Every finding on record at Regal Heights Rehabilitation and Health Care Cente

Based on observation, record review, and interview, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. This was evident during completion of the facility Kitchen Task. Specifically, expired food items were observed in the refrigerator, employees failed to practice hand washing, kitchen equipment were observed to be dirty, the dishwasher was found to be operating without appropriate oversight, and food items were found inconsistent with safe temperature ranges. The findings include: The facility policy titled, Expiration and Disposal of Kitchen-Prepared Food Items, last reviewed 02/2026, documented that refrigerated foods must be maintained at or below 41 F and frozen foods must be maintained at or below 0 F. Additionally, dietary staff must conduct daily checks of all prepared food items. Items approaching their discard date must be clearly identified. All expired items must be removed immediately. Monitoring must be documented per department protocol. All prepared food items exceeding 3 calendar days must be discarded. Day 1 is the calendar day the item is prepared, and Day 3 is the discard date. The facility policy titled, Cleaning Fans, last revised 02/2026, documented that fans in the kitchen should be cleaned weekly and as needed. The facility policy titled, Dishwashing Procedures-Low Temp Dishmachine, effective date 02/2026, documented the dishwashing procedure including allowing the machine to run until wash temperature is 120 to 140 F and that the final rinse is completed with the low temperature chemical sanitizer. The procedure failed to address the calibration of the chemical sanitizer. The facility policy titled, Food Temperature Guidelines, last revised 02/2026, documented all meals are prepared and served within the appropriate temperature guidelines to ensure food safety. All meat will be cooked to 165 F. Hot meals are held on the steam tables at temperatures of at least 145 F. All cold items are maintained and stored at temperatures of 41 F or below. On 2/9/26 at 10:00 AM, an initial tour was conducted in the kitchen with the Dietitian and the Food Service Director. Among the dated foods in the refrigerator, ham was dated 02/02/2026 and turkey was dated 02/06/2026. Kitchen Aid #8 was observed holding the garbage can lid to throw out garbage and then proceeded to throw away garbage before returning to the refrigerator without performing hand washing. Two standing fans observed filled with dust. One walk-in freezer noted with fan vents with black mold on them. On 2/10/2026 at 2:37 PM during an observation in the kitchen, the low temperature dishwasher was noted to be utilizing sanitizer. There was no documented evidence of calibration testing of the sanitizer. On 2/11/2026 at12:26 PM, during tray line observation with Kitchen Aid #7, temperatures were noted: regular baked Chicken was 134 F, a tuna sandwich was 57 F, and apple juice was 44 F. On 2/10/2026 at 2:57 PM, the Food Service Director was interviewed and stated that the dishwashing machine temperature does not work very well. The Food Service Director was unable to detail the procedure of calibrating the sanitizer for the dishwasher. Furthermore, the Food Service Director stated that the facility would obtain the right testing supplies by the end of the week. On 2/11/2026 at 2:35 PM, Kitchen Aid #8 was interviewed and explained that they forgot to perform hand washing after using the garbage due to being very nervous. On 2/13/2026 at 9:59 AM, Kitchen Aid #7 was interviewed and stated that the hot food is supposed to be between 145 and 150 , and the cold food was supposed to be iced before serving starts. Kitchen Aid # 7 further stated because they were nervous, they left the cold items out without ice. 10 NYCRR 415.14(h)

Based on observations and interviews, the facility did not ensure kitchen equipment was maintained in a safe working condition. This was observed on one steamtable during kitchen review. Specifically, the steamtable was observed with rusty brown stains. The findings are: The facility policy titled, Cleaning Steamtables, last reviewed 01/2026, documented that steam tables are to be cleaned daily and as needed. On 2/10/2026 at 3:15 PM, during a tour in the kitchen, a steamtable was observed with rusty brown stains coming up from the base of the steamtable. The hot water used for the steamtable covered the stained sections and looked discolored. On 2/10/2026 at 3:26 PM, the Food Service Director was interviewed and stated that the facility is aware of the steam table's condition and have had conversations about it. The Food Service Director further stated that the steamtable needs to be changed. 10 NYCRR 415.29

Based on record review and interviews, the facility did not ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The was evident during the review of Registered Nurse #8's employee file. Specifically, the facility failed to maintain proper oversight of the hiring process. Facility administration hired Registered Nurse #8 despite receiving an incomplete employment application and neglecting to complete pre-employment screenings and background checks. The findings are: The facility's policy and procedure titled, Abuse Prohibition, last reviewed 01/2023, documented all prospective employees will be screened prior to employment to rule out any history of abuse, neglect, or mistreatment of residents. Screening will include criminal background check as indicated, checking all pertinent references, validating credentials and verifying licenses as indicated, checking certified nursing assistant registry, and checking appropriate databases for fraud and/or abuse as indicated. The responsibilities listed in the facility's job description for Facility Administrator include, but are not limited to, to assure that appropriate identification documents are presented prior to the employment of personnel and that appropriate documentation is filed in the employee's personnel record in accordance with current regulations mandating such documentation, and to recruit and select competent department directors, supervisors, consultants and other auxiliary personnel. Registered Nurse #8's employee file revealed that the Employment Application submitted on 05/04/2023 by Registered Nurse #8 was incomplete. Specifically, the answer for the question of if they have been convicted of a crime was left blank. The facility failed to ensure all fields in the application were completed. In addition, there was no evidence of record that Registered Nurse #8's previous employers were contacted, references were checked, and professional license was verified to be free of any enforcement actions. The facility failed to provide evidence conducting exclusion checks to identify if the individual was barred from working in federally funded health care programs due to fraud, abuse or other violations. Registered Nurse #8 was hired for the Interim Director of Nursing position by the facility. On 02/17/2026 at 10:40AM An interview was conducted with Administrator who stated they oversee the hiring process with the assistance of Human Resources Director. As per the Administrator, the Human Resources Director reviews the initial application paperwork for completeness and conducts background checks. All prospective staff, including licensed nurses, are subject to license and credential verification, as well as criminal background check for any enforcement on their license through the Office of the Professions; unlicensed staff are subject to criminal history record check. All staff will have pertinent references checked. Additionally, all applicants are checked for history of abuse, neglect, misappropriation, fraud, etc. through government databases (i.e. System for Award Management, Office of the Medicaid Inspector General, Office of Inspector General). The administrator confirmed screening procedures are required to determine if applicants are qualified and do not pose a risk to residents. The administrator stated Registered Nurse #8's application should have been checked to ensure the criminal history question was answered and that thorough backgrounds checks should have been conducted prior to hiring them. The Administrator stated that they don't know what the circumstances were at the time and could not provide any details of the screening procedures conducted for Registered Nurse #8. 10NYCRR 415.14(f)(3)(4)

Based on record review and interviews, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not ensure a complete criminal background check was conducted for Registered Nurse #8. The facility failed to provide documented evidence that it verified Registered Nurse #8's professional license to be free of disciplinary actions, checked previous employers and three (3) references, or completed comprehensive background checks to uncover their criminal history prior to employment. Findings are: The facility's policy and procedure titled, Abuse Prohibition, last reviewed 01/2023 documented all prospective employees would be screened prior to employment to rule out any history of abuse, neglect, or mistreatment of residents. Screening will include criminal background check as indicated, checking all pertinent references, validating credentials and verifying licenses as indicated, checking certified nursing assistant registry, and checking appropriate databases for fraud and/or abuse as indicated. Registered Nurse #8's file was reviewed onsite. The Employment Application submitted 05/04/2023 by Registered Nurse #8 revealed the answer to the question addressing if they had been convicted of a crime had been left blank. The facility failed to ensure that the employment application was fully completed prior to hire. In addition, the facility failed to provide evidence of record that Registered Nurse #8's previous employers were contacted, and references were checked for any history of abuse, neglect, exploitation, and misappropriation of resident property. There was no evidence that Registered Nurse #8's professional license was verified to be free of any enforcement actions. There was no indication that exclusion checks were carried out to identify if the individual was barred from working in a federally funded health care program due to fraud, abuse or other violations. The facility hired Registered Nurse #8 for the position Interim Director of Nursing. On 02/12/2026 at 12:52 PM, an interview was conducted with the Human Resources Director over the phone, and they stated that they are responsible for coordinating and facilitating all activities in the staff recruitment process. They confirmed their role includes ensuring that applicants submit required information in the application and necessary documents for the job position. The Human Resource Director will review the submitted application for completeness, ensuring all required information is submitted including applicant signature. They will then verify applicants' professional license to ensure the license is active and clear of any enforcement. They also check databases, as appropriate to the respective roles, to identify individuals with any history of abuse, misappropriation, fraud, etc. that may need to be further investigated. The Human Resource Director stated they were not working at the time Registered Nurse #8 was hired, and they do not know why the previous Human Resource Director processed the application without the criminal history information completed and if required background checks were conducted at that time. On 02/17/2026 at 10:40AM An interview was conducted with Administrator who stated they oversee the hiring process with the assistance of Human Resources Director. As per the Administrator, the Human Resources Director reviews the initial application paperwork for completeness and conducts background checks. All prospective staff, including licensed nurses, are subject to license and credential verification, as well as criminal background check for any enforcement on their license through the Office of the Professions; unlicensed staff are subject to criminal history record check. All staff will have pertinent references checked. Additionally, all applicants are checked for history of abuse, neglect, misappropriation, fraud, etc. through government databases (i.e. System for Award Management, Office of the Medicaid Inspector General, Office of Inspector General). The administrator confirmed screening procedures are required to determine if applicants are qualified and do not pose a risk to residents. The administrator stated Registered Nurse #8's application should have been checked to ensure the criminal history question was answered and that thorough backgrounds checks should have been conducted prior to hiring them. The Administrator stated that they don't know what the circumstances were at the time and could not provide any details of the screening procedures conducted for Registered Nurse #8. 10 NYCRR 415.4(b)(1)(ii)

Based on observation, record review and interview, the facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice. Specifically, physician's orders related to post-dialysis treatment to remove dressing on resident's permcath (a catheter inserted into a vein to use for dialysis treatments) 24 hours post-dialysis were not implemented. This was evident in one (1) resident (Resident #18) reviewed for dialysis out of a total of 38 sampled residents. The findings are:The facility policy for, Hemodialysis Access Care, dated 07/2025, documented that, hemodialysis devices may only be accessed by medical personnel who have received training and demonstrated clinical competency regarding use of these devices. Care immediately following dialysis treatment: - The dressing change is done in the dialysis center post-treatment; If dressing becomes wet, dirty, or not intact, the dressing shall be changed by a Licensed Nurse; The dressing can be removed after 24 hours post dialysis if there are no complications.Resident #18 was admitted with diagnoses that included Anemia, Hypertension, Renal insufficiency, and renal failure/End Stage Renal Disease.The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident has moderate impairment in cognition and requires substantial/partial/moderate assistance of staff for most activities of daily living. Minimum Data Set also documented that resident is on dialysis.The Comprehensive Care Plan (CCP) for Dialysis dated 07/02/2024 and last revised 01/15/2026, documented that resident needs dialysis related to renal failure. Goals included Resident will have no signs or symptoms of complications from dialysis x 90 days. Interventions listed included: assess for alteration in mental status, muscle weakness, fatigue, irritability, confusion, delusions, hallucinations, check and change dressing daily at access site, monitor vital signs pre- and post-dialysis and notify physician of significant abnormalities, monitor/document/report any signs or symptoms of infection to access site.Physician's order dated 06/28/2024 documented: Hemodialysis on Monday, Wednesday. Friday at 2:35 PM.Physician's order dated 07/14/2025 documented Hemodialysis AV shunt: Remove Dressing 24hrs post-dialysis every day and evening shift every Tuesday, Thursday, Saturday.On 02/09/2026 at 12:01 PM, Resident #18 was observed in room; resident's dialysis shunt on left hand appears reddened with moisture, consistent with signs or symptoms of risk of infection. Resident #18 was interviewed and stated that they go to dialysis on Mondays, Wednesdays, and Fridays at 2:00 PM and return around 6:00 PM; Resident #18 stated that they always remove the dressing placed at dialysis by themselves when they get back to facility, and the staff don't apply any dressing on return.There was no documented evidence that Resident #18 had received education on dressing remaining in place for 24 hours after dialysis treatment.Resident's Comprehensive Care Plan for Behavior dated 03/21/2025 and last updated 01/23/2026, was reviewed, there was no documented evidence in the care plan that Resident #18 has been self-removing dressing from the dialysis access site against Physician order and resident's plan of care.The staff did not ensure that Physician's Order for removal of dressing after 24 hours were followed, and appropriate infection control protocol was not followed as per resident's plan of care. There was no documented evidence that the Physician was notified that resident has been removing the dressing by themself.On 02/12/2026 at 12:17 PM, Registered Nurse #1 was interviewed and stated that Resident #18 goes to dialysis Monday, Wednesday and Friday, picked up around 2:00 PM and returns about 6:00 PM. Resident's vital signs are checked prior to dialysis and logged in the dialysis book, and the evening Nurse checks the dialysis shunt on return. Registered Nurse #1 stated that when the resident returns from dialysis, the evening nurses are expected to check the dialysis shunt site and remove the dressing. Registered Nurse #1 could not explain why the dressing was not applied at the time of interview. On 02/12/2026 at 12:20 PM, Registered Nurse #1 was observed assessing Resident #18's shunt and reported that the site was noted with some drainage, and was told by the Resident that the dressing was self-removed when resident returned from dialysis. There was no documented evidence in the resident's chart that resident has repeatedly removed the dressing by themself. Registered Nurse #1 could not state the specific time that the dressing on the shunt should be removed.On 02/13/2026 at 9:39 AM Registered Nurse #2 was interviewed and stated that when the resident comes back from dialysis on evening tour, they check the resident's vital signs, the dialysis shunt site for bleeding and bruit, and they were to remove the dressing applied to the site from dialysis center. Registered Nurse #2 stated most of the time, the resident would have removed the dressing as soon as resident returned from dialysis prior to the vital signs check. Registered Nurse #2 stated that they have been educating the resident to leave the dressing on until next day, but Resident has not been compliant despite education given to the resident. There was no documented evidence in resident's chart that resident has been self-removing the dressing on the dialysis shunt, and there is no documented evidence of education given to the resident. On 02/17/2026 at 10:08 AM, the Director of Nursing was interviewed and stated that they were not aware that Resident #18 has been removing the dressing by themself when returning from dialysis. The Director of Nursing stated that the nurses on the unit should have been documenting the residents' behavior in the 24-hour report for it to be captured and updated on the resident's non-compliant care plan. The Director of Nursing further stated that they are surprised that the nurses on the unit are not documenting properly despite constant reminders and education given to them.10 NYCRR 415.12

Based on observation, interview, and record review conducted during the recertification survey from 11/27/2023 through 12/1/2023, the facility did not ensure food was served in accordance with professional standards for food service safety. This was evident for 1 (7th Floor) of 7 resident units observed during dining. Specifically, 7th Floor food service staff did not perform hand hygiene prior to serving food to residents and a fruit cup and tuna sandwich were above 41 degrees Fahrenheit (F). The findings are: The facility policy titled Dining Services dated 1/2023 documented the server will check and log temperatures of cold items. If foods are not within acceptable range (cold foods <41 F), do not serve and call the supervisor. A facility policy titled Infection Control and Sanitation dated 1/2023 documented all staff wash their hands prior to serving meals. The Dietary Meal Temperature Log dated from 11/21/2023 to 11/26/2023 did not document a log of cold food temperatures for the lunch meal. On 11/27/2023 at 11:53 AM, Dietary Aide (DA) #1 was observed arriving on the 7th Floor with the food carts. DA #1 did not perform hand hygiene, pulled gloves from their pocket, and donned gloves, picked up utensils, and began to serve the lunch meal. DA #1 was interviewed at the time of observation and stated they cleaned their hands downstairs in the kitchen and were supposed to wash their hand prior to serving lunch. DA #1 stated the gloves they pulled from their pocket were clean because their pants were clean. On 11/28/2023 at 12:05 PM, DA #2 was observed preparing for lunch meal service on the 7th floor. DA#2 did not check the temperatures of the cold food items that had already been placed on a resident's lunch tray. DA #2 was interviewed at the time of the observation and stated they are supposed to check the temperatures of the hot and cold foods prior to serving them but forgot. DA #2 then checked the temperature of the fruit cup and the tuna sandwich on the resident's lunch tray and both items were 50 F, above the acceptable range of 41 F. On 11/29/2023 at 12:00 PM, DA#3 was interviewed and stated they do not check the temperatures of the sandwiches and food that has already been placed on lunch trays prior to serving the tray to residents. DA #3 only checked temperatures for the hot food. to observed preparing for lunch meal service on the 7th floor. DA #3 took temperatures of hot food. On 11/29/2023 at 12:13 PM, an interview was conducted with Registered Dietitian (RD) #1 who stated the facility policy is to check and log the temperatures of the hot and cold foods prior to meal service on the resident units. RD #1 reviewed the Temperature Log and stated there was a section to log temperatures for cold plates. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews during the Recertification Survey from 11/27/2023 to 12/01/2023, the facility did not ensure each resident was treated with respect and dignity. This was evident for 1 (Resident #162) of one 38 total sampled residents. Specifically, Resident #162's Foley drainage bag was not covered and was visible to anyone passing by their room. The findings are: The facility policy titled Providing Resident's Dignity dated 06/2023 documented staff must ensure catheter bags were covered for privacy. Resident #162 had diagnoses of Benign Prostatic Hyperplasia (BPH) and adult failure to thrive. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #162 had severely impaired cognition and required the assistance of 2 people for toileting. During an observation on 11/27/2023 at 12:02 PM and 11/28/2023 at 10:30 AM, Resident #162 was lying in a bed closest to their room door and their Foley drainage bag was attached to the side of the bed visible from the hallway outside of the resident's room. The Foley drainage bag was uncovered and exposed for anyone passing by the room to see. During an interview on 12/01/2023 at 10:22 AM, the Certified Nurse Assistant (CNA) #2 stated they took care of the Resident #162 a few days ago and observed the resident's Foley drainage bag did not have a cover. CNA #2 told the nurse how much urine was in the bag and emptied the drainage bag. On 12/01/2023 at 10:58 AM, an interview was conducted with Registered Nurse (RN) # 2 who stated Resident #162 was transferred from another unit and RN #2 did not realize there was no cover or dignity bag for the resident's Foley catheter drainage bag. On 12/01/2023 at 11:13 AM, an interview was conducted with the Director of Nursing (DON) who stated they just found out that Resident #162 did not have a Foley drainage bag cover and they will conduct an audit of residents with drainage bags. The DON stated any resident without a cover for their drainage bag will receive a cover to maintain dignity. 10 NYCRR 415.3(c)(1)(i)

Based on observation, record review, and interviews conducted during the Recertification survey from 11/27/23 to 12/1/23, the facility did not ensure a resident's right to privacy and confidentiality was maintained for 1 of 35 sampled residents (Resident # 67). Specifically, the electronic Medication Administration Record (MAR) for Resident #67 was observed open on top of the medication cart, in the hallway, displaying personal and identifying health information. The findings are: The undated facility policy and procedure titled Safeguarding and Storing Protected Health Information documented that it is the policy of the facility to ensure, to the extent possible, that PHI is not intentionally or unintentionally used or disclosed in a manner that would violate The Health Insurance Portability and Accountability Act Privacy Rule (HIPPA) or any other federal or state regulation governing confidentiality and privacy of health information. All documents containing PHI should be stored appropriately to reduce the potential for incidental use or disclosure. Documents should not be easily accessible to any unauthorized staff or visitors. The policy also documented that Medication Administration Records, Treatment Administration Records, report sheets and other documents containing PHI shall not be left open and or unattended. The policy further documented that computer monitors shall be positioned so that unauthorized persons cannot easily view information on the screen. The undated facility policy titled Administering Medication: Interpretation and Implementation documented that during administration of medications, the cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents. On 11/30/23 at 07:51 AM, the State Surveyor arrived on Unit 3 and observed the medication cart unattended in the hallway outside of Resident #67's room which was around the corner from the nursing station. The medication cart was unlocked, and the electronic MAR screen was open, facing outward in plain view of passersby, and was displaying a photograph and identifying health information for Resident #67. On 11/30/23 at 07:55 AM, Licensed Practical Nurse (LPN) #3 returned to the medication cart and was immediately interviewed. LPN #3 stated that they were sorry and that they never do this as they pay attention to resident privacy. On 12/01/23 at 01:04 PM, Registered Nurse Supervisor (RNS) #1 was interviewed and stated that LPN #3 informed them that they had left Resident #67's medical record opened and exposed in the hallway and they were immediately in-serviced. RNS #1 stated that periodic spot checks are performed, and rounds are made checking that medication carts are locked and MAR screens on carts are closed when not in use. Staff is then educated and given verbal warnings when noncompliance is found. 415.3 (d)(1)(ii)

Based on observation, record review, and interview conducted during the recertification survey from 11/27/2023 to 12/01/2023, the facility did not ensure that the Minimum Data Set 3.0 (MDS) assessments accurately reflect the resident status. This was evident for 3 (Resident #101, #120, and #238) of 38 total sampled residents. Specifically, 1). MDS for Resident #101 and Resident # 238 did not accurately assess for contractures, 2). MDS for Resident #238 did not accurately assess for hemodalysis treatment. The findings are: 1.) Resident #101 had diagnoses of heart failure and depression. The MDS dated [DATE] documented Resident #101 did not have any impairment in their range of motion. On 11/28/2023 at 09:56 AM and 11/30/2023 at 9:56 AM, Resident #101 was observed with a right knee contracture. The Comprehensive Care Plan (CCP) dated 11/30/2023 documented Resident #101 had an alteration in musculoskeletal status and right leg stiffness. There was no documented evidence Resident #101's range of motion limitation of their right knee were accurately assessed on the 8/30/2022 MDS. An interview was conducted on 11/30/2023 at 10:04 AM with the MDS Coordinator who stated the MDS assessment helps with the planning of care, health decisions and capturing different trends or declines for a resident. The MDS Coordinator stated they were responsible for the accuracy of the MDS and Resident #101's right knee functional limitation should have been documented on the MDS assessment. 44864 2) Resident #238 had diagnoses of cancer and Alzheimer's disease. The MDS assessment dated [DATE] documented Resident #238 was cognitively intact and had no functional limitation in range of motion to their upper extremities. The Hospital Discharge Summary dated 09/26/2023 documented Resident #238 had limited range of motion to their hands and significant contractures of their bilateral 4th-digit fingers. There was no documented evidence Resident #238's upper extremity limited range of motion was documented on the 10/3/2023 MDS assessment. On 11/30/2023 at 11:32 AM, Certified Nursing Assistant (CNA) #5 was interviewed and stated Resident #238 required extensive assistance with eating because they are unable to hold the utensils in their hands due to their fingers being contracted. On 12/01/2023 at 10:13 AM, the MDS Coordinator (MDSC) was interviewed and stated they were responsible for the accuracy of the MDS assessment and although the Occupational Therapist fills out the section related to a resident's functional limitations, the MDSC was responsible for noting any errors the other disciplines made. 45349 3) Resident #120 had diagnoses of End Stage Renal Disease (ESRD) and dementia. The MDS assessment dated [DATE] documented Resident #120 had a diagnosis of ESRD and did not document the resident received hemodialysis treatment. A Physician's Order dated 6/12/2023 documented Resident #120 had hemodialysis 3 times weekly on Monday, Wednesday, and Friday. A Comprehensive Care Plan related to ESRD documented Resident #120 received hemodialysis treatment 3 times weekly. There was no documented evidence the MDS assessment dated [DATE] accurately documented Resident #120's hemodialysis treatment. On 11/30/2023 at 10:41 AM, an interview was conducted with the Director of MDS who stated the MDS Coordinators were responsible for filling out the sections of the MDS assessment related to special treatments and checking for accuracy prior to submission of the MDS. The Director of MDS reviewed Resident #120's MDS assessment and stated hemodialysis treatment should have been documented and it was human error that it was missed on the 9/11/2023 MDS assessment. On 11/30/2023 at 10:52 AM, an interview was conducted with the Director of Nursing (DNS), who stated the MDS assessments were completed by the MDS Coordinators and were checked for accuracy prior to being submitted. 10NYCRR 415.11(b)

Based on observation, interviews, and record review conducted during the Recertification survey from 11/27/2023 to 12/1/2023, the facility did not develop and implement a comprehensive person-centered care plan (CCP) that includes measurable objectives and timeframes to meet a resident's needs. This was evident for 1 (Resident # 162) of 38 total sampled residents. Specifically, a CCP related to Foley catheter use was not developed for Resident #162. The findings are: The facility undated policy titled Care Planning -Interdisciplinary Team (IDT) documented the IDT was responsible for the development of an individualized CCP for each resident to meet the needs of the resident. Resident #162 had diagnoses of Benign Prostatic Hyperplasia (BPH) and adult failure to thrive. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #162 had severely impaired cognition. The MDS did not document Resident #162's urinary catheter use. On 11/27/2023 at 12:02 PM and 11/28/2023 at 10:30 AM, Resident #162 was observed with a Foley catheter and drainage bag in place. There was no documented evidence a CCP related to Resident #162's Foley catheter use was developed and implemented. On 12/01/2023 at 10:22 AM, an interview was conducted with Certified Nurse Assistant (CNA) #2 who stated they took care of the Resident #162 a few days ago, emptied the resident's Foley drainage bag, and reported how much urine was in the bag to the nurse. On 12/01/2023 at 10:58 AM, an interview was conducted with Registered Nurse (RN) #2 who stated Resident #162 was transferred from another unit and RN #2 did not realize the resident did not have a CCP developed related to their Foley catheter. On 12/01/2023 at 11:13 AM, an interview was conducted with the Director of Nursing (DON) who stated they were made aware Resident #162 did not have a CCP related to Foley catheter use in place and a CCP will be developed and implemented immediately. 10 NYCRR 415.11(c)(1)

Based on observation, interviews, and record reviews conducted during a recertification survey from 11/27/23 to 12/01/23, the facility did not ensure that each resident was provided with the necessary care and services to attain or maintain the highest practicable mental and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. This was evident for 1 of 38 sampled residents. (Resident #256) Specifically, Resident #256 report that their sleep was disturbed at night because their roommate's television was too loud and it was not addressed. The findings are: The facility policy titled Transfers-room changes, revised 05/22, documented that to honor resident rights, promote resident choice, be sensitive to LGBT rights, and promote the highest quality of life and person-centered care for the residents and to comply with applicable federal and state regulations. Changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change. The undated policy titled Quality of Life, documented that the facility becomes a substitute for significant quality of life factors in addition to quality of health factors in its plan for resident care. Resident was admitted to the facility with diagnoses that included Cerebral Vascular Accident (CVA), COVID-19, and Pneumonia (PNA). The Admission Minimum Data Set 3.0 (MDS) dated [DATE] documented that resident's cognition is intact, and they were feeling tired or having little energy on 12-14 days during the review period. On 11/27/23 at 12:47 PM, Resident #256 was interviewed and stated that their roommate keeps the television on all night, and that they cannot go to sleep at nights. They also stated that they asked for a room change but wanted to stay on this unit. Resident #256 also stated that they spoke with the Social Worker (SW) about their roommate's television being too loud at nights, asked for a room change but wanted to stay on this unit. On 11/29/23 at 10:55 AM, Resident #256 was observed sitting out in the lounge area near to their room. Resident #256 said that they had asked the Certified Nursing Assistant (CNA) last evening (11/28) to lower the roommate's TV, but the roommate refused, and that they didn't sleep well since the TV was on all the time. Resident #256 said that the Social Worker (SW) had been made aware that they want to move but has not gotten back to them. On 11/30/23 at 10:27 AM, Resident # 256 observed sitting in the lounge outside of their room, observed resident's roommate with the TV on inside of the room. Resident #256 said that they are still unable to get a goodnight's rest, since the roommate continues to keep on the television on a loud volume at nights. A Comprehensive Care Plan (CCP) with focus of Resident #256 has a mood problem related to admission, Altered Feelings/Mood state evidenced by sadness, altered feelings/mood state evidenced by sleeplessness, disease process was created on 09/08/2023. Goals included that the resident would have improved mood state happier, calmer appearance, no signs/symptoms of depression, anxiety, or sadness) through the review date. Interventions include to allow resident time to verbalize their feelings, assist the resident, family, caregivers to identify strengths, positive coping skills and reinforce these. A Social Work note dated 11/08/23 documented that Resident #256 moved from room [ROOM NUMBER] A to 816 B, and agreed with the move. There was no documented evidence that Resident #256's concern about noise in their room or request for a room change was addressed from 11/08/23 until 11/30/23 after the Social Worker had been interviewed by the State Surveyor. On 11/30/23 at 10:41 AM, Certified Nursing Assistant (CNA) #4 was interviewed and stated that Resident #256 had complained that when they came to the unit, the roommate's television was too loud at nights but they did not want to leave the unit. CNA #4 also stated that they told the Social Worker about the resident's complaint. CNA #4 further stated that they had spoken with the roommate about the TV being too loud and the resident turned down the volume for a short time. On 11/30/23 at 12:30 PM, Social Worker (SW) #1 was interviewed and stated they could not recall when but Resident #256 had reported to them previously that they were having some trouble with the roommate's TV. They offered Resident #256 another option on another unit, but then Resident #256 said that they were okay with the roommate, since they may not have had availability on the unit they were currently on. SW #1 also stated that this issue occurred mostly at night time, and the facility policy is that it is the complainant who is to be moved when a room change is requested. SW #1 further stated that they did speak to the roommate, but the concern is mostly at night, and they had not heard anything else. On 11/30/23 at 12:38 PM, Registered Nurse Supervisor (RNS) #2 stated that Resident #256's roommate had the TV on too loud, and that Resident #256 mentioned again today that the resident kept the TV on and RNS #2 told the roommate to turn the TV down at a certain time RNS #2 also stated that they told Resident #256 that once a room becomes available, they will make a room change. RNS #2 stated that although the facility policy dictates that the complainant be moved, there are times when the other resident can be moved to another room. On 12/01/23 at 09:37 AM, during an interview the Director of Nursing (DON) stated that they were not aware that there was a situation occurring and they would look into the situation and see if there is a room available. On 12/01/23 at 09:48 AM, the Director of Social Work was interviewed and stated that regarding resident needs, they meet with the resident and try to resolve the issue, and that they would offer the room change and that if the other resident will be compatible. The DSW also stated that they were not aware that there was a concern with Resident #256 wanting to get a room change because of the roommate's TV being too loud. The DSW further stated that they would usually follow up with the assigned SW to ensure that they addressed the issue. The DSW stated that SW #1 informed them that SW #1 assumed that the issue was resolved. The DSW stated that they saw Resident #256, and that they moved them to another room. 10NYCRR 415.12

Based on observation, interviews, and record review conducted during the recertification survey from 11/27/23 to 12/01/23, the facility did not ensure a resident was provided pain management consistent with professional standards of practice and the comprehensive person-centered care plan. This was evident for 1 out of 2 residents reviewed for Pain Management out of 35 total sampled residents (Resident #238). Specifically, Resident #238 received pain medications and treatment without ongoing monitoring of the efficacy of the pain management. The findings are: The undated policy titled Pain Management documented that the purpose of pain management is to achieve highest level of pain control and comfort and the highest level of functioning in ADL. Resident #238 was admitted to the facility with diagnoses that include Multiple fracture of ribs. On 11/28/23 at 09:26 AM, Resident #238 was observed sitting in the dayroom. Resident was alert and oriented and complained of pain in both hands. Resident was observed to have contracted fingers to both hands. The Admission Minimum Data Set 3.0 (MDS) dated [DATE] documented that Resident #238 was moderately cognitively impaired, received scheduled pain medication regimen, with occasional presence of pain and with a rating of 3 out of a numerical rating scale of 00-10. The Comprehensive Care Plan (CCP) created on 09/27/23, documented Resident #238 has pain related to Sacrum and rib fracture, with goals that include the resident will not have an interruption in normal activities due to pain, through the review date, 2/5/24. Interventions included to administer analgesia as per orders, Resident #238 is currently on Lidoderm patch, gabapentin, and Tylenol as needed, to anticipate the resident's need for pain relief, and respond immediately to any complaint of pain. The Physician's order dated 10/30/23 documented Diclofenac Sodium external gel 1% (topical): apply to sacrum and chest topically two times a day for pain. The Physician's order dated 11/21/23, documented Lidocaine Pain Relief External Patch 4 %: Apply to lower back topically one time a day for pain, apply at 9 AM, remove at 9 PM. The Physician's order dated 11/30/23, documented Baclofen oral tablet 5mg: give 1 tablet by mouth two times a day for increased spasticity during therapy sessions. The Medication Administration Record (MAR) for September 2023 documented Resident #238 received Tylenol 650 mg every 6 hours for pain with a start date of 09/26/23 and discontinued 09/30/23. The Medication Administration Record (MAR) for September and October 2023 documented pain for Resident #238 with monitoring every shift for 14 days, from 09/26/23 to 10/10/23. Pain level ranging from 0-5 on a scale of 0 to 10 with o being no pain and 10 severe pain. There was no documented evidence that Resident #238 received ongoing monitoring for efficacy of the pain management after 10/10/23. A Psychiatric note dated 11/3/2023 documented patient showed writer their hands that were contracted and that their sleep fluctuates due to chronic pain in their left ankle. A Physician's Physiatry's note dated 11/8/23 documented patient was seen due to report of increased spasticity during therapy sessions, and decline in functional progress and if no underlying infection present, patient would benefit from trial of Baclofen 5mg twice daily, titrate up as needed to assist with relieving pain and tightness. On 11/30/23 at 11:32 AM, Certified Nursing Assistant (CNA) #5 was interviewed and stated that since admission on 09/26/23, Resident #238 is totally dependent on staff for Activities of Daily Living (ADLS) and needs extensive assistance with eating. CNA #5 also stated that Resident #238 is unable to hold their utensils due to their fingers being contracted and their complaint of being in pain. CNA #5 further stated that the Occupational Therapist (OT) initially used to feed Resident #238 every lunch time since they were unable to hold the cup their hands. On 11/30/23 at 12:02 PM, the Physical Therapist Aide (PTA) #1 was interviewed and stated that Resident #238 reached a plateau, so therapy was discontinued. PTA #1 also stated that they spoke with OT who said they will get something for Resident #238. PTA #1 further stated that Resident #238 hand pain in the hands all the time and that the nurse on the unit was aware. On 11/30/23 at 12:18 PM, the Registered Nurse Supervisor (RNS) #2 was interviewed and stated that Resident #238 was referred to Occupational Therapy (OT) since their hands being contracted was a concern. RNS #2 also stated that the therapist would have done an evaluation on admission. Resident was evaluated on admission. RNS #2 stated that Resident #238 was already receiving pain medication, and that they were not aware that the resident had pain to their hands. On 11/30/23 at 03:10 PM the Occupational Therapist (OT) #1 was interviewed and stated that they evaluated Resident #238 on admission, and that they were not concerned with the resident's hands, since Resident #238 had limited fine motor skills. OT #1 also stated that their hands were not as contracted as they currently are, hands were stiff and had some impairment but it was within functional limit. On 12/01/23 at 02:04 PM, Medical Doctor (MD) #1 was interviewed and stated that Resident #238 was admitted with chronic contractures. MD #1 also stated that the resident was in pain and was seen by the Physiatrist who ordered a muscle relaxant. MD #1 further stated that they were informed of the Physiatrist's recommendation by the unit nurse on 11/30/2023 and they ordered the medication then. The MD stated that the recommendations of the consultant would be reviewed when the monthly evaluation was being done. 10NYCRR 415.12

Based on observation, record review, and interviews conducted during the Recertification survey from 11/27/2023 to 12/1/2023, the facility did not ensure the physician reviewed the resident's total plan of care at each visit. This was evident for 1 (Resident #162) of 2 residents reviewed for Foley Catheter out of 38 total sampled residents. Specifically, there was no Medical Doctor Order (MDO) given specifying the treatment and care of Resident #162's Foley catheter. The findings are: The facility policy titled Doctor's Order dated 06/2023 documented MDOs should be concise with indication for use. Resident #162 had diagnoses of Benign Prostatic Hyperplasia (BPH) and adult failure to thrive. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #162 had severely impaired cognition. The MDS did not document Resident #162's urinary catheter use. On 11/27/2023 at 12:02 PM and 11/28/2023 at 10:30 AM, Resident #162 was observed with a Foley catheter and drainage bag in place. The Comprehensive Care Plan (CCP) related to Resident #162's diagnosis of BPH initiated 01/07/2022 and last revised on 06/22/2023 documented Resident #162 was monitored for urinary retention, bladder distention, and hematuria. There was no documented evidence an MDO specifying treatment and care of Resident #162's Foley catheter was given by the MD. On 12/01/2023 at 10:58 AM, an interview was conducted with Registered Nurse (RN) #2 who stated Resident #162 was transferred from another unit and RN #2 did not realize the MDO had not given an order specifying treatment and care of Resident #162's Foley catheter. On 12/01/2023 at 11:13 AM, an interview was conducted with the Director of Nursing (DON) who stated they were just made aware Resident #162 did not have an MDO in place for Foley catheter treatment and care. The DON stated staff will be inserviced that all residents with Foley catheters required an MDO. On 12/01/2023 at 11:45 AM, an interview was conducted with Medical Doctor (MD) #1 who stated Resident #162 did not have a MDO in place for Foley catheter care because of an oversight. MD #1 stated they will read hospital discharge paperwork more carefully next time. MD #1 saw the nurses were documenting that Resident #162's Foley catheter was draining well. 10 NYCRR 415.15(b)(2)(iii)

Based on observation, record review, and interviews conducted during the Recertification survey from 11/27/23 to 12/1/23 the facility did not ensure drugs and biologicals were stored in accordance with professional standards of practice for 2 of 7 units (3rd Floor and 4th Floor). Specifically, the facility medication cart was not kept locked or under direct observation of authorized staff. The findings are: The facility policy and procedure titled Medication Administration dated 2/2000 and revised 4/2023 documents that while administering medications, the nurse ensures that the medication cart is locked anytime especially if the medication cart is out of the nurse direct line of vision. The undated facility policy titled Administering Medication: Interpretation and Implementation documented that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents. 1. On 11/29/23 at 4:37 PM, during an observation of medication administration in room [ROOM NUMBER], Registered Nurse (RN) #4 did not lock the medication cart before going into the resident's room to administer medications. The cart was left unattended outside of the resident's room and out of the sight of RN #4 who was behind the resident's privacy curtain administering medication. The resident's room is located around the corner from the nursing station and there was no staff observed in the hallway. On 11/29/23 at 4:42 PM, RN #4 returned to the medication cart and was interviewed immediately. RN #4 stated that this is not something they usually do as they usually lock the cart before walking away. 2. On 11/30/23 at 7:51 AM, the State Surveyor arrived on the third floor of the facility and observed the medication cart unattended in the hallway outside of residents' room [ROOM NUMBER] around the corner from the nursing station. The medication cart was observed to be unlocked. On 11/30/23 at 7:55 AM, Licensed Practical Nurse (LPN) #3 returned to the medication cart. LPN #3 was immediately interviewed and stated they usually lock the cart before going into the resident's room. On 12/01/23 at 01:04 PM, Registered Nurse Supervisor (RNS) #1 was interviewed and stated that LPN #3 informed them that they had left Resident #67's medical record opened and exposed in the hallway and they were immediately in-serviced. RNS #1 stated that periodic spot checks are performed, and rounds are made checking that medication carts are locked and MAR screens on carts are closed when not in use. Staff is then educated and given verbal warnings when noncompliance is found. 415.18 (e)(1-4)

Based on observation, record review, and interviews conducted during a COVID-19 Focused Infection Control Survey (FICS), the facility did not ensure infection control practices were maintained to prevent the development and transmission of COVID-19 infection. This was evident for 4 of 6 residents reviewed. (Resident #2, #3, #4 and #5) Specifically, Residents #2 and #5 who were COVID-19 positive (CP), were not isolated and not separated from roommates, residents #3 and #4 who were COVID-19 negative (CN). The findings are: The facility policy titled Cohorting Residents in COVID-19 Pandemic, last revised 05/20, documented residents will be protected from COVID-19 exposure by minimizing interactions of infectious individuals from the non-infected. CP residents were kept separated from CN residents. 1.) Resident #3 was diagnosed with cerebral infarction, [CONDITION(S)], and [CONDITION(S)]. The Minimum Datat Set 3.0 (MDS) assessment dated [DATE] documented Resident #3 was cognitively intact. Resident #2 was diagnosed with malignant neoplasm of the prostate, liver, and intrahepatic bile duct. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #2 was cognitively intact. On 04/21/2022 at 10:04AM and 04/22/2022 at 09:30AM, Personal Protective Equipment (PPE) and contact isolation signage was observed at the entrance to the room of Resident #2 and #3, and Residents #2 and #3 were present in the room. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes (NN) dated 04/11/22, 04/14/22, and 04/18/22 documented Resident #3 was tested and had CN result. There was no documented evidence the facility attempted to move CN Resident #3 out of the room after Resident #2 became CP on 04/12/2022. On 4/21/2022 at 10:04AM, Registered Nurse (RN) #1 was interviewed and stated Resident #2 was CP and Resident #3 was CN and had not received their COVID-19 vaccination booster. Resident #3 had behavioral issues and did not want to move their room once Resident #2 became CP. 2.) Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] documented Resident #4 was cognitively intact. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] documented Resident #5 had severely impaired cognition. On 04/21/2022 at 10:04AM and 04/22/2022 at 09:30AM, Personal Protective Equipment (PPE) and contact isolation signage was observed at the entrance to room of Resident #4 and #5, and Residents #4 and #5 were present in the room. NN dated 03/03/2022 documented Resident #5 was tested for COVID-19, was CP, and the Medical Doctor (MD) was informed. NN dated 04/01/2022 and 04/06/2022 documented Resident #5 was on contact droplet precautions due to a CP result. MD notes dated 04/02/2022 and 04/05/2022 documented Resident #5 was assessed due to CP result and remains on contact isolation. NN dated 04/05/22, 04/11/22, 04/14/22 documented Resident #4 was tested and had CN results. There was no documented evidence the facility attempted to move CN Resident #4 out of the room after Resident #5 became CP. On 04/21/22 at 2:00PM and 4:30PM, the Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP) was interviewed and stated the Director of Nursing (DON) spoke with an epidemiologist and believed that CP and CN residents did not need to be separated and cohorted. The unit where Residents #2, #3, #4, and #5 reside was placed on quarantine. Resident #3 was tested frequently, and Resident #2 was moved once at the beginning of 04/2022; therefore, the facility did not move Resident #2 or #3 when Resident #2 became CP. The DON was on leave and the ADON was unable to provide documented evidence of epidemiological advice for the facility from 04/04/2022. On 04/21/22 at 4:30PM, the Administrator was interviewed and stated the facility no longer cohorted residents according to their CP or CN status. The facility quarantined the entire unit where Residents #3 and #4 reside. 415.19(a) (1-3), (b)(1); 400.2

Based on observation, record review and interviews conducted during the Focused Infection Control Survey (FICS), the facility did not ensure residents and/or their representatives were informed of confirmed COVID-19 infections. This was evident for 2 of 8 residents reviewed (Resident #3 and #4). Specifically, the facility did not provide verbal or written notification to Resident #3 and #4 that they were in close contact with COVID -19 residents and that they were not informed after four residents at the facility tested positive for COVID-19. The findings are: The undated facility policy titled Communication and Notification Re: COVID-19 documented the nurse or social worker will provide ongoing communication and notification to resident family members via telephone re: any change in condition that is Covid-19 suspect or positive test. A validating note will be documented in the medical record. Resident # 3 roommate, resident#2 was tested positive on 04/10/22and resident #3 was not removed or informed that they were being put on contact precautions due to exposure from close contact with a COVID -19 positive resident. 1.) Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #3 was cognitively intact. On 04/22/2022 at 12:24 PM, the Health Care Proxy (HCP) of Resident #3 was interviewed and stated they were not informed Resident #3 was exposed to a COVID-19 positive resident. On 04/22/2022 at 2:30 PM, Resident #3 was interviewed and stated the facility did not inform Resident #3 of exposure to another COVID-19 positive resident and did not offer Resident #3 a room change. There was no documented evidence Resident #3, or their HCP was informed of new positive cases of COVID-19 in the facility. 2.) Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] documented Resident #4 was cognitively intact. On 04/22/2022 at 2:15 PM, Resident #4's representative was contacted via telephone and stated they were involved in Resident #4's plan of care and did receive calls from the facility with updates re: COVID-19 cases in the facility. The representative stated they were not contacted by the facility and informed There was no documented evidence Resident #4 or their representative was informed of the resident's COVID-19 exposure and offered a room change. On 4/21/2022 at 9:30 AM, the Administrator was interviewed and stated families and residents are made aware of the facility's positive COVID-19 cases through a robo call. The social worker and the nurse were responsible for documenting any COVID-19 communication in the resident's medical record. 10 NYCRR 400.2

Based on observation, record review and interviews conducted during the Focused Infection Control Survey (FICS), the facility did not ensure actions were taken to prevent further transmission of COVID-19. This was evident for 2 of 8 sampled residents (Resident #3 and #4). Specifically,1) the facility did not respond appropriately to testing results, by not acting on the positve results by removing the COVID-19 positive roommate, and 2) Resident #3 and #4 were not provided with a room change and placed on contact isolation following exposure to COVID-19 positive (CP) roommates. The findings are: The facility policy titled Cohorting Residents in COVID-19 Pandemic, last revised 05/20, documented residents will be protected from COVID-19 exposure by minimizing interactions of infectious individuals from the non-infected. CP residents were kept separated from COVID-19 negative (CN) residents. 1.) Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #3 was cognitively intact. On 04/21/2022 at 2:30 PM, Resident #3 was interviewed and stated the facility did not inform Resident #3 of exposure to another CP resident and did not offer Resident #3 a room change. Resident #2 was diagnosed with malignant neoplasm of the prostate, liver, and intrahepatic bile duct. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #2 was cognitively intact. On 04/21/2022 at 10:04 AM and 04/22/2022 at 09:30AM, Personal Protective Equipment (PPE) and contact isolation signage was observed at the entrance to the room of Resident #2 and #3, and Residents #2 and #3 were present in the room. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing notes (NN) dated 04/11/22, 04/14/22, and 04/18/22 documented Resident #3 was tested and had CN result. There was no documented evidence the facility attempted to move CN Resident #3 out of the room after Resident #2 became CP on 04/12/2022. On 4/21/2022 at 10:04 AM, Registered Nurse (RN) #1 was interviewed and stated Resident #2 was CP and Resident #3 was CN and had not received their COVID-19 vaccination booster. Resident #3 had behavioral issues and did not want to move their room once Resident #2 became CP. 2.) Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] documented Resident #4 was cognitively intact. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] documented Resident #5 had severely impaired cognition. NN dated 03/31/2022 documented Resident #5 was tested for COVID-19, was CP, and the Medical Doctor (MD) was informed. NN dated 04/01/2022 and 04/06/2022 documented Resident #5 was on contact droplet precautions due to a CP result. MD notes dated 04/02/2022 and 04/05/2022 documented Resident #5 was assessed due to CP result and remains on contact isolation. NN dated 04/05/22, 04/11/22, 04/14/22 documented Resident #4 was tested and had CN results. There was no documented evidence the facility attempted to move CN Resident #4 out of the room after Resident #5 became CP. On 04/21/22 at 2:00PM and 4:30PM, the Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP) was interviewed and stated the Director of Nursing (DON) spoke with an epidemiologist and believed that CP and CN residents did not need to be separated and cohorted. The unit where Residents #2, #3, #4, and #5 reside was placed on quarantine. Resident #3 was tested frequently, and Resident #2 was moved once at the beginning of 04/2022; therefore, the facility did not move Resident #2 or #3 when Resident #2 became CP. The DON was on leave and the ADON was unable to provide documented evidence of epidemiological advice for the facility from 04/04/2022. On 04/21/22 at 4:30PM, the Administrator was interviewed and stated the facility no longer cohorted residents according to their CP or CN status. The facility quarantined the entire unit where Residents #3 and #4 reside. 415.19

Based on observation, interview and record review conducted during a recertification survey, the facility failed to ensure that a safe, clean, comfortable and homelike environment was provided to residents. Specifically, resident rooms were observed with dirty floor mats in disrepair and unswept and sticky floors for mutiple observeations over several days. This was evident for 3 of 7 resident units observed for Environmental Observations (Floors 2, 3, and 5). The findings are: The facility policy titled Devices (Floor Mats) revised 10/2016 documented that central supply personnel/housekeeping provides floormats, replaces non-functioning devices. 1) During multiple observations conducted on 09/02/2021 at 11:10 AM, 09/03/21 at 8:27 AM, and 09/10/2021 at 12:18 PM, Room 206 was observed with the following: There were floor mats with tears/rips in the fabric exposing the inside material. The right floor mat was ripped on left and right edges, and the left floor mat was ripped on the short edge by the footboard measuring ¼ inch to 2 inches in length. 2) During multiple observations conducted on 9/7/21 at 9:38 AM, 9/9/21 at 5:42 PM, and 9/10/21 at 11:20 AM, Room 309 was observed with the following: Room 309A bed had ripped floor mats. There was a rip along 3/4 of the long edge, exposing the inside foam, and there were tears and rips in the middle area of the mat measuring approximately 12-18 inches in length. Three rips 2-4 inches in length were noted in the bottom area. The floor mat for 309B was noted with rips in the fabric of the floor mat on the left and right corners towards the footboard. There was an 8 inch rip on the right edge in middle section, and a rip on the lower left edge and left upper corner on the left floor mat. The right floor mat had a 5 inch rip on the lower left edge and right corner where material meets (6 inches in length open). On 09/10/2021 at 12:23 PM, an interview was conducted with the Registered Nurse. The RN stated that they look at floor mats when doing rounds daily. If a floor mat is ripped, RN #5 calls downstairs and fill out a requisition in relation to the floor mat. The RN stated they checked the floor mats this morning and did not see anything out of the ordinary. On 09/10/2021 at 12:30 PM, an interview was conducted with the Director of Environmental Services (DES). The DES stated they do rounds every morning, tour the units 2 to 3 times daily, and note if anything is out of order or needs to be cleaned right away. They don't look at floor mats. Nursing or housekeeping reports any issue with floor mats to maintenance. Floor mats are wiped down by housekeeping. If floor mats are reported for damage, the covers can be changed if the mat inside is in good condition. If not, the mat is replaced. 3) On, 09/07/21 at 12:52 PM, Room 508B was observed. The floor in front of the bed was dirty and sticky. On 09/08/21 at 09:17 AM, Room 508B was observed, The floor was still dirty and sticky, and there were pieces of alcohol swab paper on the floor. The floor mat on the right side of the bed was dirty. On 09/09/21 at 9:15 AM and 9/10/21 at 7:56 AM, Room 508B was observed with a sticky and unswept floor with pieces of paper on the floor. Three dirty floor mats were piled on top of each other on the right side of the bed. During an interview on 09/10/21 at 08:00 AM, the Housekeeper, Staff #5, stated they clean the room when the resident is not inside because the Housekeeper does not know if the residents can walk. The Housekeeper stated they cleaned the room a couple days ago, but sometimes they wait until the nursing staff takes the residents out of the room. The Houskeeper stated they don't have a schedule for room cleaning. During an interview on 09/10/21 at 07:55 AM, the RN Supervisor #1 stated Room 508 should not be in the current state. The RN Supervisor stated the room probably wasn't cleaned, and Housekeeping should mop the rooms even if the residents are inside. When the residents are out of bed, the floor mats should be placed on the side of the bed. Housekeeping is responsible for cleaning the floor mats. During the interview 2 of the floor mats were removed. During an interview on 09/10/21 at 08:25 AM, the Director of Environmental Services (DES) stated that there is a cycle cleaning schedule that is done monthly. If a room needs to be cleaned and the residents inside are non-ambulatory, the room can be mopped. If there is an ambulatory resident inside the room, the room can be swept. The Housekeeper can can make arrangements to clean the rooms of ambulatory residents with nursing staff, who will take residents out of the room so it can be cleaned. The DES also stated housekeeping staff is responsible for cleaning the floor mattresses. If the floor mats are soiled, the housekeeper can wipe it, and torn floor mats should be replaced. The DES stated that they would in-service the housekeeper. 415.5(h)2

Based on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, an RN was observed using a Blood Pressure (BP) cuff for multiple residents without sanitizing the equipment in between the residents. This was evident during medication pass for 4 of 4 residents observed during the Medication Administration Facility Task out of investigative sample size of 35 residents. (Residents #143, #190, #488, #489). The findings are: The undated facility policy titled Equipment Care documented Resident-care devices (e.g., electronic thermometers, blood pressure cuffs, glucose monitoring devices, etc.) may transmit pathogens if devices are shared between residents without cleaning and disinfecting between residents. These are all cleaned after each resident use with EPA approved cleaning material that is pathogen appropriate. On 09/07/21 at 09:30 AM, Registered Nurse (RN) #6 was observed obtaining Blood Pressure (BP) during the medication administration observation on the 7th floor. RN #6 removed the blood pressure machine that was in the hallway near the medication cart and took it into Resident # 488's room. RN#6 applied the blue BP cuff to the resident's arm and assessed the BP. When the reading was obtained, RN #6 removed the BP cuff and placed it in the basket attached to the machine. RN #6 was not observed cleaning or sanitizing the blood pressure cuff before or after use. On 09/07/21 at 09:42 AM, RN #6 was observed entering the room of Resident #143. RN #6 was observed using the BP cuff that had been used previously and not sanitized onto the arm of Resident #143 and obtained the BP reading. RN #6 removed the BP cuff and placed it back into the basket on the medication cart. RN #6 was not observed cleaning or sanitizing the blood pressure cuff before or after use. On 09/07/21 at 09:51 AM, RN #6 was observed obtaining blood pressure reading for Resident #190. After obtaining the reading, RN #6 removed the blood pressure cuff and placed it in the holding basket attached to the BP machine. RN #6 was not observed cleaning or sanitizing the blood pressure cuff before or after use. On 09/07/21 at 09:59 AM, RN # 6 was observed assessing blood pressure for Resident #489. After use of the BP cuff, it was returned to the holding basket attached to the machine. RN #6 was not observed cleaning or sanitizing the blood pressure cuff before or after use. On 09/07/21 at 10:05 AM, RN #6 was interviewed. RN #6 stated the facility protocol is to clean the Blood Pressure (BP) machine or any equipment used on a resident before moving on to the next resident. RN #6 also stated the BP cuff used needed to be cleaned in between every resident and they usually clean blood pressure cuff with alcohol wipes in between residents but did not do so today because they were very nervous. RN #6 stated they had been trained to use antibacterial wipes to clean equipment including the BP cuff, but was unable to locate any wipes on the medication cart to demonstrate what was used for cleaning. On 09/07/21 at 10:14 AM, RN #3, Unit Supervisor (US) was interviewed. The US stated that the facility protocol is that the BP machine must be cleaned before and after every resident use. The US also stated the facility protocol is to use antibacterial wipes to clean the equipment. The US further stated they monitor staff periodically throughout the day and have a morning meeting with all staff reminding them to adhere to the facility infection control practices and they stay late to observe medication administration on other shifts. The US stated that staff was inserviced on this issue and wipes are readily available on the unit and with housekeeping and staff can ask the US for wipes or can call housekeeping to obtain wipes. On 09/09/21 at 05:33 PM, the Infection Control Preventionist (ICP) was interviewed. The ICP stated the facility policy is to clean the BP cuff and reusable equipment in between resident and after use with the antibacterial wipes on the unit. The ICP also stated the wipes are readily available to all the staff on all units and stated all staff get the supplies from the Environmental Director in a large bucket delivered for use on the unit. The ICP further stated supplies are regularly checked by housekeeping and the nurses have been informed that the wipes are available. All staff including nursing know where to find the wipes in the basement if run out on the unit. The ICP stated they inserviced all staff in the facility recently to remind the staff of the protocol for cleaning equipment before and after use. The ICP stated they monitored the staff by making rounds, meeting with the managers, and doing spot checks to see that staff adhere to the Infection Control Practices. The ICP further stated all nurses need to clean BP cuff before and after use. 415.19(b)(4)

Based on observation, record review, and interview during the Re-certification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, staff members were observed entering resident rooms without knocking on the door. member was observed entering a dementia resident's room and another staff member was observed entering a cerebral infarction resident's room without knocking on the door. This was evident for 2 of 5 residents reviewed for Dignity (Resident #393 and 395) . The findings are: The facility policy & procedure (P&P) titled Resident Rights was effective on 6/5/17 and revised on 6/5/17. The policy documented that Staff acknowledges presence in resident's room prior to entering by either knocking on the door and /or greeting resident. 1) Resident #393 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #393 had severely impaired cognition. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] A sign posted on Resident #393's door read, Welcome to our home. Please knock before entering. On 09/07/21 at 03:28 PM, the Certified Nursing Assistant (CNA #2) was observed carrying a blood pressure machine and entering Resident #393's room to check Resident #393's vital signs without knocking on the door or greeting Resident #393. The Comprehensive Care Plan (CCP) for Impaired Cognitive Function r/t (related to) Dementia, Initiated 07/12/2021 and revised 07/15/2021, included the interventions: identify yourself at each interaction, face the resident when speaking and make eye contact, and reduce distractions. On 09/07/21 at 03:34 PM, CNA #2 was interviewed. CNA #2 stated Resident #393 was alert but not oriented. CNA #2 stated they knocked on the door when they went to Resident #393's room around 3 PM, and CNA #2 thought they did not need o knock again because the door was open. CNA #2 also stated the facility protocol was to knock on the door before entering resident rooms. CNA #2 further stated they received a lot of in-services throughout the year, including respecting residents' privacy and knocking on the door before entering the room. 2) Resident #395 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The resident was totally dependent on the assist of 2 persons for transfers. There was a post on Resident #395's door stating Welcome to our home. Please knock before entering. On 09/08/21 at 09:57 AM, CNA #3 was observed entering Resident #395's room with the hoyer lift without knocking on the door or greeting the resident. The Comprehensive Care Plan (CCP) for The resident able to follow simple commands, initiated 07/29/2021, revised on: 08/05/2021, included the interventions allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding, and use alternative communication tools as needed. On 09/08/21 at 10:11 AM, the Certified Nursing Assistant (CNA #3) was interviewed. CNA #3 stated they knocked on the door when entering the room earlier, and they did not knock on the door this time because the door was open and Resident #395 expected them to return with the hoyer lift. CNA #3 also stated that all staff had to knock on the door before entering the resident's room for privacy and respect. CNA #3 further stated they had training for privacy and dignity like knocking on the door at the new hire orientation and in-services throughout the year. On 09/09/21 at 03:42 PM, the Registered Nurse (RN #3) was interviewed. RN #3 stated all staff had to knock or greet the resident before entering or re-entering the room for privacy and respect. RN #3 also stated staff received training on privacy, including knocking on the door or closing the privacy curtain when providing the care, at the new hire orientation. RN #3 further stated staff watch a video on privacy and dignity during orientation. RN #3 stated they did not remember if there was in-service for privacy and dignity after the orientation. On 09/08/21 at 02:42 PM, the Director of Nursing (DON) was interviewed. The DON stated all staff had to knock on the resident's door before entering or re-entering the resident's room every time. The DON also stated there was training and in-service for staff about privacy, including knocking on the door before entering the resident's room during new hire orientation and regular and as needed in-services. 415.3(c)(1)(i)

Based on observation, interviews and record review during an abbreviated survey, the facility did not ensure a resident was provided the necessary services to maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. This was evident in 1 of 3 sampled residents (Resident #1). Resident #1 was served zucchini, despite a documented zucchini allergy. Subsequently, the resident suffered an anaphylactic reaction and was transferred to the hospital. Additionally, the dietary and nursing staff were not aware of facility policies for identification of resident food allergies. This resulted in actual harm that is not Immediate Jeopardy. Complaint # NY 452 The findings include: Resident # 1 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment 3.0 dated 7/21/11 identified that the resident was cognitively intact. He required supervision in eating with no physical help from staff. A review of the Nursing Admission assessment dated [DATE] documented that the resident had food allergies to squash and zucchini. The Comprehensive Care Plan (CCP) for Food Allergy initiated on 7/15/11 documented that the resident is allergic to zucchini and squash. The facility interventions included providing alternate vegetables and avoiding zucchini and squash. A review of Resident #1 ' s lunch meal ticket dated 7/28/11 documented that the resident was allergic to squash and zucchini. The allergy was identified on the meal ticket with an indicator of skull and crossbones next to these listed items. On 7/28/11 the resident was served the Italian Blend Frozen vegetables during lunch. A review of the packaging for the Italian Blend Frozen vegetables revealed that the vegetables included zucchini. A nurse ' s note dated 7/28/11 at 12:30PM documented that at 12:01PM the resident was noted to be holding his face in the main dining area. He was observed pointing at the meal plate. The resident was immediately taken to his room. The resident spit out one piece of cherry. A finger sweep was done and there were no food particles in his mouth. The resident ' s face was noted to be red with visible difficulty breathing. The nurses called a stat code. The nurse noted that the resident was not able to give verbal response except for " [MEDICATION NAME]. " The MD was notified and ordered [MEDICATION NAME] 0.3 milligrams (mg) intramuscular injection (IM) stat. The resident persisted with respiratory distress despite [MEDICATION NAME]. The MD was notified and ordered [MEDICATION NAME] 50mg IM with immediate response. The generalized redness subsided and the resident was verbally responsive and was no longer in respiratory distress. The resident was transferred to the hospital. A nursing note dated 7/28/11 stated that the resident returned from the hospital emergency room at 4:30PM. The policies and procedures on Resident Meal Service effective 2/2000 last reviewed on 6/03 documented a centralized tray system is used to plate meals. Each tray is identified by a computer-generated ticket (meal ticket) that includes the resident ' s name, room number, diet order, food preferences and allergies. A Food Service Supervisor individually checks the trays as they leave the tray assembly line to ensure accuracy of the diet and to maintain quality assurance. A review of the meal ticket revealed that the ticket contains the resident ' s identifying information, menu items, resident preferences with a " happy face " or " sad face " symbol and allergies with a skull and crossbones symbol. A review of in-service records revealed that the CNA staff was in-serviced on meal consumption by the in-service coordinator on 4/6-4/9/2010. A review of the lesson plan revealed that the in-service did not include staff education related to residents ' with food allergies. On 8/3/11 at 10:00AM a telephone interview was conducted with Resident # 1. He stated that on 7/28/11 around 12:00PM he was served lunch that included Hawaiian chicken glazed with pineapple chunks, 2 or 3 cherries and mixed vegetables. Resident # 1 stated that the cherries had mixed with the juice from vegetables. He stated that he picked up a cherry and put it in his mouth. His lips started tingling and his throat started to feel like it was closing. He stated that he knew he was in trouble. While he was holding his throat, he tried to wave to the Certified Nurse ' s Aide (CNA) who was serving lunch. He stated that he was not able to talk. A few minutes later a CNA noticed him and called the Nurse. On his way to his room, he felt his whole body was shaking and swelling. Resident # 1 stated that the nurse did not know what was going on until he coughed out the cherry from his mouth. The staff administered an [MEDICATION NAME] injection, but it did not work. He stated that he was given [MEDICATION NAME] and he felt better. He was transferred to the hospital via 911. On 12/15/11 at 11:27AM a telephone interview was conducted with the Registered Dietitian who was assigned to the resident. The Dietitian stated that Resident #1 had a known food allergy to zucchini. She stated that the resident chooses his meal each day off of the menu. This is done with a CNA. The Dietitian stated that it is the responsibility of the food service staff to know the ingredients in all food items, know resident specific food allergies and prevent incorrect food items from being served to the resident. The Dietitian stated that all modifications for food allergies are done by the food service staff in the kitchen. On 8/1/11 at 1:35PM the Dietary Aide Supervisor was interviewed. She stated that on 7/28/11 she was the " caller, " calling meal foods. She was responsible for informing the line staff what food items belonged on each tray. She stated that she was aware that Resident # 1 was allergic to zucchini and squash but she was not aware that the mixed vegetables had zucchini. The Dietary Aide Supervisor stated that she looked at the mixed vegetables and she did not see any zucchini. She thought that the mixed vegetables were the California Blend without zucchini. She stated that she is aware that the Italian Blend has zucchini. On 8/1/11 at 2:25PM Dietary Aide # 2 was interviewed. He stated that he worked on the end of the tray line. He stated that he was working on the day of the incident. He was aware that the resident was allergic to zucchini and squash, but he did not see any zucchini or squash on the resident ' s tray. He stated that he was not aware that the Italian, California or Normandy blends of mixed vegetables contained zucchini. On 8/1/11 at 3:20PM a telephone interview was conducted with CNA # 2. She stated that on 7/28/11 she gave the tray to Resident # 1 and left without opening the cover. CNA # 2 stated that the resident is alert and wants to open his tray. She stated that she was not aware that the resident ' food allergy was written on the meal ticket. She was also not familiar with the meal ticket symbol for food allergy. CNA # 2 stated that she was not aware that the resident had a food allergy. She stated that prior to the incident she checked the meal trays for the resident ' s name and room number, but never checked diet or allergy. On 8/1/11 at 11:50AM Dietary Aide # 1 was interviewed. She stated that she works as the starter in the tray line. Dietary Aide # 1 stated that on the menu ticket a sad face means food allergy or that a resident does not like the food. A happy face means a resident likes the food. On 8/1/11 at 4:05PM CNA # 3 was interviewed. CNA #3 stated that a resident food allergy is identified on the bottom of the meal ticket. She stated that there are 2 faces on the meal ticket. The smiling face means not allergic and the sad face means allergic to certain food. On 8/1/11 at 4:25PM CNA # 4 was interviewed, she stated that the symbol for food allergy is a sad face or not smiling face. On 8/1/11 at 4:45PM CNA # 5 was interviewed. CNA # 5 stated that she never noticed the symbol for allergy on the meal ticket. She was not sure if the skull symbol was on the meal ticket until the 7/28/11 incident. On 7/28/11 at 2:00PM the Dietitian #2 was interviewed. She stated that allergies are recorded in the meal ticket designated by a small skull and crossbones. A follow-up telephone interview was conducted with the Dietitian on 8/5/11 at 9:20AM. She stated that in the past [AGE] years the dietary staff was in-serviced that the skull and crossbones symbol stands for food allergies. The Dietitian stated that the skull and crossbones are for dietary staff only. She was not aware of training or in-servicing for the nursing department. On 8/5/11 at 1:20PM a telephone interview was conducted with the Food Service Director. He stated that on orientation a dietary aide is shown a sample of the meal ticket and how to identify the symbols. According to the Food Service Director, a happy face indicates that a resident likes or can have that food, a sad face indicates that a resident does not like or cannot have that food and the skull and crossbones is to alert the staff the food is " not good. " The Director of Food Services stated that he has never in-serviced staff on specific food allergies, only the 3 symbols. He stated that the Dietitian also gives the staff in-service. A follow-up interview was conducted on 12/15/11 at 11:52AM. The Food Service Director stated that the cook informs the kitchen line staff of the ingredients of the food items that are being served. 415.12