, was totally dependent with bathing and rejected care 1 to 3 of 7 days. The Resident Profile (care instructions) initiated 9/9/20 documented the resident required extensive assistance of 1 person for personal hygiene. The profile did not include resident shaving preferences. The comprehensive care plan (CCP) initiated 9/9/20 and reviewed 4/22/21 documented the resident required assistance with ADLs. Interventions included provide extensive assistance of 1 for personal hygiene. The following observations were made of Resident #22: -on 6/29/21 at 12:34 PM, the resident was lying on top of the bed dressed, with a long beard extending to the lower neck. -on 6/30/21 at 9:43 AM, the resident was in bed with a shirt on. Their blanket was covering their lower body. The resident had a long beard extending to the lower neck and the resident's hair was uncombed. At 2:04 PM the resident was in bed and had a beard extending to the lower neck. -on 7/01/21 at 8:28 AM, the resident was in bed wearing a hospital gown and remained unshaven with long facial hair and uncombed hair. -on 7/01/21 at 11:58 AM, the resident was sitting on the edge of the bed eating lunch wearing a hospital gown. The resident's fingernails were 1/4 inch past the tip of the fingers and had a brown substance under the nails. The resident's toenails were approximately 1/4 inch past the tip of the toes. The resident's hair was unkempt, and their beard was long. During an interview on 7/1/21 at 1:42 PM, a family member stated they were not satisfied with the resident's personal care at the facility. The resident had not received a haircut since entering the facility and had not been shaved. The family member stated the resident had never had a beard and now had one of considerable length and they did not think the resident would like the beard. During an interview with licensed practical nurse (LPN) #20 on 7/2/21 at 12:18 PM they stated males and females should be shaved as needed. Some CNAs shaved residents every 3 days. Resident #22 would sometimes be combative with care but if snacks were offered the resident would do better. The LPN stated staff had attempted to shave the resident several days ago and were unsuccessful. When interviewed on 7/2/21 at 12:57 PM, CNA #10 stated the resident usually allowed staff to perform care. Resident shaving should be done with care and it should be in the care plan if the resident refused care. The CNA stated the hairdresser was in weekly to perform haircuts. During an interview on 7/2/21 at 2:54 PM with registered nurse (RN) Unit Manager #2 they stated residents should be shaved when needed and allowed. The RN Manager stated there were no notes in the chart about the resident refusing to be shaved and refusal was not documented in the care plan. The RN Manager stated the RN was responsible for trimming the nails of the resident and had not had time to do so due to short staffing. The Director of Nursing (DON) was interviewed on 7/2/21 at 3:39 PM and stated males should be shaved at a minimum every other day. The DON thought Resident #22 had a beard when they were admitted . The resident could be combative with care at times, but 2 staff could possibly assist with shaving. 3)Resident #54 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, required total assistance with bathing, and extensive assistance of 1 person with toileting and personal hygiene. The comprehensive care plan (CCP) for urinary incontinence initiated 7/24/20 and edited 5/17/21 documented the resident was completely continent of bowel and bladder. The CCP for ADLs initiated 11/4/20 and edited 5/17/21 documented the resident was incontinent of bowel and bladder and required extensive assistance of 1 for toileting. The resident profile (care instructions) initiated 11/4/20 and active on 7/2/21 documented the resident required extensive assistance for toileting and was incontinent of bowel and bladder. The following observations were made of Resident #54: -on 7/1/21 at 10:10 AM, the resident was observed in bed with their incontinence brief soaking wet. The brief had leaked onto the bed blanket and the bed was wet. The resident had a t-shirt around their neck, with one arm through and the other arm out. Their gown was sliding off their shoulders and their incontinence brief was exposed. -on 7/1/21 at 10:36 AM, the resident's bed was soaked with urine and the resident was sitting in a chair. -on 7/1/21 at 10:55 AM, the resident's bed was wet with urine. During an interview with CNA #24 on 7/02/21 at 10:48 AM they stated the resident only needed help of one person. The resident could help a little but required between limited and extensive asssistance. The resident was not continent and wore a brief. The CNA stated when they arrived at the facility that morning the resident was in pajamas, the resident was wet, so they dressed the resident and removed the resident from their room. During an interview with registered nurse (RN) Unit Manager #16 on 7/02/21 at 11:31 AM they stated the resident had periods of incontinence but could also be continent. Staff should offer the resident to go to bathroom and the resident should be on a 2-hour toileting schedule. The RN stated they had seen the resident was saturated and had the CNA change the resident's brief. 10NYCRR 415.12 (a)(3) Surveyor: [NAME], [NAME] L. Surveyor: Brunnett, [NAME] M. Surveyor: [NAME], [NAME] M.

Based on observation, interview and record review during the recertification and abbreviated surveys (NY 642, NY 020, and NY 985) conducted 6/29/21 through 7/2/21, the facility failed to ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychsocial well-being for all 108 residents in the facility. Specifically, the facility did not ensure there was sufficient staff to meet resident needs in the areas of activities of daily living, medication administration, resident rights, and nutrition/hydration status. In addition, during the resident group meeting multiple anonymous residents stated meals were late and cold, medications were given late, showers were not given, call lights were not answered timely and beds were not changed or made. Findings include: During the Entrance Conference on 6/29/21 at 11:08 AM, the Administrator stated the facility census was 108. The 6/29/21 Day Shift Actual Staffing documented: - The 100 Wing Census was 47 with 2 registered nurses (RN), 1 licensed practical nurse (LPN), and 5 certified nurse aides (CNAs) - The 200 Wing Census was 57 with 1 RN, 2 LPNs, and 5 CNAs The 6/29/21 Evening Shift Actual Staffing documented - The 100 Wing had 1 RN, 1 LPN, and 3 CNAs - The 200 Wing had 2 RNs, 2 LPNs, and 3 CNAs The 6/29/21 Night Shift Actual staffing documented: - The 100 Wing had 1 RN (the DON was covering at 3:00 AM), 3 CNAs with 1 CNA with a physician's note for light duty - The 200 Wing had 1 LPN and 2 CNAs The 7/2/21 Day Shift Actual Staffing documented: - The 100 Wing Census was 47 with 2 RNs and 1 additional Corporate RN, 1 LPN, and 4 CNAs (the schedule did not note that CNA #24 came in early on their day off to assist) - The 200 Wing Census was 60 with 2 RNs, 2 LPNs, and 5 CNAs. During the Resident Council Meeting on 6/30/21 at 3:37 PM, 7 anonymous residents stated the following: - 1 anonymous resident stated they did not get medications until 10:30 AM. - 1 resident stated they had not received a shower in 2 weeks as staff stated they were busy and had multiple residents to take care - 1 resident stated they were scheduled for showers twice weekly and received showers once a week and did not receive the second one as staff said they did not have enough help; their call bell was also not responded to timely and they would not be out of bed until near lunch time. - 1 resident stated they did not get their scheduled treatments on certain shifts as nurses state they are short staffed. - 1 resident stated staff was short as they had a lot of residents to take care of. - 1 resident stated their roommate sat in a soiled brief for an hour or longer - 1 resident stated they were on a 2-hour toileting schedule; if they requested toileting assistance in between the schedule, staff would not assist them, they went to the bathroom in the hallway and were not cleaned up timely. The residents stated the schedule was correct and then staff would call out. Staff told the residents they did not have time to take care of them. There was often 1 nurse for both floors which was not enough. 1) ACTIVITIES OF DAILY LIVING (Refer to F677) The facility did not ensure there was enough staff to provide ADL Care for Residents #2, 18, 22, 36 and 54. Resident #18 was not assisted with showers as scheduled. Resident #22 was not provided facial hair grooming or nail care. Resident #54 was not toileted timely. Residents #2 and #36 were not dressed or assisted out of bed per their preference. 2) NUTRITION/HYDRATION STATUS MAINTENANCE (Refer to F692) The facility did not maintain acceptable parameters of nutritional status for Residents #22 and 99 Residents # 22 and 99 had significant weight loss and were not re-weighed to ensure proper nutritional interventions were in place. 3) MEDICATION ADMINISTRATION (Refer to F 759) The facility failed to ensure medication rates were not greater than 5 percent. Resident #20 was administered three medications over one hour late. 4) RESIDENT RIGHTS (REFER TO F 550) The facility did not ensure each resident had a right to a dignified existence. Residents #71 and 72 were not served their meals and other residents were served and eating before them During an interview on 7/2/21 at 10:32 AM, TNA #14 stated there was not enough staff to get everything done. They had started working that week and on the second day, they worked 16 hours. They were not told they were going to be expected to work that much when they were hired. A lot of residents received sponge baths because they could not get into the shower. During an interview on 7/2/21 at 10:48 AM, CNA #24 stated it was their scheduled day off and they came in at 10:00 AM to help. There was not enough time to provide showers to residents during the day. During an interview on 7/2/21 at 10:59 AM, CNA #1 stated that staffing was a concern. There was often only one other CNA on Unit 2 and they were unable to get to all the care. CNA #1 stated trays often did not come up on time. Some residents needed assistance with eating while staff were still attempting to pass trays for the rest of the unit. During an interview on 7/2/21 at 11:04 AM, licensed practical nurse (LPN) #15 stated they had to assist CNAs with care at times due to staffing. During an interview on 7/2/21 at 11:31 AM, RN Unit Manager #16 stated staff did not have time to record all the intakes. During an interview on 7/2/21 at 1:23 PM, RN Unit Manager #2 stated they just hired a full time nurse. The RN stated they previously had to cover medication carts, which kept them from the Unit Manager job tasks. The RN stated the Director of Nursing (DON) was often working medication carts and had worked on every shift. The RN felt that the CNAs did not have enough time to document care and the focus was more on providing care in the time they had. During an interview on 7/2/21 at 1:57 PM, the Scheduler stated they were responsible for CNA and temporary nurse aide (TNA) staffing. They tried to staff the units to have 1 CNA/TNA per 10 residents during the day shift and 1 CNA/TNA per 14 to 15 residents on evenings. It was difficult to manage as there were residents with behaviors, and residents who were more difficult or required assistance with feeding. The Scheduler stated if there were extra staff available, they assigned them to cover the call outs. A lot of staff were using COVID-19 symptoms as an excuse to call out and staffing had been all over the place. The 200 Wing had more residents and the facility was starting to accept residents from a nearby facility that was closing. They attempted to have at least one more senior CNA on the schedule and 2 on the evening shift. The night shift had been hard to staff. The Scheduler was not notified of the shower schedule and stated that a lot of staff complained about staffing. The facility had not been utilizing agency staff and the LPN schedule was managed by the DON. During an interview on 7/2/21 at 2:54 PM with RN Manager #2, they stated they were responsible to trim nails and had not has time due to having to perform other duties due to staffing. 10NYCRR 415.13(a)(1)(i-iii)

Based on observation and interview during the recertification survey conducted from 6/29/21-7/2/21, the facility did not ensure food and drink was palatable, attractive, and at safe and appetizing temperatures for 2 of 2 meals reviewed. Specifically, food was not served at palatable temperatures for 2 lunch meals. Findings include: The undated Food Preparation and Service documented the danger zone for food temperatures is between 41 and 135 degrees Fahrenheit (F.). This temperature range promotes the rapid growth of pathogenic microorganisms. Potentially hazardous foods include meats poultry, and milk. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. On 6/29/21 at 12:24 PM, Resident #82 stated the food was not good and the portions were too small. On 6/29/21 at 12:40 PM, lunch trays were observed on a meal cart near the nursing station on the 100 Wing. At 12:55 PM, meal trays were delivered to residents on that unit. At 1:44 PM staff removed a tray from the meal cart and brought it to Resident #18's room. Temperatures of the food on Resident #18's tray were measured, and a replacement tray was ordered: -French fries tasted cold and the temperature was measured at 84 degrees Fahrenheit (F); -roast beef sandwich (containing 2 small half pieces of roast beef between white bread) tasted lukewarm and had a temperature measured at 77 degrees F; -apple juice was measured at 54 degrees F; -coffee was measured at 110.5 degrees F and tasted lukewarm; and -apple sauce was measured at 72.3 degrees F. On 6/29/21 at 2:00 PM, Resident #31 stated their French fries were cold and did not taste good. On 6/29/21 at 2:00 PM, Resident #39 stated their French fries had been cold at lunch and they did not eat them. On 6/29/21 at 4:37 PM, 1 anonymous resident stated hot food was not served hot and cold food was not cold. On 6/29/21 at 5:15 PM, 1 anonymous resident stated the food was not always hot. During the resident council meeting held on 6/30/21 at 3:37 PM, 4 anonymous residents stated the meals were always cold, the French fries were cold the previous day, and lunch and dinner meals were served late. 1 anonymous resident stated their milk and juice were served warm. During an observation on 7/1/21 at 12:05 PM, the food cart was delivered to Unit 2. At 12:15 PM, a tray was delivered to Resident #50's room. Temperatures of the resident's tray were measured at 12:17 PM. The chocolate pudding in a graham cracker crust was 71 F. The pudding was not palatable. During an interview on 7/2/21 at 2:00 PM, the Food Service Director stated hot food should be held/maintained at 145 F or higher and cold food should be 36 F or colder. All hot foods left the steam table in the kitchen at 170 F or higher. The Food Service Director did tray audits from a resident area 2 or 3 times per week and check temperatures, palatability, and what was on the meal ticket. The #10 can of pudding was in a refrigerator before being opened and plated into bowls. Once the pudding was plated it went back into refrigerator until service. Chocolate pudding at 71 F. was not acceptable or palatable. The Director stated French fries at 85 F could be unpalatable to some residents. Apple juice was kept in the same ice bin as the milk, and they were not sure how long it was kept at room temperature. Apple juice was shelf stable and could be served over 45 F but could be unpalatable to some residents. A roast beef sandwich at 77 F was not acceptable or palatable. Apple sauce should have been in an ice bin prior to serving and 71 F was not acceptable or palatable. 10NYCRR 415.14(d)(1)(2)

Based on observation and interview during the recertification survey conducted from 6/29-7/2/21, the facility did not ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences for 9 residents (Residents #4, 18, 31, 33, 39, 50, 54, 82, and 96) and 3 anonymous residents. Specifically, Residents #4, 18, 31, 33, 39, 50, 54, 82, 96 and 3 anonymous residents at the resident group meeting did not receive food items as specified on their meal tickets. Findings include: The facility's undated Food Preparation and Service Policy did not address resident meal accuracy. During an interview on 6/29/21 at 12:24 PM, Resident #82 stated the kitchen was often running out of food. They were served a salad for lunch that was supposed to have tomatoes but there were no tomatoes on the salad. The resident's family brought in food items for the resident to eat since the kitchen could not provide food they preferred. The following observations were made: -on 6/29/21 at 1:44 PM, Resident #18 received their lunch meal and did not have condiments for their roast beef sandwich or French fries. The staff did not offer condiments. -on 6/29/21 at 1:57 PM, Resident #33 stated they did not eat their French fries yet as they had not received any ketchup. -on 6/29/21 at 2:00 PM, Resident #31 was seated in their room having lunch. The resident stated they had a milk carton but did not have a cup or straw for their milk and they did not have any ketchup for their French fries. -on 6/29/21 at 2:00 PM, Resident #39 was seated in their room having lunch. The resident stated they did not have mayonnaise for their roast beef sandwich or ketchup for their French fries. The resident's meal tray was observed and there no condiments on the tray. During a resident council meeting on 6/30/21 at 3:37 PM, 3 anonymous residents stated menus were not posted ahead of time on the units. When meal tickets/meals arrived the items on the tray did not always match the meal ticket or were missing items/condiments. During an observation on 7/1/21 at 12:17 PM, Resident #50's lunch tray ticket documented a cherry vanilla tart. There was no cherry vanilla tart on the tray but a chocolate pudding. On 7/1/21 at 12:56 PM, Resident #96 was overheard asking residents nearby if they received chocolate pudding for lunch. Resident #96 stated I did, and I didn't want one. During an observation on 7/1/21 at 1:04 PM, Resident #82's tray ticket documented the resident was to receive a cherry vanilla tart and the tray had a chocolate pudding pie. Resident #98's tray ticket documented vanilla pudding and the tray had chocolate pudding. The Week 4 menu documented for the 7/1/21 dinner lentil soup was to be served; no alternate soup was listed. The following was observed: -on 7/1/21 at 5:31 PM, Resident #4 was seated in their room with their meal tray. The resident had a bowl of potato soup on their tray and the resident's meal ticket read lentil soup. At 5:45 PM, a CNA entered the room to assist the resident with their meal and did not check the meal ticket or offer the soup listed on the meal ticket. -on 7/1/21 at 5:46 PM, Resident #54 was seated in the dining area with a meal tray in front of them and there were no staff present in the room. The resident's meal ticket read lentil soup and there was a bowl of creamed potato soup on the resident's tray. During an interview on 7/2/21 at 9:06 AM, food service worker #39 stated they ran out of vanilla pudding in the kitchen the day before and the Food Service Director approved chocolate pudding instead. During an interview on 7/2/21 at 9:20 AM, certified nurse aide (CNA) #10 stated staff should be checking the tray ticket when delivering the tray to make sure they were correct. The CNA stated they were not notified there was a change in the dessert for lunch on 7/1/21, they did not notice the dessert was different on the trays, and the kitchen often made changes without notifying the nursing staff. Often the meal listed on the board would be different from what was served, which the resident's found frustrating. During an interview on 7/2/21 at 9:58 AM, food service worker #30 stated the tray tickets said the tart was the dessert for 7/1/21 lunch and they served whatever the cooks told them to. During an interview with the Corporate Food Service Director on 7/2/21 at 10:04 AM, they stated food service staff were expected to follow the tray tickets when putting items on the tray. The vanilla pudding cans were dented, and they had to make a substitution for the lunch dessert on 7/1/21 to chocolate pudding. The Director stated they notified the nursing supervisor. The Director stated they had cleared it with the Regional Registered Dietitian prior to making the substitution. At 10:19 AM, the Director stated that the cook made potato chowder and lentil soup the night before. The potato chowder was the primary soup and there were some residents with lentil soup on Unit 100. During an interview with CNA #24 on 7/2/21 at 10:48 AM, they stated that the meal tickets did not match what was on the resident meal trays. The facility would have 2 types of soups available and the residents did not always receive the soup that was listed on their ticket. She felt condiments were usually on meal trays. During an interview with cook #23 on 7/2/21 at 11:25 AM, they stated they made potato chowder soup and then a small batch of lentil soup based on the tray ticket tallies. The cook stated the lentil soup was the main option and the resident's requested the potato chowder, which is why a larger batch of the potato chowder was made. The cook was told what to make and the resident meal tickets were printed the night prior. The cook filled the soup bowls and the food service aides were responsible for placing the correct soup on the tray based on the tray ticket. 10NYCRR 415.4(d)(4)

Based on observation, interview, and record review during the recertification survey conducted from 6/29/21-7/2/21, the facility did not establish and maintain an infection prevention and control program to ensure the health and safety of residents and to prevent the transmission of COVID-19 and communicable diseases and infections for 1 of 3 residents (Resident #252) reviewed for transmission based precautions, 1 of 1 licensed practical nurse (LPN #11) reviewed for tube feeding administration, and 1 of 4 nurses (LPN #18) reviewed for medication administration. Specifically, the facility did not ensure proper hand hygiene and infection control practices (LPNs #11 and 18) and proper personal protective equipment (PPE, Resident #252) were used. Findings include: The New York State Department of Health (NYSDOH) Revised Health Advisory entitled COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/20, documented all healthcare personnel (HCP) and other facility staff shall wear a facemask while within 6 feet of residents. Extended wear of facemasks is allowed; facemasks should be changed when soiled or wet and when HCP go on breaks. The Centers for Disease Control and Prevention (CDC) guidance titled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, dated 2/23/2021, recommended the following additional strategies to minimize chances for exposure to COVID-19: Hand Hygiene: HCP [healthcare personnel] should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. The 3/29/21 CDC guidance, titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 (COVID-19) Spread in Nursing Homes, directs nursing homes to implement source control measures. Per such guidance, source control means the use of well-fitting cloth masks, facemasks, or respirators to cover a person's mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing. In addition to providing source control, these devices also offer varying levels of protection against exposure to infectious droplets and particles produced by infected people. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. The undated facility policy Administering Medications documents staff were to wash their hands and apply clean, disposable gloves prior to enteral tube feeding medication administration. For injectable medications, staff were to wash hands and apply gloves prior to administering. The facility policy COVID-19: Personal Protective Equipment (PPE) revised 5/24/21 policy documents a surgical face mask is required to be worn at all times while in the facility. Eye protection was optional but is required to be worn at all times on observation/quarantine units or when caring for residents on observation/droplet precautions. There were no positive COVID-19 cases at the facility during the recertification survey. 1) Medication Administration and Mask Use During an observation on 6/29/21 at 4:41 PM, licensed practical nurse (LPN) #18 sat on Resident #50's bed to administer insulin. LPN #18 put the capped end of the insulin needle in their mouth and used their teeth to hold the cap while they removed the needle and gave the resident their insulin. The following was observed on 6/30/21 at 3:24 PM, during a medication administration with LPN #18: - LPN #18 removed [MEDICATION(S)] (pain medication) from the packaging and the pill fell on the top of the medication cart. LPN #18 picked up the pill with their bare hands and put the pill in a medication cup. LPN #18 entered the resident's room and assisted the resident to a sitting position and gave the resident the [MEDICATION(S)]. The LPN touched the resident's walker and assisted the resident to lie down and left the room without performing hand hygiene. - LPN #18 returned to the medication cart without performing hand hygiene, entered Resident #35's room, sat on the resident's bed and asked if the resident had pain. LPN #18 left the room and returned to the medication cart without performing hand hygiene. - LPN #18 removed their surgical mask to speak with Resident #22 within 6 feet of the resident. The LPN stated the resident became nervous when they could not see the staff member's face. LPN #18 pricked the resident's finger for glucose testing and blood dripped onto LPN #18's left glove. LPN #18 then adjusted their mask with their left gloved hand. LPN #18 touched the computer mouse at the medication cart with the same left gloved hand. LPN #18 drew 6 units of insulin wearing the same gloves and entered Resident #22's room. LPN #18 pulled their surgical mask away from their nose and mouth and leaned toward the resident and administered the insulin. The LPN touched their face, adjusted their surgical mask with their left hand, removed their gloves, and began to wipe the glucometer and medication cart with a bleach wipe. LPN #18 did not perform hand hygiene. - LPN #18 entered Resident #14's room, removed their surgical mask, asked the resident their pain level, and replaced their mask. The LPN was within 6 feet of the resident. - LPN #18 walked over to Resident #21, who was in the same room as Resident #14, asked their pain level, and left the room without performing hand hygiene. LPN #18 then used the computer on the medication cart. - LPN #18 entered Resident #97's room, shook their hand, and left the room without performing hand hygiene. During an interview on 6/29/21 at 3:24 PM, LPN #18 stated they put the insulin needle cap in their mouth as they did not have a free hand to provide the insulin and stated they should not have put the needle cap in their mouth due to bacteria. LPN #18 stated they should perform hand hygiene every time they left a resident room. They stated they should have performed hand hygiene after repositioning Resident #75. The LPN stated they were aware there was blood on their gloved hand, and they took the glove off. They stated they wiped their hand with the bleach wipe when wiping the glucometer. The LPN stated they should have taken off the gloves when leaving the resident's room and put on a new pair. They stated they should have completed hand hygiene between residents to prevent the spread of germs from one resident to another. During an interview on 7/2/21 at 12:08 PM, registered nurse (RN) Manager #2 stated a syringe cap should never be removed with teeth or held in the nurse's mouth. The RN stated the LPNs should change their gloves immediately after doing a finger stick and perform hand hygiene. LPNs were expected to wash their hands with soap and water after using hand sanitizer three times. During an interview on 7/2/21 at 2:12 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist stated nurses were to wear gloves whenever completing finger sticks or administering insulin. The ADON expected staff to change their gloves when leaving resident rooms and before touching the computer. There was a risk of sticking themselves with the needle if they used their mouth to remove a needle cap and that was absolutely not an acceptable practice. Masks were to cover the staff member's nose and mouth. The ADON expected the nurse to change gloves and perform hand hygiene before they continued with their duties, especially if blood was involved. During an interview on 7/2/21 at 4:19 PM, the Director of Nursing (DON) stated it would never be appropriate for a nurse to use their teeth to uncap an insulin needle and they expected the LPN to remove the glove with blood on it, perform hand hygiene, and put new gloves on if needed. Gloves should be disposed of before leaving the resident's room. 2) Resident #252 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/22/21 nursing progress note documented the resident refused the COVID-19 vaccine. The 6/25/21 comprehensive care plan (CCP) documented the resident required extensive assistance with most activities of daily living (ADL) and was a new admission. The resident was to be on contact and droplet transmission-based precautions for 14 days unless they received the COVID-19 vaccine. Personal protective equipment (PPE) used by staff was to include gowns, gloves, and face coverings with hand hygiene. During an interview on 6/29/21 at 4:32 PM, licensed practical nurse (LPN) #11 stated the resident was on droplet precautions, staff needed to wear a gown, gloves, eye protection, and a surgical mask when in the room with the resident. On 6/29/21 at 4:53 PM, temporary nurse aide (TNA) #12 was observed entering Resident #252's room wearing a surgical mask and eyeglasses. The TNA exited the room and reentered the resident's room and was not wearing gloves, gown, or eye protection. The TNA repositioned the resident and exited the room. During an interview on 7/2/21 at 11:04 AM, registered nurse (RN) Manager #2 stated residents admitted without the COVID-19 vaccine were placed on droplet and contact precautions for 14 days following admission and staff were required to wear gowns, gloves, surgical masks, and eye protection. Staff were expected to wear PPE every time they entered the room. PPE was to be donned in the hallway and doffed before exiting the room. During an interview on 7/2/21 at 11:53 AM, TNA #12 stated droplet precautions required a gown, gloves, surgical mask, and goggles or face shield. The TNA stated they were supposed to put on a gown when they repositioned the resident and they forgot. PPE was to be donned in the hallway and doffed inside the room. The TNA stated they should have put on a gown because COVID-19 was highly contagious and there was no guarantee the resident did not have COVID-19. During an interview on 7/2/21 at 2:12 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist stated staff knew if a resident was on isolation precautions by the cart in front of the room, documentation in the electronic record, on the certified nurse aide (CNA) care sheet and the assignment sheet. They also received this information from the LPNs during report. CNAs were expected to wear goggles, a gown, gloves, and change their surgical mask when caring for residents on isolation precautions. During an interview on 7/2/21 at 3:39 PM, the Director of Nursing (DON) stated when entering isolation rooms for contact/droplet precautions, staff were expected to wear gowns, gloves, and eye protection. 3) Resident #20 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/16/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and received more than half of their nutritional needs from a tube feeding. The 1/14/21 comprehensive care plan (CCP) documented the resident had a feeding tube. On 7/1/21 at 9:19 AM, licensed practical nurse (LPN) #11 was observed providing the resident's medications, tube feeding, and water flushes and was not wearing gloves. During an interview on 7/1/21 at 9:19 AM, LPN #11 stated they did not have to wear gloves when administering tube feedings. Gloves were used to protect staff from body fluids. During an interview on 7/2/21 at 2:12 PM, the Assistant Director of Nursing (ADON)/Infection Preventionist stated nurses should wear gloves whenever there was a potential to come in contact with bodily fluids. The ADON expected staff to wear gloves during a tube feeding administration as it was possible the nurse could come in contact with bodily fluids. During an interview on 7/2/21 at 2:54 PM, registered nurse (RN) Manager #2 stated they expected nurses to wear gloves when accessing G-tubes for protection against bodily fluids. During an interview on 7/2/21 at 3:39 PM, the Director of Nursing (DON) stated they expected staff to wear gloves when accessing resident's G-tubes to protect against bodily fluids, as well as eye protection to protect against backsplash. 10NYCRR 415.19(a)(1-3)

Based on observation, record review, and interview during the abbreviated surveys (NY 600 and NY 270), the facility did not ensure residents received treatment and services to prevent and/or heal pressure ulcers for 2 of 4 residents (Residents #1 and 3) reviewed for pressure ulcers. Specifically, Resident #1's pressure ulcer was not assessed and treated appropriately resulting in the ulcer deteriorating. Resident #3 developed a pressure ulcer and a treatment order was not obtained for 4 days. This resulted in actual harm to Resident #1 and no actual harm with potential for more than minimal harm for Resident #3. Findings include: The Skin Care Rounds Policy effective ,[DATE], documented the facility will ensure weekly skin care rounds are conducted on all residents with skin concerns including pressure injuries, skin tears, surgical wounds, moisture associated [MEDICAL CONDITION], and deep tissue injuries. The skin team will round on all identified residents weekly. The wound team was to document orders, progress notes, and update the care plans. Information from the wound team was to be provided to the medical provider. The (undated) Pressure Ulcers/Skin Breakdown Clinical Protocol documented the physician would order wound treatments including pressure reducing devices, wound cleansing and debridement (removal of dead tissue) approaches, dressings, and application of topical agents. The physician will help identify medical interventions related to wound management. During the resident visits, the physician will evaluate and document the progress of wound healing, especially for those with complicated, extensive, or poorly-healing wounds. 1) Resident #1 had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was moderately impaired, the resident was dependent on staff for most activities of daily living (ADLs), was at risk for pressure ulcer development, and did not have a current pressure ulcer. The [DATE] comprehensive care plan (CCP) documented the resident was at risk for skin breakdown. Interventions included a gel foam overlay, good sources of Vitamin C in the diet, barrier cream with each instance of incontinence, and 2 Cal (supplement) with medication passes. The [DATE] Pressure Ulcer/Skin Assessment sheet completed by the Director of Nursing (DON) documented the resident had a Stage I (reddened, intact skin) pressure ulcer to the buttocks. The area was large and Zinc (barrier cream) was to be applied every shift. The [DATE] licensed practical nurse's (LPN) progress note for the 7 AM to 3 PM shift, documented the pressure ulcer on the resident's buttocks was now open. The area was cleansed and the treatment was applied. The [DATE] Treatment Administration Record (TAR) documented Zinc was applied to the resident's pressure ulcer on all 3 shifts. The [DATE] at 5:40 AM, LPN #4's progress note documented the resident had a large, moist, open area on the buttocks and Zinc was applied. The [DATE] TAR documented Zinc was applied to the resident's pressure ulcer on all 3 shifts. During a telephone interview with the DON on [DATE] at 2:42 PM, she stated on [DATE], she documented on the Pressure Ulcer/Skin Assessment sheet that the resident had a large, red area on the buttock that was not open and Zinc was applied. When the wound opened up that same day, she did not know if the resident was reassessed. She stated Zinc would not have been an appropriate treatment after the resident's wound opened. The [DATE] physician #14's progress note documented the resident did not have any acute problems. The note did not document the resident had a pressure ulcer. The [DATE] Pressure Ulcer/Skin Assessment sheet completed by the DON documented the resident had a large Stage I pressure ulcer on the buttocks and the treatment was Zinc. The [DATE] telephone order from physician #11, written by the DON, documented to cleanse the resident's wound and apply a Duoderm dressing and change every 3 days. During a telephone interview with the DON on [DATE] at 2:42 PM, she stated on [DATE] and [DATE] when she documented on the resident's wound, she did not see the wound or assess the resident. She wrote her notes based on what the LPN told her. She stated registered nurse (RN) #12 was the Manager of the resident's unit and was following his/her wound care. The [DATE] Pressure Ulcer/Skin Assessment Sheet completed by the DON documented the resident's pressure ulcer was unstageable (depth unknown), measured 4 centimeters (cm) x 2 cm, was worse, and there was necrotic tissue. The resident complained of pain at the ulcer site, the skin around the ulcer was red, and the treatment was Duoderm. There was no documented evidence the physician was notified when the resident's pressure ulcer was necrotic and worsened. During a telephone interview with the DON on [DATE] at 2:42 PM, she stated necrotic wounds typically had a [MEDICATION NAME] agent ordered and should be evaluated by the physician. When the wound was necrotic, the Nurse Manager should have called the physician for orders. Duoderm was ordered when the resident's wound was necrotic and Duoderm was usually used for Stage I pressure ulcers, did not work well with draining wounds, and did not debride necrotic wounds. The [DATE] at 7 AM, LPN #4's progress note documented the resident's pressure ulcer was much larger, black, and tender to touch. The area was cleansed and left open to air. There was no documentation an order was obtained from the physician to leave the resident's ulcer open to air or that the physician was notified of the change in the resident's wound. The ,[DATE] TAR documented the next time the Duoderm dressing was applied to the resident's wound was on [DATE] (48 hours after it was left open to air on [DATE]). During a telephone interview with LPN #4 on [DATE] at 9:01 AM, she stated the resident's pressure ulcer was very large, very deep, and necrotic. On [DATE], she left the resident's dressing off because it looked extremely moist and the dressings she had available to her were too small to cover the wound. She stated she notified the RN and did not call the physician as that would be the RN's responsibility. She stated the next morning, she also told the oncoming LPN and RN that she was not able to provide the prescribed treatment. She did not know that a treatment order was not obtained or that no one documented they completed his/her treatment until [DATE]. During a telephone interview with the DON on [DATE] at 2:42 PM she stated on [DATE] when LPN #4 left the resident's wound open to air, LPN #4 should have called the physician for an order. She stated it was not acceptable for the wound to be left without a dressing for 2 days. The [DATE] at 10:30 AM, LPN #5's progress note documented the resident had a very large unstageable ulcer on his/her coccyx. The wound had 80% eschar (dead tissue), 20% yellow slough (dead tissue), and a moderate amount of serosanguinous (blood and serum) drainage. The [DATE] Pressure Ulcer/Skin Assessment Sheet completed by the DON documented the resident's ulcer was worse and the resident needed a treatment change. The DON documented Duoderm was applied and an order for [REDACTED].>The [DATE] at 3 PM, LPN's progress note documented the resident's coccyx pressure ulcer had an extremely foul odor. There was a large amount of green, yellow drainage and he complained of pain. The area surrounding the ulcer was discolored, swollen, warm to touch, and the Supervisor was made aware. There was no documentation of follow-up done by the Supervisor or documentation the physician was notified of changes with the resident's wound. During a telephone interview with LPN #4 on [DATE] at 9:01 AM, she stated when the resident's wound began to look infected and had a horrible smell, she reported it verbally to a RN but did not recall who she reported it to. During a telephone interview with LPN #5 on [DATE] at 9:14 AM, she stated on [DATE], she notified one of the RNs, the resident's wound was worse and had a foul odor but did not recall who she notified or if the RN assessed the resident. During a telephone interview with the DON on [DATE] at 2:42 PM, she stated on [DATE], that could have been a sign of an infection so the RN should have called the physician. She was not notified of the foul green drainage. The [DATE] Pressure Ulcer/Skin Assessment sheet completed by the DON, documented the resident had a 4 cm x 2 cm unstageable pressure ulcer with a small amount of brown drainage. There was a foul odor, necrotic tissue, and the ulcer appeared worse. The skin around the ulcer was red with slough. The plan was to continue Duoderm dressings. On [DATE] at 11 AM, LPN #5's progress note documented the resident complained of pain and the pressure ulcer was getting worse every day. The ulcer measured 6 cm x 7.5 cm with black eschar and yellow slough. There was some new purple discoloration at the peri-wound and foul odor. During a telephone interview with the DON on [DATE] at 2:42 PM, she stated on [DATE], when the LPN measured the wound, it was larger and she would have expected the LPN to notify a RN for an assessment. The [DATE] physician's progress note documented the resident had a Stage III pressure ulcer (full thickness loss of skin involving the tissue underneath the skin). The recommendations were for a new bed, Prostat (high protein supplement), and a wound clinic consult. The [DATE] wound clinic consult documented the resident's wound had an odor and when debrided, had moist necrotic muscle present. The resident was not on antibiotics and came without paperwork from the facility so obtaining a complete history was difficult. The wound was located midline coccyx and measured 8.8 cm x 10.8 cm x 0.8 cm. There was a large amount of serosanguinous drainage and large amount of necrotic tissue within the wound bed. Post debridement wound was a Stage IV. The wound was to be washed with soap and water, apply Dakin's (wound treatment) solution twice daily and cover with ABD pad (abdominal pad, used for large wounds). [MEDICATION NAME] (antibiotic) was ordered for 14 days. The [DATE] physician's orders [REDACTED]. The [DATE] at 7 AM, LPN #4's progress note documented the resident was uncomfortable during treatment and moaned even when turned. Tylenol was given at 12 AM and 6 AM with a little relief noted by resident. The [DATE] at 6:30 AM, LPN #4 note documented the resident declined to be turned and positioned x 3 because it hurt too much. The resident received Tylenol at 12 AM and 6 AM with some effect. The [DATE] (untimed) DON's progress note documented a Foley (drains urine) catheter was placed for wound healing. The [DATE] wound clinic consult documented the resident's wound culture was positive for E. Coli, Proteus, and [MEDICATION NAME] (bacteria) that were sensitive to [MEDICATION NAME]. The Stage IV wound was debrided and measured 10.2 cm x 11.3 cm x 2.6 cm. There was undermining at 1 o'clock and ending at 9 o'clock. There was a large amount of purulent (pus) drainage, a large amount of necrotic tissue, and the periwound was tender. The [DATE] LPN's progress note documented the resident complained of pain at a level of 10 out of 10 at the pressure ulcer site. He received medications to promote comfort and reported some relief. The [DATE] nursing progress note documented the resident complained of pain and had difficulty taking medications. His/her pressure ulcer dressing was changed and was sent to the hospital for a bone scan. The wound continued to worsen and was 90% black eschar that was like tar and the bottom left portion of the wound was beefy red and tunneling was present. The peri-wound was purple and looked like a DTI (deep tissue injury, injury to underlying tissue below the skin's surface). The [DATE] nursing progress note documented the hospital called and the resident was admitted with septic shock. On [DATE] at 10:25 AM, the RN Clinical Coordinator at the wound clinic stated in a telephone interview: - On [DATE], the resident arrived to the clinic with a Duoderm covering the pressure ulcer. She stated Duoderm was primarily a preventative dressing and was not an appropriate treatment for [REDACTED]. - The wound measured 8.8 cm x 10.8 cm x 0.8 cm, it was infected, and [MEDICATION NAME] was ordered that day. - On [DATE], the resident was seen again and the wound measured 10.2 cm x 11.3 cm x 2.6 cm with undermining of 4.5 cm. The wound care physician believed the resident had protein malnutrition, he recommended a high protein diet, and a bone scan was ordered because of the infection and bone could be visualized. - On [DATE], the resident was seen again and was doing poorly. The resident was hypotensive (low blood pressure), his/her pulse was thready, and the resident appeared septic. The wound worsened, was necrotic and had a horrible odor. The wound physician sent the resident to the hospital where he/she later died . On [DATE] at 11:10 AM, RN Manager #12 could not be reached by phone and a return phone call was not received. On [DATE] at 12:53 PM, the attending physician (physician #11) stated in a telephone interview, the resident was seen after admission by physician #14 because he was out of the country at that time. He stated he expected to be notified of new or worsening pressure ulcers within 24 hours so he could treat residents. He expected the nurses to document weekly assessments which included measurements and staging so they could monitor wound progression. When the resident's wound became necrotic on [DATE], he did not recall being notified. When the resident's wound was left open to air, he should have been notified. He stated leaving a resident for 2 days without a dressing was not acceptable. He expected to be notified of foul green drainage from a pressure ulcer as that could indicate infection and he would possibly do a wound culture and refer the resident to the wound clinic. He was not aware the resident went 5 days with foul green drainage from [DATE] until [DATE]. 2) Resident #3 had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance with bed mobility and transfers, was incontinent of urine, and had no pressure ulcers. The [DATE] registered nurse's (RN) admission assessment documented the resident had a bruise on the coccyx (tailbone). The undated comprehensive care plan (CCP) documented the resident was at risk for skin breakdown. Interventions included good sources of Vitamin C and iron in diet, post- incontinence care, and moisturized skin. The CCP did not document the resident had a bruised coccyx. The [DATE] at 10:18 PM licensed practical nurse (LPN) #7's progress note documented the resident had a pressure ulcer starting on her buttocks, it was red and irritated, and she complained of pain. There was no documented evidence a treatment order was obtained for the pressure ulcer. The [DATE] physician's orders [REDACTED]. The ,[DATE] Treatment Administration Record (TAR) documented the Greer's Goo treatment was initiated on [DATE] (5 days after the pressure ulcer was identified). The [DATE] at 10:29 PM registered nurse (RN) #6's note documented she was alerted at 3:50 PM, of a dark purple area approximately 2 centimeters (cm) in length and with skin break down on the resident's bottom. The [DATE] at 7:01 PM, RN's progress note documented the resident had 2 pressure ulcers. The left buttock measured 2 cm x 3 cm x 0.2 cm and was a Stage III. The area on the coccyx measured 2 cm x 3 cm x 0.2 cm, was a Stage III and had 100% slough (dead tissue). The [DATE] physician's orders [REDACTED]. The [DATE] at 5:36 AM, DON's progress note documented a Foley (drains urine) catheter was inserted for wound healing. The ,[DATE] Treatment Administration Record (TAR) did not document the treatment of [REDACTED]. The [DATE] nursing note left buttock Stage III was now full thickness of skin and subcutaneous tissue layer with yellow slough. MD called and changed treatment to Santyl. The coccyx pressure ulcer was a Stage II and showing improvement with hydrogel. On [DATE] at 8:35 AM, the resident's pressure dressing change was observed with LPN Manager #9. The resident's dressing was removed from her coccyx. The coccyx wound was pink and measured 2 cm x 1 cm. Hydrogel was applied to the wound and covered with dressing. The left buttock dressing was removed. A 4 cm x 2 cm square shaped unstageable wound was observed covered in yellow slough. The peri-wound was pink. Santyl was applied and it was covered with a dressing. On [DATE] at 11:12 AM, LPN #7 stated in an interview, she did not recall if the RN assessed the resident's wound on [DATE] and would be too busy to have noticed. She stated when she first saw the wound, it was red and irritated, probably not open and she did not apply a treatment because she wanted the RN to see it. On [DATE] at 11:22 AM, RN #6 stated in a telephone interview, when she assessed the resident on [DATE], she had a DTI that was 2 cm, it was dark purple and not open. She stated her role was to assess the wound, document the assessment, and call the physician for orders. On [DATE] at 2:46 PM, LPN #8 Manager stated in a telephone interview it was not timely when the LPN found the resident's pressure ulcer [DATE] and a treatment was not ordered for 4 days. On [DATE] at 2:42 PM, the Director of Nursing (DON) stated in a telephone interview she was not aware on [DATE] the resident had and open area, she expected an RN assessment to be done right away, and the assessment and obtaining treatment orders were not done timely. 10NYCRR 415.12(c)(1)

Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY 010), the facility did not ensure 2 of 5 residents (Residents #50 and 127) reviewed for pressure ulcers received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #50 was admitted with a Stage II pressure injury (partial loss of skin), there was no evidence the pressure ulcer was addressed following admission to promote healing. The pressure ulcer worsened and interventions and treatment measures were not implemented timely. Resident #127 developed Stage II pressure ulcers on both heels, the root cause was not eliminated timely to promote healing and the pressure ulcers worsened. This resulted in actual harm to Resident #50 and #127 that is not immediate jeopardy. Findings include: 1) Resident #50 was admitted on [DATE] and re-admitted to the facility on [DATE] after a hospitalization [MEDICAL CONDITION] (widespread infection) from 12/22-12/29/2017. Additional [DIAGNOSES REDACTED]. The 11/29/17 Minimum Data Set (MDS) assessment documented the resident was alert and oriented, required total assist of two with bed mobility, transfers and toileting; required extensive assistance with personal hygiene and was at risk for developing pressure ulcers. Interventions included pressure reducing devices for both chair and bed and nutrition or hydration. A turning and positioning program was not documented on the MDS. The 12/06/17 certified nurse aide (CNA) care instructions documented the resident was a total assist for bathing, dressing and grooming, had a Foley catheter (urinary drainage tube), wore incontinence products and required assistance of one to turn in bed /chair and assistance of two to sit up or lie down. The resident had a skin problem on his buttocks and groin. There was no documentation what the skin problem was. There was no documented pressure ulcer/skin assessment sheet. The 12/04/17 pressure ulcer risk assessment sheet documented the resident was at high risk for pressure ulcers related to positioning and constant moisture. The 12/06/17 comprehensive care plan (CCP) documented the resident was at risk for further skin breakdown due to decreased mobility and incontinence with interventions to include a pressure reducing mattress and encouragement to change position, relieving pressure on his back. The 12/29/17 registered nurse (RN) #1 re-admission progress note documented the resident had a large red area on the buttocks measuring 15.0 centimeters (cm) x 17.0 cm and three small open areas. No further description of the areas were documented. The 12/29/17 clinical admission record completed by RN #1 documented the resident had a Stage II pressure ulcer on his coccyx measuring 3.0 cm x 2.0 cm. There was no further documentation in the record on the 12/29/17 areas noted in the RN documentation. On 01/08/18 at 09:27 AM the resident stated to the surveyor that his buttocks was sore and he had an area that the staff put cream on. On 01/10/18 at 11:15 AM during a wound observation by a surveyor with the Director of Nursing (DON), she stated she was not aware of any breakdown of the resident's skin. She looked at the area on the resident's coccyx and agreed it was an unstageable ulcer with white, yellow slough (moist, dead tissue) tissue. The entire buttocks was excoriated (red, inflamed area). The DON stated she had not been notified the resident had any pressure ulcers and the current treatment was applying barrier cream. On 01/10/18 at 02:50 PM RN Unit Manager #3 stated that tracking was documented for any skin issues in each resident's chart. Only pressure ulcers were tracked and they were not currently tracking any wounds on the unit. On 1/10/18 at 3:14 PM during an observation of the resident's pressure ulcer with RN Unit Manager #3, the resident was incontinent of stool. She stated she had not seen the resident's buttocks since readmission from the hospital and was not able to recall when the resident was readmitted . The resident's buttocks had a large area of excoriation with scattered small open areas. The area of excoriation extended down the back of his right thigh. At the bottom of the excoriated area of the right thigh was a scabbed area. Directly over the coccyx was an open wound and the middle of the wound bed contained moist, white yellowish tissue. The RN stated that the resident had an unstageable pressure ulcer over a bony prominence as the resident had yellow slough tissue partially covering the wound bed. She used her fingers to measure the wound and stated the pressure ulcer measured 1.0-2.0 cm x 0.5 cm in size. The RN stated she had not been aware of this pressure ulcer. The resident had a history of [REDACTED]. The resident had a Foley catheter in place and often had stools 3-4 times a shift. The RN thought he was toileted 2-3 times per shift. She stated the resident got up in the morning and he would sometimes go back to bed. During an interview on 01/11/18 at 09:00 AM with CNA #4, she stated she was the resident's primary CNA and she would report skin changes to the medication nurse and follow up with the RN or the nursing supervisor. She would change the resident's brief at 11:00 AM, which he sometimes refused. He had not refused lately related to his skin. He did not use the toilet, he went back to bed and was changed there. She stated his bottom looked worse after a recent hospitalization and she did not recall any current open areas on his bottom. During an interview on 01/11/18 at 09:20 AM with CNA #5, she stated for changes in the skin of a resident she would fill out a pink notification sheet and give it to the charge nurse. The CNA showed surveyors where these forms were kept at the nursing station. During an interview on 01/11/18 at 09:10 AM with licensed practical nurse (LPN) #6 she stated she had been off for the prior four days. When she saw the resident's buttocks four days ago, it was red and not open. If the areas opened or a pressure ulcer worsened she would notify the RN. During an interview on 01/11/18 at 11:00 AM with RN Unit Manager #3, she stated re-admission after a hospitalization included a skin assessment. When shown the skin assessment completed upon readmission on 12/29/17 she stated she was not aware of the nurses note or readmission record. Changes should have been made to the care plan and they were not. She stated the process was for each resident with a pressure ulcer to be assessed by the LPN daily and the RN weekly. The LPN would notify the RN of any changes and the RN would assess the area, document and notify the physician to obtain a treatment order. During an interview on 01/11/18 at 11:55 AM, the DON stated after seeing the wound on 01/10/18, Peri guard ointment was applied and she did not change the care plans as she was waiting for Unit Manager #3 to obtain physician orders [REDACTED]. During a telephone interview with physician #7 on 01/11/18 at 12:15 PM, he stated that he had not seen the resident since he came back from the hospital and did not remember what the treatment he ordered was. He was notified yesterday of a new pressure ulcer on 01/10/18 and that if there was a new identified area he would want to be notified. 2) Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 01/04/17 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, she exhibited rejection of care 1-3 days during the assessment period and she required extensive assistance with bed mobility, transfers and was totally dependent for personal hygiene. The resident was at risk for pressure ulcers, did not have any unhealed pressure ulcers and interventions included pressure reducing device for bed, nutritional interventions and application of ointments/medications. A turning and repositioning program and pressure reducing device for a chair was not indicated on the MDS. The comprehensive care plan (CCP) dated 10/19/16 documented the resident was at risk for skin breakdown related to incontinence and immobility. The goal was the resident would not develop any skin breakdown and interventions included pressure reducing mattress, alternating air pressure mattress and post incontinence care. A CNA care sheet (care instructions) documented the care sheet was reviewed on 10/15/16, 01/04/17 and on 03/28/17. Under skin problems the sheet documented the resident did not require offloading of heels. Interventions added to the care instructions included to only wear gripper socks while treatment in place to heels and heels up device in bed. Both interventions did not contain a date indicating when they were initiated. A physician progress notes [REDACTED]. Nursing progress notes documented: - On 01/13/17, the resident continued to require one assist from staff with all activities of daily living (ADLs). - On 01/14/17, the resident had Stage II pressure ulcers on both heels. The right heel measured 1.2 centimeters (cm) x 1.5 cm and the ulcer had a large amount of bloody drainage and a dry dressing was applied to both heels. The assessment documented there were changes made to the resident's care plan. The progress note did not indicate what those changes were. The note also documented a communication slip was sent to dietary and physical therapy and Will need to update MD and family tomorrow. There was no documented evidence in the medical record the physical therapy evaluation was completed or that the physician was notified until 1/16/2017. Physician orders [REDACTED]. There was no documentation there were physician orders [REDACTED]. An undated document added to the resident's CCP documented the resident wore shoes without socks, she was to have pillows placed underneath her feet and to use a heels up cushion. On 1/16/2017 the document stated a treatment was in place to both heels and the resident was to wear gripper socks without shoes. The 01/27/17 weekly skin assessment documented the resident's right heel measured 2.0 cm x 2.5 cm, was a Stage II and there was a large amount of greenish drainage. The left heel measured 3.0 cm x 2.5 cm and contained a large amount of bloody drainage. Both pressure ulcers had worsened and changes were made to the care plan and the treatment was changed from a dry dressing to [MEDICATION NAME] (describe). The skin assessment did not contain a description of the wound bed. A nursing progress note dated 01/31/17 documented a call was placed to the resident's daughter and the nurse asked what happened to the resident's white pair of diabetic shoes as the black ones continued to rub on her feet and were not allowing the areas on the heels to heal. The daughter stated she would return the white shoes. A physician order [REDACTED]. A physical therapy progress note dated 02/03/2017 documented the resident was fitted for new diabetic shoes and it was recommended the resident not wear shoes and new shoes would be ordered and would be applied when the heels were improving. A nursing progress note dated 03/21/17 documented the resident's white shoes were taken for cleaning and she was left with a black pair in which after 2 days of wearing she developed blisters to both heels. There were treatments in place to both heels. The CCP was updated on 03/29/17 and documented the resident was at risk for further skin break down as she had pressure ulcers to both heels and a decreased intake. There were no new interventions documented from the previous CCP. The CCP documented the resident had a Stage IV (exposed bone or tendon) pressure ulcer on the right heel caused from diabetes and pressure. The area would continue to worsen as the resident wore shoes without socks and the family declined a surgical intervention. Interventions included to assess daily pressure and pain on heel. Heels were to be elevated on a cushion, a pillow underneath the feet and the resident would reposition and ambulate herself. A physician progress notes [REDACTED]. Nursing progress notes documented: - On 04/19/17, by a licensed practical nurse (LPN), the right and left heel had an increase in drainage, the right heel had a dark area in the center that seemed larger, and there was no change to the left heel pressure ulcer. - On 04/19/17, the resident had developed black eschar over the right heel, the area had enlarged in size, and the left heel had 10% slough (moist, dead tissue) in the center of the wound bed. The physician was updated and the treatment was changed to Santyl (an enzyme used to break down dead tissue) daily. - On 05/05/17, the resident's heels were observed with the physician who recommended a surgical consult. A physician progress notes [REDACTED]. He ordered [MEDICATION NAME] for a wound infection. Nursing progress notes documented: - On 05/07/17, the area on the right heel seemed larger and soft and area toward the back much deeper this shift. - On 05/11/17, there was yellow and greenish drainage from the left heel and 1st great toe. A surgical consultation dated 05/23/17 documented the reason for the consult was the resident developed blisters on both heels from her shoes. The consultation results documented the resident had a very large right heel ulcer with eschar (dry, dead tissue) and exposed bone with probable osteo[DIAGNOSES REDACTED] (infection of the bone). The resident required an orthopedic consult for the exposed bone. An orthopedic consult dated 05/30/17 documented the resident had a necrotic ulcer of the right heel with osteo[DIAGNOSES REDACTED] and recommended a consult for a [MEDICAL CONDITION]. A physician progress notes [REDACTED]. During an interview with CNA #11 on 1/11/2018 at 10:20 AM, she stated the resident had developed sores on both feet as her shoes were too tight and they were rubbing on her feet. The resident's shoes were not taken away as the resident was ambulatory and they were to ensure the resident's feet were kept as clean as possible. Eventually the shoes got taken away as the areas on her heels worsened. During an interview with a physical therapist on 01/11/18 at 10:50 AM, she stated when a resident developed a pressure ulcer on their heels physical therapy would do an evaluation to ensure they had proper fitting shoes. An evaluation would be communicated to them by a communication form in a folder located at the nursing station and the evaluation would be completed the same day as the evaluation was received. During an interview with RN Unit Manager #14 on 01/11/17 at 11:00 AM, she stated the resident developed the pressure ulcers on her feet when her family had removed her white diabetic shoes, left a pair of black ones to wear and they did not tell us. The resident's shoes were immediately removed when the areas were found and gave her grippy socks and the daughter was contacted to find out what happened to her white shoes. She stated preventative measures were diabetic socks and shoes to prevent any breakdown on her feet and that should be part of the resident's care plan and CNA care plan. The resident was sent for a surgical consult who recommended amputation as she had exposed bone and the family did not want aggressive treatment done. On 01/11/18 the surveyor requested a copy of any PT evaluation forms for the resident and was notified by Medical Records staff at 1:34 PM the resident did not have any. During a telephone interview with physician #12 on 01/11/18 at 03:30 PM, he stated the resident had pressure ulcers on both heels and a contributing factor was the poor circulation in her legs and advanced dementia. He could not recall how the pressure ulcers had developed and what they could have done to prevent the areas from occurring. The resident did have osteo[DIAGNOSES REDACTED] as a result of the pressure ulcers. He thought the nursing staff had done the best they could have regarding the resident. During an interview with RN #13 on 01/11/18 at 4:00 PM, she stated when she was notified of any pressure ulcers, she would assess it, call a physician, get a treatment, and would fill out a communication slip to notify dietary and PT. The communication slip would be placed in the folder on the unit. She had been notified Resident #127 had areas on her heels, she assessed them and determined the pressure ulcers on her heels were caused by her shoes and they ended up getting the resident new shoes. At one point during the resident's stay an LPN notified her the right heel pressure ulcer contained black areas. The physician was in the building at the time and she asked him if he had seen the resident's heels. She was told no the nurses were monitoring them. She had the physician look at the resident's heels and his reaction was Oh my God she needs a surgical consult. 10NYCRR 415.12(c)(1)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure 1 (Resident #2) of 2 residents reviewed for hydration concerns, was provided with sufficient fluid intake to maintain proper hydration and health. Specifically, Resident #2 required hospital treatment with antibiotics and IV fluids in July 2010 for urosepsis and dehydration, as the facility did not ensure her actual fluid intake and hydration status were assessed and monitored, with timely care plan evaluations and revisions. This resulted in Resident #2 experiencing actual harm that was not immediate jeopardy in July 2010. Additionally, after the resident was readmitted , the facility did not ensure Resident #2's interventions were revised when the resident consumed fluids below her assessed needs; and did not ensure a system was implemented to monitor the resident's actual fluid intake and evaluate, in a timely manner, the effectiveness of planned interventions. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: During survey, the "Poor Fluid Intake Protocol" (December 2005) was provided, as requested. When it was suspected or identified that a resident was not drinking adequate fluids, the policy documented measures to be implemented included: reviewing dietary assessments to determine residents' actual fluid needs; starting intake and output (I&O) monitoring; adding the problem to the certified nurse aide (CNA) care sheet and comprehensive care plan (CCP); notifying key staff; and notifying the physician. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. diff, intestinal infection). The resident's CCP, dated June 18, 2010, documented the resident had a problem with constipation due to decreased mobility. Interventions included to "maintain adequate intake of fluid and fiber." Additionally, the CCP documented the resident's intake and output would be monitored "every shift". The I&O Flowsheet documented the resident consumed 1000 cc (cubic centimeters) of fluid on June 19, 2010 and 840 cc on June 20, 2010. The resident's June 21, 2010 admission nutrition assessment, completed by the diet technician, documented the resident had a UTI, constipation, and leg [MEDICAL CONDITION]. Fluid needs were assessed at 35 cc per kg (kilogram), (2004 cc/day), due to the resident's UTI and antibiotic use. The resident's intake was identified as "poor"; and her fluid intake ranged from 1000-1499 cc per day. The resident's hydration status was not documented as a "problem" on this assessment. The resident's CCP, dated June 22, 2010, documented the resident was "at risk for altered hydration status due to multiple factors, including dementia and the need for assistance with intake. Interventions included: "monitor intake"; "monitor for signs and symptoms of dehydration"; "assist with fluid intake as needed"; and "supplements" (ice cream at dinner and 4 ounces of Ensure Plus twice a day). The I&O Flowsheet for June 21 to June 28, 2010 was incomplete as the resident's intake was documented on 6 of the 8 days. Of those 6 days, the resident consumed less than 1500 cc of fluid/day (minimum recommended intake), with her lowest recorded intake of 720 cc/day on June 22, 2010. The facility did not ensure the resident's care planned intake and output was monitored and evaluated. The registered dietitian (RD) co-signed the above resident's admission nutrition assessment on June 28, 2010 and did not revise the resident's plan of care. The June 28, 2010 admission Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition; was dependent on staff for all activities of daily living (ADL) except eating; fed herself after meal set-up; was frequently incontinent of bowel and bladder; had a UTI in the past 30 days, had diarrhea in the previous 14 days. A June 29, 2010 nursing note at 2 PM documented the resident briefly complained of nausea in the morning; ate no breakfast, and consumed 440 cc with no output on that shift. On June 30, 2010 at 2:55 PM, a nursing note documented the resident consumed 1/4 of her breakfast and lunch. The resident's certified nurse aide (CNA) Flowsheet for June 2010 documented the resident consumed 40% at meals, on average. The documentation did not specify whether this percentage specified the resident's food or fluid intake, or both. The RD's progress note, dated July 2, 2010, documented the physician ordered 4 ounces of Ensure Plus (liquid nutritional supplement) twice a day per family's request to provide additional protein and calories for the resident. There was no documented RD assessment of the resident's actual fluid intake and/or her hydration status at that time. Review of the resident's July 2, 2010 I&O Flowsheet revealed the resident was documented to consume 780 cc fluid that day. The July 3 through 5, 2010 I&O Flowsheets were incomplete, and the resident's total intake could not be determined. The facility did not ensure the resident's intake and output was consistently monitored, as specified in their "Poor Fluid Intake Protocol". On July 5, 2010 at 2 PM, a nursing note documented the resident complained of nausea at 7:30 AM; refused breakfast; and only ate a few bites at lunch. The resident's intake was 240 cc for that shift and her temperature was 98.2 degrees. The note specified the resident "does not respond to continuous encouragement to eat/drink more." On July 6, 2010 at 2:20 PM, nursing notes documented the resident's temperature was 99.8 degrees and then 98.9 degrees. The resident consumed 1/4 of her breakfast. The comprehensive care plan (CCP), updated on July 6, 2010, documented the resident was at risk for altered hydration status. Approaches included ice cream at dinner, monitoring labs, monitoring for signs/symptoms of dehydration, and providing Ensure Plus twice a day. The I&O Flowsheet documented the resident consumed 1320 cc fluid in July 6, 2010 and 1370 cc on July 7, 2010. A nursing note, dated July 7, 2010 at 2:15 PM, documented the resident's temperature was 97.9 degrees; and "transferred with 2 assist today without ambulating". At 3 PM, nursing notes documented the resident consumed 0% at breakfast and 1/4 of lunch. The note specified the resident had a very small emesis at 1:40 PM. At 6:30 PM, nursing documented the physician was in and made aware of the resident's weight loss, poor appetite, frequent complaints of nausea. The physician's progress note, dated July 7, 2010, documented the resident had a history of [REDACTED]. The physician noted the resident's UTI was improved and medication changes were made to address the resident's nausea. The physician did not document on the resident's hydration status. At 9:30 PM on July 7, 2010, a nursing note documented the resident's temperature was 100.2 degrees. The note specified the resident was "educated on the need to drink more. She stated 'I just can't.'" There was no documented evidence the interdisciplinary team, including clinical nutrition staff, re-assessed the resident's hydration status, in view of her inadequate fluid consumption. On July 8, 2010 at 10 AM, a nursing note documented the resident refused breakfast and only took "sips of fluids despite encouragement." The note specified the resident "has not been eating or drinking well" and "this morning", the resident's temperature was 101.5 degrees. "She is weak and hard to transfer from the recliner to the commode." The nursing note documented that at 10:20 AM, the physician was contacted and ordered the resident sent to the emergency room for evaluation. The hospital history and physical, dated July 8, 2010, documented the resident had a UTI, dehydration, and bilateral pleural effusion, with gross amounts of white and red blood cells (abnormal findings) in her urine, elevated white blood cells in her blood, and a moderate amount of stool in her colon. The resident was admitted and given intravenous (IV) fluids and antibiotics. The hospital discharge summary documented the resident was discharged back to the facility on [DATE], with recommended medications, including an antibiotic for 5 more days and a potassium supplement. On July 20, 2010, the diet technician completed the resident's re-admission nutrition assessment (co-signed by the RD on July 21, 2010), and specified the resident's meal plan used prior to her hospitalization , was resumed. The assessment specified the resident's intake was "poor"; and her fluid needs were assessed to be 30 cc/kg, or 1745 cc per day (lower than her June 2010 assessed fluid needs). The resident continued to have constipation, leg [MEDICAL CONDITION], and a UTI, similar to her June 2010 assessment. Review of the resident's I&O Flowsheet revealed the resident: - consumed 880 cc on July 23, 2010; - consumed 360 cc on July 24, 2010; - had incomplete data documented from July 25 through July 31, 2010. On July 30, 2010, the physician's dictated progress note documented the resident was recently treated for [REDACTED]. The physician did not address the resident's recent re-admission (July 19, 2010) after requiring an 11 day hospitalization for urosepsis, dehydration, and pleural effusion. On August 4, 2010, the CCP was updated and continued the resident's hydration plan of care, with no revisions after she returned from the hospital. Review of the resident's I&O Flowsheet revealed the resident complete data was recorded on 8 of the 12 days from August 1, 2010 through August 12, 2010. The facility did not ensure the resident's intake and output was consistently monitored, as care planned. On each of the above 8 days, the resident consumed less than 1500 cc/day; with the lowest documented intake at 625 cc/day on August 8, 2010. The August 12, 2010 diet technician's progress note documented the resident's meal intake "improved" to 25-50%; had abnormal lab values, including a potassium level of 5.0 (3.5 - 5.0 mEq/l). The diet technician did not documented the resident's actual fluid intake and did not evaluate the resident's hydration status. The diet technician added a 2 PM house nourishment, as the resident experienced a 9 pound weight loss in 30 days; this was intervention was added to the resident's CCP on that date. Review of the resident's I&O Flowsheet revealed it was discontinued on August 19, 2010. The September 18, 2010 RD's quarterly progress note documented the resident's "appetite/intake varies" from 25% to 100%; it was unclear whether the resident's documented intake was her food or fluid intake. The RD made no changes to the resident's plan of care at that time. The December 4, 2010 RD's quarterly progress note documented the resident's "appetite/intake varies" from fair to poor. It was unclear whether the resident's intake was in regard to her food or fluid, or both. The plan was to continue with meal plan without changes. On January 12, 2011, the diet technician documented staff offered and the resident accepted ice cream at breakfast. The resident's plan of care was changed. The February 12, 2011 RD's assessment documented the resident's intake was 50-75% at meals. The RD noted the resident's assessed needs could be met with the current meal plan. The CCP, last updated February 18, 2011, documented the resident remained at risk for altered hydration and was to be monitored for signs and symptoms of dehydration. The undated CNA care sheet, currently in use, did not document care instructions to monitor the resident's intake; and did not document the need to "assist with fluid intake as needed", as specified on the CCP. The March 22, 2011 RN's note documented the resident refused to drink, the physician was notified, and was offered jello and broth for supper. There was no documented evidence the resident's actual intake, her hydration status, and her plan of care, were re-assessed by clinical nutrition staff. The April 12, 2011 RD's assessment documented meal intakes were 50-75%. The RD notes the resident's needs could be met with current meal plan. On April 12, 2011 at 12:53 PM, the surveyor observed the resident sitting in the unit dining room. Staff were assisting residents out of the room who had finished their meals. Resident #2's meal tray remained on the table in front of her. The resident received hot tea and juice and was observed not to drink them. The April 12, 2011 CNA Flowsheet documented the resident consumed 50% of the lunch meal. The Flowsheet did not specifically document fluids consumed. On April 13, 2011 at 7:30 AM, the surveyor observed the resident lying in bed feeding herself. The resident was provided with juice, tea, and milk, as her beverages. At that time, the resident had not consumed any of these beverages. The CNA Flowsheet, dated April 13, 2011, documented the resident consumed 25% of the meal; the Flowsheet did not specify the amount of fluids the resident consumed. On April 13, 2011 at 11 AM, the surveyor interviewed the diet technician who stated she set-up the resident's initial fluid plan. She stated in addition to fluids served at meals, all the residents received fluids with medications, and said there was a twice daily hydration cart. The diet technician stated activities staff provided the hydration cart and did not document these fluids given to residents. She stated CNAs used daily worksheets where they recorded residents' actual fluid intake. She said she reviewed those worksheets, and then they were shredded. She stated she thought the intake documented on the CNA Flowsheets were a percentage of foods and fluids consumed. She said the surveyor would have to "ask nursing to be certain." On April 13, 2011 at 3:10 PM, the surveyor interviewed the RD who stated extra ice cream was provided to the resident in June 2010 for hydration. The RD stated she did not know if the consumption records in the CNA Flowsheets included solids, liquids, or both. She said she did not remember if the resident was on I&O monitoring in the facility. She was unable to state how she monitored the resident's actual fluid intake, and was unable to provide the resident's actual fluid intake to the surveyor. The surveyor asked the RD and diet technician (who was present during this interview) how they assessed the effectiveness of their interventions for the resident. The diet technician stated "you can put drinks there, but can't pour them down their throats." On April 13, 2011 at 4:40 PM, the RD returned to the surveyor and stated hydration interventions put in place for the resident included the extra ice cream and Ensure Plus. She stated the resident had been on I&O and did not drink well. She stated no other hydration interventions had been tried. She said if the surveyor reviewed the resident's medical record, she thought there would be some nursing notes that the resident was encouraged to drink. In summary, Resident #2 experienced harm in July 2010 with urosepsis and dehydration requiring hospital treatment with antibiotics and IV fluids, as the facility: - did not ensure the interdisciplinary team, including clinical nutrition staff, assessed the resident's actual fluid intake, her hydration status, and the effectiveness of her plan of care before she was hospitalized , in view of her meal refusals and poor consumption, her frequent complaints of nausea, and her history of UTIs, intestinal infection with diarrhea, and constipation. After the resident's hospitalization , the facility: - did not ensure the resident's plan of care and actual fluid intake was re-assessed by the interdisciplinary team, including clinical nutrition staff, when the resident's fluid intake was less than her assessed needs; - did not ensure interventions were revised when the resident consumed fluids below her assessed needs to assist the resident to improve her fluid intake; - did not ensure a system was implemented to monitor the residents' actual fluid intake and evaluate the effectiveness of planned interventions in a timely manner. 10 NYCRR 415.12 (j)