Every finding on record at Safire Rehabilitation of Southtowns, L L C

Based on observation, interview, and record review conducted during an Abbreviated survey (complaint #2717679), the facility failed to keep the resident's environment free from accidents. Specifically, one (1) (Resident #1) of three (3) residents reviewed for accidents was transferred via mechanical lift by Certified Nurse Aide #1, without assistance of another staff member, and the resident fell out of the sling sustaining a laceration on their leg.The findings include: The policy and procedure titled Resident Transfer Using a Total Mechanical Lift, dated 11/03/2017, documented two (2) or more caregivers must be present and assisting at all times during the use of a total mechanical lift, and there must be a minimum of two (2) caregivers interfacing with their hands on the resident and the total mechanical lift. Resident #1 was admitted to the facility with dementia and type 2 diabetes mellitus. The Minimum Data Set (a resident assessment tool), dated 01/30/2026, documented Resident #1 usually understands others and usually was understood by others; was cognitively impaired; and needed assistance of two (2) staff members for transfers. The care plan profile, dated 01/14/2026, documented Resident #1 was dependent on two (2) staff members for transfers with a gait belt (a safety device worn around a patient's waist to assist with mobility and prevent falls during transfers and walking). Interdisciplinary progress note, dated 01/14/2026 at 9:23 PM, documented Registered Nurse Supervisor #1 was called to Resident #1's room. Resident #1 was noted to be on their left side near the mechanical lift with a six-inch laceration on their left leg. Resident #1 was subsequently sent to the emergency room. Interdisciplinary progress note, dated 01/15/2026 at 1:12 AM, documented the sling and the mechanical lift were examined by Registered Nurse Supervisor #1 and the Director of Nursing, and were found to be in good working order. The investigation of Resident #1's fall, dated 01/21/2026, documented Certified Nurse Aide #1 used the mechanical lift by themselves and stated they could not find another staff member to assist them with the transfer. Certified Nurse Aide #1's personnel file documented they received training for mechanical lift transfers of residents during their orientation with the facility. During an observation and interviews on 04/29/2026 at 8:15 AM, Resident #1 was transferred from their bed to their chair by Certified Nurse Aide #2 and Certified Nurse Aide #3, and there were no issues with the transfer. Certified Nurse Aide #2 stated there should always be two (2) staff members when they transfer with a mechanical lift for the residents' safety. Certified Nurse Aide #3 stated they worked on 01/14/2026 and they did not recall Certified Nurse Aide #1 asking them for help. Certified Nurse Aide #3 further stated there were two (2) aides on each hallway working that shift. During an interview on 04/29/2026 at 9:05 AM, Registered Nurse Supervisor #1 stated Certified Nurse Aide #1 admitted to them they transferred Resident #1 by themselves. Additionally, Registered Nurse Supervisor #1 stated they recalled Resident #1 was found on the floor near the mechanical lift and saw the laceration after they put Resident #1 into the bed. During an interview on 04/30/2026 at 11:00 AM, Resident #1's physician stated they did not believe it was harm because the resident did not receive stitches, instead, they received Steri-Strips (adhesive tape that are used for small, shallow cuts). Resident #1's physician further stated the resident was not admitted to the hospital and their baseline did not change. During an interview on 04/30/2026 at 11:30 AM, the Director of Nursing stated they expected Certified Nurse Aides to always use two (2) staff members before they transferred anyone with a mechanical lift. The Director of Nursing further stated that you need two (2) staff members for resident safety. During an interview on 04/30/2026 at 12:04 PM, the Regional Clinical Educator stated Certified Nurse Aide #1 received training for mechanical lift transfer. The Regional Clinical Educator further stated there should be a minimum of two (2) people to transfer a resident in a mechanical lift. During an interview on 04/30/2026 at 12:14 PM, the Administrator stated they expected staff to find other staff members to transfer a resident with a mechanical lift. The Administrator further stated Certified Nurse Aide #1 should have asked someone for help before they attempted to transfer a resident with a mechanical lift, and there was enough staff, including a nursing supervisor, that could have helped Certified Nurse Aide #1. During an interview on 04/30/2026 at 12:28 PM, Certified Nurse Aide #1 stated they did transfer Resident #1 by themselves. Certified Nurse Aide #1 further stated they could not find anyone to help them transfer Resident #1. Additionally, Certified Nurse Aide #1 stated they knew they should not have transferred Resident #1, but Resident #1 kept asking to put them to bed. Certified Nurse Aide #1 stated it was the end of their shift at 10:00 PM, and they did not want to leave the resident for the next shift to take care of them. Furthermore, Certified Nurse Aide #1 stated they never intended to hurt Resident #1, and they felt awful that Resident #1 was hurt. Certified Nurse Aide #1 concluded by stating they were terminated from the facility after this incident. New York Codes, Rules, and Regulations (NYCRR) 415.12(h)(1)

Based on observation, interview, and record review conducted during a Standard and Complaint (#2655733) survey completed on 12/09/2025, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for three (Green Unit, Yellow Unit, and Blue Unit) of three test trays. Specifically, food and beverages during meals were served at suboptimal temperatures and were not palatable. Residents #4, #7, #12, #41, #81, #82, #88, #92, #106 and #136 were involved.The findings are:The facility policy and procedure titled Food Preparation and Service dated 06/26/2018 documented food service employees shall prepare and serve food in the manner that complies with safe food handling. The danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods must be maintained at 40 degrees or below or at 136 degrees or above. During a Resident Council Meeting with survey staff on 12/02/2025 at 11:28 AM, Residents #7, #41, #88, #92, #106, and #136 all stated food was served cold for all meals, was bland with no taste, and portion sizes were too small. Additionally, all resident council members stated they received too much pasta and was always added into the meal.During an interview on 12/01/2025 at 7:57 AM, Resident #12 stated the food was hit or miss and was always served lukewarm, vegetables were either cold or mushy, or the food was dry.During an interview on 12/01/2025 at 9:54 AM, Resident #4 stated the food was disgusting, had no taste and was served cold even when the plate was covered. Further interview on 12/02/2025 at 9:23AM, Resident #4 stated their breakfast was cold and pancakes tased like rubber.During an interview on 12/01/2025 at 1:18 PM, Resident #7 stated meals were served cold and at times they received burnt grilled cheese They stated on Thanksgiving they were served a slice of deli meat turkey with gravy that was cold, salty and gross.During an interview on 12/02/2025 at 9:47 AM, Resident #82 stated meals were served cold, there was no variety, received too many saucy foods and pastas for lunch.During a lunch meal observation on 12/04/2025 the first dietary cart arrived on the [NAME] Unit at 12:14 PM and the second cart arrived at 12:24 PM. All the lunch trays from the [NAME] Unit were passed to the resident's by 12:41 PM. The Food Service Director was not present for the test tray and the temperatures were taken by the state surveyor using a digital thermometer at 12:44 PM. The temperatures and taste were as follows:-Sliced turkey, 105.1 degrees Fahrenheit - tasted salty, pale in color, unappealing, not palatable.-Mashed potatoes, 122.7 degrees Fahrenheit - lacked flavor, warm but not hot.-California vegetable mix, 105.8 degrees Fahrenheit - cool to taste, watery, mushy, flavorless.-Milk, 51.3 degrees Fahrenheit - was cool but not cold-Orange drink, 57.7 degrees Fahrenheit- cool to taste but not cold, flavor was weak and tasted watered downDuring an interview on 12/04/2025 at 1:00 PM, Resident #4 stated their lunch was terrible and had thrown most of it out. They stated it was cold; vegetables were watery and lacked flavor. The grilled cheese was burnt and not edible.During a lunch meal observation on 12/04/2025 the dietary carts arrived on the Yellow Unit at 12:29 PM. All lunch trays from the Yellow Unit were passed to the resident's by 12:40 PM. The test tray temperatures were taken by the Food Service Director at 12:45 PM using the facility's thermometer. The temperatures and taste were as follows:-Sliced turkey, 100 degrees Fahrenheit - single slice of turkey on plate, light beige in color, unappealing, cool to taste, and had no flavor.-California vegetable mix, 116 degrees Fahrenheit - cool to taste, bland and no flavor-Milk, 48 degrees Fahrenheit- tasted cool but was not cold-Orange drink, 58 degrees Fahrenheit - cool to taste but not coldDuring an interview on 12/04/2025 at the time of the test tray, the Food Service Director stated that the temperatures for the turkey and vegetables were low, they would have expected the hot foods to be served between 130-140 degrees and cold foods were to be served below 40 degrees Fahrenheit. The Food Service Director stated the turkey was not served with gravy per resident preference and were unaware of any cold food complaints from the resident council.During an interview on 12/04/2025 at 1:00 PM, Resident #92 stated they did not want the turkey, requested the alternate meal (hamburger) which was served warm, they stated the vegetables were bland, needed seasoning and could have been warmer.During an interview on 12/04/2025 at 1:02 PM, Resident #7 stated they did not eat the turkey, it was not appetizing and looked gross. They stated they did not like the texture of the mashed potatoes, they ate some of the vegetables and drank their boost.During a lunch meal observation on 12/04/2025 the first dietary cart arrived on the Blue Unit at 12:30 PM and the second cart arrived at 12:51 PM. All lunch trays for the Blue Unit were passed to the residents by 12: 58 PM. The test tray temperatures were taken by the Food Service Director at 1:03 PM using the facility's thermometer. The temperatures and taste were as follows:-Sliced turkey, 110 degrees Fahrenheit - flavorless, cool to taste, unappealing in color.-Brussel sprouts, 120 degrees Fahrenheit - mushy, lukewarm-Milk, 56 degrees Fahrenheit - cool to taste but not cold-Orange drink, 58 degrees Fahrenheit- cool to taste, flavor was weak and tasted watered downDuring an interview on 12/04/2025 at the time of the test tray, the Food Service Director stated they would expect the hot temperatures to be higher and the cold temperatures to be lower. They stated the turkey should have been served hotter and the brussels sprouts needed to be a little warmer. The Food Service Director stated there was no concern with food borne illness because the food had not been sitting out for four (4) hours.During an interview on 12/08/2025 at 2:24 PM, the Director of Nursing stated they were not aware of any cold food complaints made by the residents. They stated there was a resident food committee that met monthly but did not attend. The Director of Nursing stated they were usure what the exact temperatures should be to serve hot and cold foods but would be concerned with food borne illness if not maintained at the proper temperatures. 10 NYCRR 415.14 (d) (1) (2)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/09/2025, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This affected one (1) of one (1) Main Kitchen and one (1) (Green Unit) of three (3) Nourishment Rooms. Specifically, the Main Kitchen had issues with opened undated, outdated, and/ or unlabeled foods. [NAME] restraints were not being worn during food preparation. There was a water leak from plumbing in the dishwash area and the window air conditioning unit in the food preparation area was dust laden. In addition, a Nourishment Room refrigerator contained undated and/ or unlabeled food.The findings are:The policy titled Food Receiving and Storage, issued 06/26/2018 documented foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Food items and snacks kept on the nursing units must be maintained as indicated: all food items must be placed in the refrigerator located at the nurses' station and labeled with a use by date, all foods belonging to residents must be labeled with resident's name, the item, and the use by date, beverages must be dated when opened and discarded after twenty-four (24) hours, other opened containers must be dated and sealed or covered during storage. The policy titled Refrigerators and Freezers, revised 02/27/2020 documented the facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines for all refrigerators on the nursing units and in the Food Services Department. The Dietary Service Department personnel will surface clean the nourishment refrigerators on the nursing units daily and discard any outdated items. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened, and all food/ liquids dated past 24-hours should be discarded. Dietary Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates.The policy titled Food Preparation and Service, issued 06/26/2018 documented dietary staff shall wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.The policy titled Foods Brought by Family/ Visitors, revised 02/19/2020 documented food brought into the facility by visitors and family is permitted. Family members and visitors are requested to inform nursing staff of their desire to bring foods into the facility. All food is to be brought to the nursing station. Food brought by family/ visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility prepared food. Perishable foods must be stored in re-sealable containers that are labeled with the resident's name, the item, and the use by date. Beverages must be dated when opened and thrown out in 24 hours. Other food items must be dated and sealed or covered during storage and thrown out in 48 hours. The dietary staff will discard perishable foods every 24 hours on or before the use by date.The policy titled Sanitization, issued 06/26/2018 documented the food service area shall be maintained in a clean and sanitary manner. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The Food Service Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas.1.Observation in the Main Kitchen on 12/01/2025 between 7:35 AM and 8:20 AM revealed the following:-The reach-in cooler contained a small half-eaten dessert with no name or date, a zippered lunch box, a half-full ten (10) ounce container of Mexicali dip with no name, date, or manufacturer's date, about one (1) quart of chicken broth dated 11/21/2025, and about one (1) cup of cheese dip with no date. This cooler contained a small bin labeled Employee that was full of food. During an interview on 12/01/2025 at 7:40 AM, the Food Service Director stated there was a bin in the reach-in cooler for employees' food, but the bin had been superseded. Employees' food was in the rest of the cooler too, and it should not be. The Food Service Director stated they were unsure why the chicken broth was in this cooler, but it needed to be thrown out because of its date.-The walk-in cooler contained a tray of approximately ten (10) vanilla pudding cups with no date on cups or tray, a tray of various nourishments including pudding cups, cereal cups, and wrapped sandwiches with no date on individual items or tray, four (4) wrapped sandwiches on the rack with no date, a tray of fifteen (15) wrapped sandwiches with no date on sandwiches or tray, approximately five (5) pounds of sliced ham dated 11/18/2025, approximately four (4) pounds of egg salad dated 11/25/2025, approximately two (2) pounds of sliced turkey labeled Turkey 4 Sandwiches dated 10/24/2025, approximately one and a half (1 1/2) pounds of sliced turkey in a clear plastic container with no date, eight (8) ounces of chicken broth dated 11/22/2025, approximately twenty (20) hot dogs in a bucket dated 11/21/2025 or 11/24/2025 (unable to decipher handwriting), tray of cups of pickles and cups of cranberry with no date on cups or tray, approximately 40 ounces of a tomato and cucumber salsa dated 11/26/2025, a bucket of twenty (20) individual cups of diced tomato and cucumber with no date on the cups or the bucket, a tray of approximately twenty (20) sandwiches on the top shelf with no date on the sandwiches or the tray, approximately forty (40) croissants stored in two (2) bags with no date on the bags, approximately twenty (20) hot dogs in clear plastic wrap with no date and two (2) raw hamburgers in clear plastic wrap with no date.During an interview on 12/01/2025 at 7:45 AM, Dietary Aide #2 stated when foods were placed on trays in the walk-in cooler, there should be a date on the tray. They also stated they personally just placed the tray of vanilla puddings in this cooler this morning and they did not write the date on the tray.During an interview on 12/01/2025 at 7:55 AM, the Food Service Director stated trays of food in the walk-in cooler should have the date written on them. They stated no food item was kept longer than three (3) days, except breads could go up to five (5) days. If there was no date on the bags of croissants, they will get thrown out. All items in this cooler that are more than three (3) days old must be thrown out. The Food Service Director also stated the opened packs of hot dogs and hamburgers should have been labeled with the date they were removed from their original packaging. Additionally, on 12/01/2025 at 8:30 AM, the Food Service Director stated it was everyone's responsibility to ensure foods were labeled with the date they were made and to add a date to new packaging when food was removed from its original packaging. They stated checking dates on food was not a documented task, but they were personally on the lookout all the time for dates on foods, along with the Food Service Supervisor. At this time, the Food Service Director also stated the sliced turkey dated 10/24/2025 must have been mislabeled because they were certain it was from November and not October. -The window air conditioning unit had a visible coating of dust on its louvers and clumps of dust on the windowsill below. Additional observation revealed the window air conditioning unit was located approximately two (2) feet from the sink, approximately two feet from the oven, and approximately four (4) feet from the tray line.During an interview on 12/01/2025 at 10:40 AM, the Maintenance Director looked at the air conditioning unit and stated it needed to be cleaned. They opened the front louvers and determined there was no filter inside. They stated since there was no filter, cleaning it would be the responsibility of the Kitchen staff, not the Maintenance staff. During an interview on 12/01/2025 at 10:55 AM, the Food Service Director stated the window air conditioner needed to be cleaned, but they were not sure whose responsibility it was. -A bucket of water was observed under the plumbing to the right of the automatic dishwasher. During an interview on 12/01/2025 at 10:40 AM, the Maintenance Director ran the water from the food grinder and observed the water dripping from the plumbing into the bucket. They stated they were not aware of this leak.During an interview on 12/01/2025 at 11:00 AM, the Food Service Director stated they put a work order about the water leak in the facility's automated maintenance work order system back in August.During an interview on 12/01/2025 at 3:05 PM, the Maintenance Director stated they did receive a work order request for a Kitchen plumbing leak back in August, and they repaired it, and the current leak was a different issue.2. A continuous observation on 12/04/2025 from 11:56 AM to 12:52 PM of the Kitchen tray line for the lunch service revealed that [NAME] #1 was not wearing a beard cover to cover their facial hair while preparing residents' lunch trays.During an interview on 12/04/2025 at 12:52 PM, [NAME] #1 they stated they should have been wearing a beard guard, so their hair does not go into the food.During an interview on 12/04/2025 at 12:55 PM, Dietary Aide #1 stated they would expect staff with facial hair to be wearing a beard guard, so their hair does not go into the food.During an interview on 12/04/2025 at 1:03 PM, the Food Service Director stated they did not realize [NAME] #1 was not wearing a beard guard. They stated they have beard guards for facial hair and would expect staff to wear the beard guards, so hair does not get into the food.3.Observation in the [NAME] Unit Nourishment Room on 12/01/2025 at 8:55 AM revealed the following: -A sign on the refrigerator read, 4/24/24 Attention all staff any staff food or drink found in the refrigerator will be discarded immediately. -Another sign on the refrigerator read, This refrigerator is for resident use only! All items must be labeled with resident's name and date! Audits will be conducted spontaneously! Any items found unlabeled or over 3 days old will be discarded. Any employee belongings will be discarded as well.-The refrigerator contained a pizzeria box with chicken nuggets inside with no name or date, iced tea in a pitcher with no date, an opened box of orange juice with approximately 24 ounces remining and not dated when opened, garlic bread wrapped in tin foil with no name or date, a plate of food covered with tin foil that was labeled with a resident's name and no date, and a restaurant style foil container of ravioli with no name or date. There was also a bag labeled with a resident's name and room number and Don't Touch. Inside the bag was macaroni and cheese and ham. There was no date on the outer bag or inner container. The refrigerator also contained two foil containers of beans labeled with a resident's name and Don't Touch and dated 11/27/2025.During an interview on 12/02/2025 at 9:15 AM, the Food Service Director stated food in Nourishment Room refrigerators should be kept for a maximum of three (3) days. They stated resident families were typically good about labeling the foods that they brought in, but residents themselves were not as good. Residents needed to label and date their own foods before putting them in the Nourishment Room refrigerator or ask for assistance if they needed it. The Food Service Director stated if they discovered food in a Nourishment Room refrigerator that had a name without a date, they would personally talk to that resident, educate them about the importance of properly labeling their food, and add the date to their food if they could recall the date. If the resident was unable to recall the date the food was brought in, it would be discarded.During an interview on 12/04/2025 at 3:00 PM, the Director of Nursing stated food in the Nourishment Room refrigerators always needed to be labeled with the resident's name and date. It must be used within three (3) days for safety, to avoid potential foodborne illness. They stated the Dietary staff was responsible for checking the refrigerators in the Nourishment Rooms, but Nursing staff would also discard food if they noticed it was over three (3) days old.10 NYCRR 415.14(h)Subpart 14-1: 14-1.43, 14-1.110(d), 14-1.140

Based on observation, interview, and record review conducted during complaint investigations (NY00353449/786213) conducted during a Standard survey completed on 12/09/2025, the facility did not ensure sufficient staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not have sufficient nurse staffing on a 24-hour basis to adequately care for residents' needs. This involves Residents #2, #4, #7, #22, #41, #55, #67, #72, #77, #82.The findings are:Reference: F 561 Self DeterminationThe policy titled Nursing Department Staffing dated 12/28/2017, documented the facility maintained adequate staffing on each shift to ensure that their residents needs and services were met. Certified Nursing Assistants (CNAs) were available to provide the needed care and services of each resident as outlines on the resident's comprehensive care plan. The facility would provide sufficient numbers of licensed and non-licensed personnel (Registered Nurses, Licensed Practical Nurses, and Certified Nurse Aides) on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. The policy titled Emergency Staffing Call-in for Off Duty Personnel, revised 06/28/2019, documented in case of an emergency or disaster to meet minimum staffing and resident care needs, off-duty personnel shall be recalled to the facility as needed. The Nursing Administrator staff would be on-call to cover the emergency such as excessive licensed nurse call offs, weather emergencies, etc. The Administrator would contact department heads to contact ALL staff to come into the facility as assist the nursing staff with non-care interventions during emergency situations.The Dear Administrator letter 23-11 dated 06/30/2023 sent to nursing home administrators documented starting 04/01/2022 nursing homes were required to maintain at minimum daily average staffing hours equal to 3.5 hours per resident per day (HPRD) by a certified aid (CNA) and a licensed practical nurse (LPN) or registered nurse (RN). Out of such 3.5 hours, no less than 2.2 HPRD shall be provided by a certified nurse aide, and no less than 1.1 HPRD shall be provided by a Licensed Practical Nurse or Registered Nurses. The Facility assessment dated [DATE] documented the facilities staffing plan: one (1) Registered Nurse per regulation, eight (8) hours a day, seven (7) days a week and two (2) Licensed Practical Nurses in the building for all three (3) shifts. That applied to weekends as well. Minimum staffing numbers for staff providing direct care were as follows: -Director of Nursing Registered Nurse one (1) full time days, -Assistant Director of Nursing one (1) full time days, -one (1) Registered Nurse Minimum Data Set Coordinator full time days, -two (2) Licensed Practical Nurses (Monday - Friday days) (census dependent) including weekends ,-two (2) Charge Nurses (Monday - Friday days) (census dependent) including weekends , -two (2) Charge Nurses (Monday - Friday evenings) (census dependent) including weekends,-two (2) Charge Nurses (Monday - Friday nights) (census dependent) including weekends. The above does not include 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM supervisors.-7:00 AM to 3:00 PM shift: four (4) Certified Nurse Aides (Monday - Friday days) (census dependent) including weekends.-3:00 PM to 11:00 PM shift: three (3) Certified Nurse Aides (Monday - Friday days) (census dependent) including weekends.-11:00 PM to 7:00 AM shift: three (3) Certified Nurse Aides (Monday - Friday days) (census dependent) including weekends.1. The facility Daily Census Report by unit dated 10/31/2025 documented the following:-Blue unit, the total resident census was 38.-Green unit, the total resident census was 38.-Yellow unit, the total resident census was 40.Review of the facility nursing schedule titled Nursing Department 24-hour staffing sheet dated 10/31/2025 documented the following:-Blue unit, the 3:00 PM - 11:00 PM shift had one Certified Nurse Aide that left at 10:00 PM; one Licensed Practical Nurse 3:00 PM to 11: PM, and one Registered Nurse 3:00 PM - 7:00 PM. -Yellow unit, the 3:00 PM - 11:00 PM shift had zero Certified Nurse Aides listed and one Licensed Practical Nurse 3:00 PM - 11:00 PM.-Green unit, the 3:00 PM - 11:00 PM shift had two Certified Nurse Aides, one left at 9:00 PM: one Licensed Practical Nurse 3:00 PM - 7:00 PM and one Licensed Practical Nurse 7:00 PM - 11:00 PM.There was one Registered Nurse Nursing Supervisor 3:00 PM - 11:00 PM, two (2) Licensed Practical Nurse Nursing supervisors 7:00 PM - 11:00 PM (one training), and one Registered Nurse Assistant Director of Nursing called in to assist from 8:45 PM to 10:45 PM.A review of Resident Council minutes from October 2025 documented residents complained that on the evening shift on October 31st, 2025, there was no staff. Residents requested to invite Registered Nurse #6 (former) Assistant Director of Nursing to attend the next council meeting.A review of Resident Council Department Response Form dated 11/05/2025 documented Resident #106 complained they did not get their shower on the evening of 10/31/2025 and other residents complained there was no staff. Registered Nurse #6 (former) Assistant Director of Nursing documented a response dated 11/11/2025 that Resident #106 was correct, there were several call ins that evening; they personally came in to assist at 8:30 PM and put residents on the yellow unit to bed, signed by Registered Nurse #6 Assistant Director of Nursing on 11/11/2025.During an interview on 12/02/2025 at 9:23 AM, Resident #41 stated on the night of 10/31/2025 staffing was horrible in the facility, residents were afraid to ring for assistance because no staff was there. Resident #41 stated usually staff would come around and do rounds, but they did not. When the residents found out how many staff were in the facility, the residents just waited until someone came around to help them. Additionally, Resident #41 stated about 50 percent (%) of the staff working the evening shift (3:00-11:00 PM) were staff from the morning shift (7:00 AM-3:00 PM), sometimes even more. Wait times for call lights to be answered was typically a half hour in the morning and almost an hour on the evening shift, and weekend evenings were even worse.During a telephone interview on 12/04/2025 at 1:32 PM, Licensed Practical Nurse #13 stated they worked the evening shift (3:00 PM - 11:00 PM) on 10/31/2025 and stated they did work short staffed, as holidays tended to be a little shorter. They stated they try to help the aides, when possible, everyone tried to work as a team; some residents may have not gotten to bed before 11:00 PM, but they got to bed eventually.During a telephone interview on 12/0402025 at 1:32 PM, Certified Nurse Aide #3 stated they worked the evening shift (3:00 PM - 11:00 PM) on 10/31/2025 and there were multiple call offs. They stated there were two aides, including themself on the [NAME] unit, and one aide on the Blue unit, and no aides on the Yellow unit. They were eventually floated down to the Yellow unit and assisted Registered Nurse #6 (former) Assistant Director of Nursing with putting residents to bed. Certified Nurse Aide #3 stated residents had been touched, and rounds had not been completed for residents on the yellow unit when they floated down there, so they had to hustle and bustle to get residents toileted and into bed. During an interview on 12/04/2025 at 12:03 PM, Certified Nurse Aide #10 stated they worked a double (7:00 AM - 9:00 PM) on 10/31/2025 because there was no staff for the evening shift (3:00 PM - 11:00 PM). Certified Nurse Aide #10 stated they worked on the [NAME] unit with Certified Nurse Aide #3 and two nurses, and all their work was completed on the unit when they left at 9:00 PM. There was one aide on the Blue unit, and no aides the Yellow unit. Certified Nurse Aide #10 stated Certified Nurse Aide #3 went to the Yellow unit around 9:00 PM to assist with putting residents to bed. Additionally, Certified Nurse Aide #10 stated showers were not able to be completed that night. They added there have been times in the past that they worked that short, and a lot of morning staff would work doubles to help.During an interview on 12/05/2025 at 9:55 AM, Staffing Coordinator stated a lot of staff called off on 10/31/2025, but that was after they left for the day. The nursing supervisor tried to call people in, and nurses helped with aide duties.During an interview on 12/05/2025 at 3:15 PM, the Director of Nursing stated they were out of town during the week of 10/31/2025 so they were unable to come in when there were multiple call offs in the facility, or else they would have come in to help. They stated Registered Nurse #6 Assistant Director of Nursing (former) came in and helped put people to bed on the Yellow unit, and all the nurses helped when they could. They have the right to call off. The Director of Nursing stated it was not brought to their attention that showers were unable to be completed on 10/31/2025, or any other day, due to short staffing. They would have expected that information to have been relayed to them. During an interview on 12/09/2025 at 10:10 AM, the Administrator stated the emergency minimum staffing for each shift would be three nurses and three aides to the building, and they were aware of one day recently where the facility did not meet their minimum numbers for the evening shift, 10/31/2025. The Administrator stated they came in to assist with non-nursing duties on 10/31/2025 during the evening. Additionally, the Administrator stated they were aware that some residents did complain about staffing on 10/31/2025, but the staff worked as hard as they could with what they had, but they were unable to recall if showers were able to be completed.2a. During multiple observations on 12/02/2025 at 9:43 AM, 12/03/2025 at 8:56 AM, and 12/04/2025 at 9:06 AM, Resident #7 was in their bed, in their pajamas.During an interview on 12/01/2025 at 1:08 PM, Resident #7 stated they have expressed to staff, including Licensed Practical Nurse Unit Manager #1 they wanted to be out of bed by 7:45 AM, but was told staff had to change residents who were not changed all night. Resident #7 stated staff do not usually get them up until 11:00 AM, sometimes later. Resident #7 stated I do not get to choose what time I get up, and that was not right.During a telephone interview on 12/04/2025 at 5:11 PM, Licensed Practical Nurse #5 stated they worked the night shift (11:00 PM to 7:00 AM) and were aware Resident #7 wanted to be up by 7:45 AM. The resident used to be on the early riser list due to needing assistance in the dining room, for safety reasons, and because their preference was to be up by 7:00 AM. Licensed Practical Nurse #5 stated sometimes staff could not get to Resident #7 before the shift was over because there was not enough staff. Sometimes there was only one aide, or none, so they would complete aide rounds on top of completing their nursing duties, sometimes they would have one aide float between two units to help.During an interview on 12/05/2025 at 2:59 PM, Licensed Practical Nurse Unit Manager #1 stated they were aware that Resident #7 wanted to be out of bed by 7:00 AM. They stated staff should be following Resident #7's care profile preferences, but because of low staffing they could not always honor the resident's choices.During a follow up interview on 12/05/2025 at 4:40 PM, the Director of Nursing stated they expected staff to honor Resident #7s preferences for getting up at 7:00 AM, and if there was not adequate staff to do so on the night shift, then they should pass it along to the morning shift so that Resident #7 could be their priority. If there was an emergency staff may not have been able to honor their preference, they would expect staff to document that.2b. During an interview on 12/02/2025 at 9:37 AM, Resident #82 stated they had not had a shower in three weeks, since they admitted to the facility; they were itchy, and it bothered them. During an interview on 12/05/2025 at 12:10 PM, Certified Nurse Aide #3 stated there was not enough staff on the evening shift to give Resident #82 an actual shower because they were a two assist, so they gave them a bed bath on their shower days. They stated if there was not enough staff then they were not able to give all their showers, they have asked nurses to help but they were just as busy.During an interview on 12/08/2025 at 8:38 AM, Licensed Practical Nurse Charge Nurse #3 stated they could put Resident #82 into the shower with a Hoyer (mechanical lift requiring two people assist) into the shower chair, it just depended on how many staff they had that day. The nurses needed to help the aides when it came to situations like that. Licensed Practical Nurse Charge Nurse #3 stated the unit can be very busy and the staff may not always be able to get to showers.3. Resident/family interviews on 12/01/2025 revealed the following:9:48 AM, Resident #4 stated there was not enough staff in the facility to care for the residents daily; they wait at least a half hour at minimum for their call light to be answered, it did not matter what time of day it was. Resident #4 stated the night prior they rang their call light for a pain pill at 11:30 PM and staff did not answer it until 5:30 AM.10:07 AM, Resident #135 stated they must wait around 45 minutes for staff to answer their call light on a regular basis, and on the weekends the wait time was even longer. Resident #135 stated there have been days when there was not enough staff to get them out of bed or administer their nightly medications.11:57 AM, Resident #128 stated they were mostly independent and getting an aide to help you was like pulling teeth. They have had their call light on from 9:00 AM to 3:00 PM without anyone answering it or checking on them. They stated their showers were on Fridays, they would gather their things for the shower, but no one would ever come. They stated they had not had a shower in three months, it was supposed to be on the 7:00 am to 3:00 PM shift.12:58 PM, Resident #72's family member stated there was a delay in care due to lack of staff in the facility, especially on the weekends. There was typically one nurse and two aides for the whole floor.1:08 PM, Resident #7 stated they wait a half hour or longer for their light to be answered on a regular basis. There were times when they would be on the toilet, ring their bell, staff would tell them they had to get another aide to help them, and then take even longer to return. Staff have even shut off the call light and never returned.3:09 PM, Resident #67 stated there were not enough aides in the facility, especially on the weekends and holidays. Staff call off, the shifts were not filled and there was a delay in care being provided when that occurred.Resident/family interviews on 12/02/2025 revealed the following:9:18 AM, Resident #2 stated the facility staffing was worse on weekends, if they put their call light on, they would wait hours for it to be answered. Normal wait time was between a half hour to one hour; it took a long time for staff to come and change their incontinent briefs.9:30 AM, Resident #82 stated when they ring the bell and call for help, it takes an hour, sometimes an hour and a half, across all shifts, for anyone to answer. There was a delay in getting staff into complete care. Between shifts nobody answered lights. They do not even come in to tell you they will be back and do not return.10:55 AM, Resident #22's family member stated they come and visit every weekend, and staffing always seems very light. There was one time they were visiting, and their family member rang the bell because they had soiled themselves and the light was not answered for thirty minutes.11:45 AM, Resident #55's family member stated the facility was understaffed and staff were over worked. Their family member had fallen twice and was constantly in the same saturated brief for extended periods of time due to understaffing.3:51 PM, Resident #77 stated the facility could use more staff, sometimes it took three (3) hours for staff to answer your call light, but typically it was a half hour. The weekends were especially bad. Staff say they will be with you in a minute but do not come back for an hour then you're told the same thing.Additional staff interviews revealed the following:12/03/2025 at 11:27 AM, Certified Nurse Aide #13 stated staffing was awful; they're usually working with two or three Certified Nurse Aides on the unit, and for 40 people it was too much. Certified Nurse Aide #13 stated even when there were four aides to the unit, they would each have ten residents. On their assignment, out of those ten residents, nine were two assists and five residents needed assist to eat. So, it was very difficult to get to everyone and do everything that they needed in a timely manner. Certified Nurse Aide #13 stated the weekends staffing were even worse and residents were left for hours without getting changed at times. The nurses were usually working with one nurse per unit so they cannot assist the aides with care, passing trays, or feeding. Tee aides were skipping their breaks to make sure residents were changed and fed, and then were yelled at for skipping their breaks.12/04/2025 at 9:11 AM, Licensed Practical Nurse #12 stated when there was only one nurse to the unit for 40 residents, they were not able to get their work done. If they were down aides that made it even more difficult, because they try to help the aides but can barely do that.12/04/2025 at 1:32 PM, Certified Nurse Aide #3 stated all shifts were short staffed occasionally. A general complaint from residents on the evening shift was that showers were not done and residents were not gotten out of bed, the staff just try to reassure the residents that things will be done as soon as they can get to it, pass things on to the next shift if they were not able to complete them, but they were not sure if things were completed after they left or not.During an interview on 12/05/2025 at 9:55 AM, the Staffing Coordinator stated if there were multiple call offs, they would contact the staffing agency they utilized to see if someone was able to come in. On holidays they purposely overstaff the facility in case staff did not show up.During an interview on 12/05/2025 at 3:15 PM, the Director of Nursing stated they expected there to always be an adequate number of staff in the facility to provide the care to residents in accordance with the plan of care. If there were call offs, they would try to have other staff come in to fill the open positions.During an interview on 12/09/2025 at 10:10 AM, the Administrator stated some staff have said they had issues getting their work done even when there was full staff, but it had not been conveyed to them that they were having trouble completing care. The Administrator stated the staff should relay their issues to their supervisor or department heads, who would bring it to their attention.10 NYCRR 415.13(a) (1) (i-iii)

Based on observation, interview and record review conducted during a complaint investigation (Complaint #'s 786244 and 2655733) during the Standard survey completed on 12/09/2025, the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (3) (Yellow, Blue and Green) of three (3) resident units. Specifically, there were stained privacy curtains in resident rooms (first floor-Yellow unit); dirty shower room floors/walls, ceiling tiles in disrepair, and a toilet seat in disrepair (first floor-Blue unit); oxygen (02) concentrator filters covered with thick grey dust, hair in shower drain, personal resident items in shared bathroom and shower room; ripped and stained mattress; lack of paper towels for staff and resident use, and malodorous odors in resident areas (second floor-Green unit). Residents #2, #5, #67 and #72 were involved. The findings are: The policy titled Cleaning and Disinfection of Resident- Care Items and Equipment, dated 02/01/2017, documented resident-care equipment, including reusable items and durable medical equipment would be cleaned and disinfected to current CDC (center for disease control) recommendations for disinfection and the OSHA (occupational safety and health administration) bloodborne pathogens standard. Semi-critical items consisted of items that may come in contact with mucous membranes or non-intact skin (respiratory therapy equipment) Such devices should be free from all microorganisms. Reusable items were cleaned and disinfected or sterilized in between residents (durable medical equipment) according to manufacturer's instructions. Infection control compliance rounds would be conducted to ensure compliance with infection control standards and oversight of resident specific personal care items. The Nursing Department was responsible for replacing and labeling residents personal care items with room number and date distributed; items included soap, body wash, lotion, etc. The undated policy titled Maintenance Service documented maintenance service shall be provided to all areas of the building, grounds, and equipment. The Maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel included maintaining the building in good repair and free from hazards, providing routinely scheduled maintenance service to all areas. The Maintenance Director was responsible for developing and maintaining a schedule of maintenance services to assure that the buildings, grounds, and equipment were maintained in a safe and operable manner. The undated facility document titled Housekeeping Procedure Manual-Cleaning Resident & Non-Resident Areas documented the purpose was to improve sanitation and ensure the highest level of cleanliness throughout the facility, to control cross contamination, the spread of bacteria and infection and to maintain the outward appearance of the facility. Daily cleaning of resident rooms consisted of cleaning all vertical and horizontal surfaces, including the bed. Complete detailed room cleaning was performed monthly, and each housekeeper was responsible for one (1) per day. A complete room cleaning included disinfecting furniture and any beds located within the room and the removal, washing; bed washing and disinfection included to inspect the mattress for any damage, if any was discovered, notify supervisor; rehanging of cubicle curtains within the room at least semi-annually or as needed. Showers were cleaned to maintain cleanliness, sanitation, optimum levels of safety, to control the spread of infection and bacteria to minimize unpleasant odors and maintain the outward appearance of the facility. Safety precautions included to report any damage or problems to supervisor immediately. Cleaning a shower room included inspecting the area and picking up any large pieces of trash, linen, clothing, etc.; wash walls, windowsills and ledges with disinfecting solution, clean shower stall, shower curtains, and partitions; sweep floor, then damp mop floor, including inside of stall showers and against all walls. The job description of a housekeeper documented they were to implement required housekeeping procedures in an efficient, cost-effective manner meeting all federal, state, and local requirements while providing a safe environment for the residents. Specific job functions: maintained resident room by cleaning restrooms, walls, baseboards, doors, ceilings, mirrors, dusting, washing windows, removing trash, etc., dust and cleaned all furniture and fixtures in the resident rooms, day rooms, nursing stations, and shower rooms using various cleaners. Review of the undated (formal name) Healthcare oxygen concentrator manual documented the air filter prevented dirt, dust, and lint from entering the unit. The manual further documented the air filter and connector should be cleaned at least once a week using the following steps: remove the air filter located on the back of the unit; wash in a solution of warm water and dishwashing detergent; rinse thoroughly with warm tap water and towel dry. The manual documented to clean the concentrator exterior cabinet as needed using a damp cloth or sponge with a mild household cleaner and wipe it dry. First Floor: Intermittent observations and interviews revealed the following: YELLOW UNIT- Resident Rooms: -12/03/2025 at 11:40 AM, privacy curtain in Resident room [ROOM NUMBER] at the door was discolored a brownish-gray color. The privacy curtain in the middle of the room was soiled with multiple dark marks on the lower half that appeared to be food or beverage splatter.-12/04/2025 at 9:00 AM, privacy curtain in Resident room [ROOM NUMBER] had was soiled with a black debris. During an interview on 12/03/2025 at 11:40 AM, the Maintenance Director stated both privacy curtains in Resident room [ROOM NUMBER] needed to be washed. During an interview and observation on 12/04/2025 at 9:00 AM, Housekeeper #1 stated that the privacy curtain in Resident room [ROOM NUMBER] was washed but they were probably stained. They stated they thought maintenance takes care of the curtains but, they were not sure. They stated that it was not homelike. During an interview on 12/05/2025 at 10:18 AM, Maintenance Director stated there was only one spare privacy curtain for the entire facility to swap out for stained curtains, and they could not find any others to replace the stained curtains. They plan on ordering more but not sure when that would be. Laundry was supposed to wash the soiled curtains but can only do one at a time. BLUE UNIT-Resident Room, and Shower Room -12/03/2025 at 12:30 PM, the toilet seat in the bathroom of Resident room [ROOM NUMBER] was loose; when pushed, the toilet seat moved approximately five (5) inches side to side. During an interview on 12/03/2025 at 12:30 PM, Resident residing in room [ROOM NUMBER] stated the toilet seat in their bathroom was loose and it bothered them. -12/04/2025 at 12:21 PM, the shower stall had approximately 10 (ten) small black fuzzy balls of what appeared to be hair on the floor, pink/orange debris on the wall and floor where they meet approximately half an inch high up the shower wall; the ceiling tile above the shower stall where the circular light fixture was centered in, had a three by five foot tan circular area with a dark brown ring around it, that was bowing, damp, and soft to the touch. During an observation and interview on 12/04/2025 at 12:23 PM, Certified Nurse Aide #13 stated the shower stall should have been cleaned by the certified nurse aide after they gave a shower. Someone forgot to clean it up, but they should have. They stated they thought maintenance cleaned the shower stalls because they never saw housekeeping in the shower rooms. They stated the ceiling tile in the shower stall had been bowing and discolored for about four (4) months, maintenance was aware; it made them nervous to give a shower in that area because the tile could fall on a resident's head. During an observation and interview on 12/04/2025 at 12:28 PM, Registered Nurse #3 Unit Manager stated a certified nurse aide had not been back to clean up after they gave a shower yet; the shower stall could use some scrubbing and housekeeping was responsible for cleaning the shower stall walls and floors. They stated the ceiling area in the shower stall had been fixed previously because there was a plugged drain in the shower room directly above that one and it leaked down into the shower room. Registered Nurse #3 Unit Manager then touched the ceiling tile and stated they did not know the ceiling tile was damp and would let maintenance know. During an observation and interview on 12/04/2025 at 12:35 PM, The Regional Plant Operation Director poked the ceiling tile in the shower room and their index finger went directly through the tile, stated it was damp; they exited the shower room, and stated to the Administrator, it was old; they were going to check the shower room on the unit directly above. During a follow up interview on 12/04/2025 at 12:45 PM, The Regional Plant Operations Director and Maintenance Director stated the shower room was dry upstairs, so the leak may have been from the night prior or earlier that morning; they pulled a large clog of hair out of the drain upstairs and the drain started working again. During an observation and interview on 12/04/2025 at 8:52 AM, the Housekeeping/Laundry Supervisor stated the certified nurse aides were responsible for cleaning the shower stall and equipment after use. They stated they would expect the housekeeping staff to mop the shower room floors daily but had to find out who cleaned the wall tiles. Second Floor: Intermitted observations and interviews revealed the following:GREEN UNIT- Resident Rooms, Shower Room -12/01/2025 at 9:18 AM, Resident #2 was observed lying in bed and receiving oxygen at three (3) liters per minute via nasal (nose) cannula administered through an oxygen concentrator; the outside of the oxygen concentrator was dusty and the sponge like filter to the back of the concentrator was covered in thick grey dust. -12/01/2025 at 9:23 AM, Resident room [ROOM NUMBER] bathroom was without paper towels and there were four (4) unlabeled, used eight (8) ounce bottles of body wash on the sink ledge. -12/01/2025 at 9:35 AM, Resident #5 was observed lying in bed, receiving oxygen at two (2) liters per minute via nasal (nose) cannula administered through an oxygen concentrator. The outside of the oxygen concentrator was observed to be dusty and the sponge like filter to the back of the concentrator was covered in thick grey debris. -12/01/2025 at 10:20 AM, Resident #67's air mattress outer waterproof cover was ripped and peeling revealing a large, brown/red stained area. -12/02/2025 at 8:44 AM, Resident room [ROOM NUMBER]'s shared bathroom floor was tacky, with a malodorous urine odor, grout lines between tiles surrounding toilet were dirty and dark black in color. There were two (2) unlabeled, used, eight (8) ounce bottles of body wash and one (1) uncapped, unlabeled, used, four (4) ounce bottle of body lotion on the sink ledge remained. Additionally, there were no paper towels present. -12/02/2025 at 8:52 AM, Resident #2's oxygen concentrator and filter remained soiled.-12/03/2025 at 8:30 AM, Resident #2's oxygen concentrator remained soiled and unchanged.-12/03/2025 at 10:37 AM, Resident #67's air mattress remained stained and in disrepair.-12/03/2025 at 11:11 AM, shower room stall had four (4), unlabeled, used, eight (8) ounce bottles of body wash present on hand railing; clump of hair on the floor in the corner of the stall and hair covering the drain; the floor had debris and candy wrappers on floor and in the shower stall. -12/03/2025 at 11:27 AM, personal items remained in room [ROOM NUMBER]'s shared bathroom, the floor remained tacky, the malodorous urine odor remained, grout remained black in color.-12/03/2025 at 4:40PM, Resident #5's oxygen concentrator remained dust laden.-12/04/2025 at 8:52 AM, Resident #5's oxygen concentrator remained dust laden. During an interview on 12/03/2025 at 10:37 AM, Resident #67 stated their air mattress did not hold air when they were lying in it, and it alarmed all the time. They stated it had been like that for 2-3 weeks and that maintenance had looked at it, but did not do anything about it; it was ripped and unsanitary. During an interview on 12/03/2025 at 11:29 AM, Certified Nurse Aide #12 stated body wash and lotion should be labeled by whoever was placing them in the resident's room for infection control purposes. During an observation and interview on 12/03/2025 at 11:45 AM, Housekeeper #4 stated Resident room [ROOM NUMBER]'s bathroom smelled like urine. The grout was a mess and that the urine odor absorbed into the floor. It should not smell like that and was not homelike. They stated facility floor techs do not go into resident rooms/bathrooms, they just clean the hallway floors on the unit. Housekeeper #4 stated they do not carry paper towels on their housekeeping carts. Only the Housekeeping/Laundry Supervisor, Maintenance Director and Administrator have access to the paper towels. They stated if paper towels were available, they replace them as needed. They stated it was unsanitary not to have access to paper towels when hands were washed. Additionally, they stated there were eight (8) resident rooms without paper towels on the [NAME] Unit that day. During an interview on 12/03/2025 at 11:29 AM, Certified Nurse Aide #12 stated there has been a shortage of paper towels, toilet paper accessible to them and they have had to give residents boxes of tissues to use as toilet paper. They stated they go to different areas, rooms to use paper towels to dry their hands. They stated they tell housekeeping if they were present; and has reported it to the Housekeeping/Laundry Supervisor and told they were out of stock. During an observation and interview on 12/03/2025 at 11:57 AM Resident #72's bathroom did not have paper towels available, and the toilet paper was on the edge of the sink. There was no toilet paper holder in bathroom. The Family member present stated the resident's room had been without paper towels now for twelve days and that the bathroom had not had a toilet paper holder since resident was moved into that room. During an interview on 12/04/2025 at 8:28 AM, the Director of Nursing/Infection Preventionist stated all body washes and lotions should be labeled, and have caps present on them to prevent cross contamination. Additionally, they stated personal care items should not be stored in the bathroom for infection control reasons. During an interview on 12/04/2025 at 8:28 AM, the Director of Nursing/Infection Preventionist stated Resident room [ROOM NUMBER]'s bathroom had an odor. They stated the bathroom needed to be disinfected, deep cleaned for a homelike environment. During an interview on 12/04/2025 at 8:41 AM, Registered Nurse #5 stated the shower room stall was unsanitary due to the floor having dirt debris, clumps of hair, and wrappers on the floor. They stated the nursing aides should be cleaning the shower stall after resident care and then letting housekeeping know if additionally, cleaning was needed. They stated the shower stall was not homelike and should be cleaned thoroughly for infection control purposes. During an observation and interview on 12/04/2025 at 9:18 AM, Registered Nurse #5 stated the maintenance department places mattress on beds and that if there was an issue with a mattress, they would place a work order into the computer. Registered Nurse #5 stated Resident #67 has never brought any concerns regarding their mattress to them. Registered Nurse #5, removed bottom sheet covering mattress and stated the mattress looked unsanitary due to the outer waterproof cover being ripped, peeling and was stained. Additionally, they stated in the past they have been told the facility did not have replacement mattresses available. During an observation and interview on 12/04/2025 at 9:25 AM, Certified Nurse Aide #10 stated Resident #67's air mattress was ripped, stained and was not sanitary. They stated the Housekeeping/Laundry Supervisor was aware of it and believed an unknown nurse placed an electronic work order about a month ago. They stated the air mattress alarms all the time and that Resident #67 will not sleep with their head at the head of the bed due to the unsanitary condition of the mattress. During an observation and interview on 12/04/2025 at 8:52 AM, the Housekeeping/Laundry Supervisor stated the nursing aides were responsible for cleaning the shower stall and equipment after use. They stated they would expect the housekeeping staff to mop the shower room floors daily but had to find out who cleaned the wall tiles. They stated disinfectant was supplied for sanitizing the equipment in the shower room but that it disappears all the time. There was no disinfectant for sanitizing present in the shower room. Additionally, they stated prices for supplies have gone up and their budget had not changed. They stated they have to supply rooms for a 120 people and the kitchen with paper towels and they only order supplies once a month with the Administrator. They stated supplies, paper towels, were limited and they do not have enough to supply the whole building. They stated they have run out and they must tell the staff, Sorry. During an interview on 12/04/2025 at 10:37 PM, Registered Nurse #5 stated nurses were responsible to change oxygen tubing weekly and they believed the maintenance department was responsible to clean the oxygen concentrators and filter. Registered Nurse #5 stated Resident #5's filter was covered in dust and should be cleaned. During an interview on 12/05/2025 at 7:20 AM, the Director of Nursing/Infection Preventionist stated approximately a week ago a staff member brought Resident #67's mattress to their attention and it was discussed at morning meeting. They stated Resident #67's mattress was supposed to be swapped out with a regular mattress because Resident #67 did not have any wounds; requests for replacement mattress was not placed in the electronic work order system if it is an emergency, they call the Maintenance Director directly. Additionally, they stated there have been no concerns brought to their attention regarding lack of supplies. They stated it was important for resident bathrooms to have paper towels so staff can dry their hands after washing them for infection control purposes. During an interview on 12/05/2025 at 9:45 AM, Maintenance Supervisor, in the presence of the Maintenance Director, stated all work orders were supposed to be placed in the electric work order system. They stated the Director of Nursing told them last week Resident #67 needed a new mattress, and they told the Director of Nursing that a new one needed to be ordered. They stated they did not have any bariatric mattresses available. Maintenance Supervisor stated they go through the facility and check mattresses once a month. They stated a mattress was not thrown away until after the Maintenance Director approved it. The Maintenance Director stated they do not have any documented evidence of the resident's mattresses being checked/audited monthly. During an interview o 12/08/2025 at 11:16 AM, Licensed Practical Charge Nurse #2 stated they believed maintenance was responsible to clean oxygen concentrator filters and were usure how often that should be done. They stated it would be important to have the oxygen filters cleaned for infection control purposes, additionally they stated a dusty filter may interfere with the functioning of the oxygen. During an interview on 12/08/2025 at 2:24 PM, the Director of Nursing stated there was no scheduled for cleaning oxygen concentrators and filters. They stated any staff member could wipe down the oxygen concentrators with bleach wipes and clean the oxygen filters; they would expect this to be done when needed to remove dust and debris. The Director of Nursing stated it was important to keep the oxygen concentrator filters clean and free from dust for infection control reasons. During an interview on 12/8/25 at 4:54 PM, the Administrator stated all oxygen concentrators received routine service from an outside contracted company. They stated the contracted company came annually to the facility to inspect all equipment and were present in the building monthly to repair any equipment including oxygen concentrators if needed. The Administrator stated they were unsure if there was a routine cleaning schedule for oxygen concentrators and filters and did not know who was responsible to clean them. 10 NYCRR 415.5(h)(1)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/09/2025, the facility did not 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 three (3) (Residents #4, #19, and #41 ) of three (3) residents reviewed for infection control. Specifically, during a wound care observation, Resident #4's soiled brief and soiled wound dressing were placed directly on the floor without a barrier; staff did not wear personal protective equipment including gowns during wound care, personal care, and transferring of Resident #41, who was on enhanced barrier precautions; a nurse dispensed Resident #19's medications into their bare hands, when the medications fell onto the top of the medication cart, the nurse placed the medications into souffle cup with ungloved hands and was prepared to administer medications to the resident; and during a medication observation, staff's personal beverages were observed on the top of the medication cart. Additionally, there was no conspicuous signage throughout the facility offering COVID-19 vaccinations/boosters per facility protocols. The findings are:The policy titled Enhanced Barrier Precautions, dated 04/01/2024, documented enhanced barrier precautions were used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDRO) to residents. Gloves and gowns were to be applied prior to performing high contact resident care. Examples of high contact resident care activities requiring the use of gown and gloves included dressing, bathing/showering, transferring, providing hygiene, changing briefs or assisting with toileting, and wound care. Enhanced barrier precautions were indicated for residents with wounds and/or indwelling medical device that placed them at increased risk and would remain in place for the duration of the residents stay or until resolution of the wound or discontinuation of indwelling medical device. Signs were posted on the door or wall outside the resident room indicating the type of precautions and personal protective equipment required.The policy titled Infection Prevention and Control Program, last revised 05/23/2025, documented the infection prevention and control program was a facility wide effort involving all disciplines and individuals and was an integral part of the quality assurance and performance improvement program. The elements of the program consisted of coordination/oversight, policies and procedures, prevention of infection, and identifying, recording and correcting infection control program incidents.The policy titled Administering Oral Medications dated 12/01/2017, documented the desired number of tablets or capsules from a bottle are poured into the bottle cap and transferred to the medication cup. Do not touch the medication with your hands. Place packaged unit dose tablets or capsules medications directly into the medication cup.The policy titled Storage of Medications dated 12/01/2017, documented nursing staff shall maintain medication storage and preparation areas in a clean, safe and sanitary manner.The policy titled COVID-19 Vaccinations of Nursing Home Residents and Personnel revised 09/30/2024, documented there will be conspicuous signage throughout the facility offering COVID-19 vaccinations/boosters.1.Resident #4 had diagnoses that included congestive heart failure, diabetes mellitus, and pressure ulcer of sacral (area above the tail bone) region unspecified stage. The Minimum Data Set (a resident assessment tool) dated 10/31/2025, documented Resident #4 was cognitively intact, required partial/moderate assistance (helper does less than half the effort) for personal hygiene and was dependent (helper does all the effort) on staff for toileting hygiene. Resident #4 had an indwelling catheter (tube inserted into the bladder to drain urine), a colostomy (artificial connection of the bowel to the skin surface), and one (1) Stage 3 (full thickness tissue loss) pressure ulcer.The comprehensive care plan dated 10/27/2025 documented Resident #4 was at risk for infection related sacral pressure ulcer. Interventions included enhanced barrier precautions; skin care as ordered; and administer medications as ordered. The resident had an alteration in elimination related to colostomy and indwelling catheter. The Physician Wound Consultant note dated 11/28/2025 documented Resident #4 had a stage 3 (full thickness tissue loss) left posterior thigh pressure ulcer and a stage 3 pressure ulcer to their coccyx (tailbone) with a moderate to large amount of purulent (pus like fluid yellow or green in color) drainage.During an observation of wound care on 12/04/2025 at 11:16 AM, Licensed Practical Nurse #6 and Certified Nurse Aide #7 performed hand hygiene, donned gown and gloves and turned Resident #4 onto their right side. Certified Nurse Aide #7 unfastened the resident's incontinence brief and two (2) wound dressings were observed on the coccyx and left posterior thigh. The wound dressing to Resident #4's coccyx was observed with moderate amount of yellow drainage that had soaked into Resident #4's incontinence brief. Certified Nure Aide #7 rolled up the incontinence brief under the resident and Licensed Practical Nurse #6 removed both wound dressings, cleansed the wounds and applied the wound treatments as ordered. Certified Nurse Aide #7 then rolled Resident #4 onto their left side pulled out the brief soiled with drainage from their wound and placed the brief directly on the floor without a protective barrier in place for the duration of care.During an interview on 12/04/2025 at 11:29 PM, Licensed Practical Nurse #6 stated Resident #4 was on enhanced barrier precautions because they had pressure ulcers, a foley catheter and colostomy. Licensed Practical Nurse #6 stated Resident #4's brief was soiled with wound drainage and was wet from sweat. They stated during care they observed Certified Nurse Aide #7 remove the soiled brief and place it on the floor without a barrier. Licensed Practical Nurse #6 stated for infection control purposes soiled linen or briefs should never be placed on the floor, there should have been a barrier in place to prevent germs from spreading.During an interview on 12/04/2025 at 11:41AM, Certified Nurse Aide #7 stated while providing care to Resident #4 they had removed their old brief and placed it on the floor. They stated Resident's brief was soiled with light yellow drainage from sweat. Certified Nurse Aide #7 stated they should have placed a barrier down either a sheet, blanket, or used a garbage bag for infection control reasons. They stated it was important to keep the resident's room clean, and germs could spread when soiled items were placed on the floor.During an interview on 12/05/2025 at 3:08 PM, the Director of Nursing/Infection Preventionist stated they expected staff to follow appropriate infection control practices. They stated soiled linen, and briefs should never be placed on the floor, it was an infection control issue and would have expected staff to ensure a barrier was used for all soiled linen and briefs.2. Resident #41 had diagnoses including contracture (permanent tightening and shortening of muscles causing joint stiffness) of muscle, left forearm, major depressive disorder, and paraplegia (paralysis of lower half of body). The Minimum Data Set, dated [DATE], documented Resident #41 was cognitively intact, required partial/moderate assistance (helper does less than half the effort) for rolling left and right and was dependent (helper does all the effort) on staff for toileting hygiene, showering/bathing, and transferring.The comprehensive care plan, dated 12/10/2023, documented Resident #41 was at risk for infection related to comorbidity infection with interventions to monitor for signs/symptoms of infection and maintain enhanced barrier precautions (initiated on 07/12/2024).The Physician Wound Consultant note dated 11/21/2025 documented Resident #41 had a 3.5 centimeter (cm) by 5.5 centimeter by 0.1 centimeter skin tear to their left posterior thigh that had declined in status since the last assessment; was a full thickness wound with fat layer exposed, had a moderate amount of exudate (drainage), and the peri-wound (surrounding skin) was macerated (moist). An alginate dressing (highly absorbent dressing that transforms into a gel) covered with a superabsorbent bordered dressing was ordered.During an observation on 12/03/2025 at 11:23 AM, Resident #41 was being wheeled down the hall towards their room on a shower bed from the shower room by Certified Nurse Aide #18 and Certified Nurse Aide #2. Resident #41 was attached to the Hoyer lift by the Certified Nurse Aides and lifted off the shower bed and wheeled into their room and placed on the bed. Neither certified nurse aide had on a precaution gown during the observation or transfer.During an observation on 12/03/2025 at 11:39 AM, Licensed Practical Nurse #12 and Registered Nurse #3 Unit Manager gathered wound care supplies on the cart outside of the Resident #41's room then entered the room wearing only gloves. Enhanced Barrier Precaution signage was posted on the door frame of Resident #41's room. Resident #41 was turned onto their left side by Registered Nurse #3 Unit Manager, Licensed Practical Nurse #12 removed the old dressing from Resident #41s left posterior thigh and placed it in the garbage can next to the bedside. The dressing fell out of the full garbage can and landed on the floor, making a plop noise when hitting floor. Licensed Practical Nurse #12 stated there was dark brown/tan drainage observed on the old dressing and Resident #41 had just received a shower, so they dressing was saturated from the shower. Licensed Practical Nurse #12 removed their gloves, applied new gloves, cleansed wound with normal saline, applied alginate, then covered with superabsorbent dressing, rolled resident #41 over, and secured their brief, cleaned up soiled items, secured resident, then exited the room.During an observation and interview on 12/03/2025 at 11:47 AM, Registered Nurse #3 Unit Manager and Licensed Practical Nurse #12 reviewed the signage outside of Resident #41's door and both stated they forgot to wear their precaution gowns during wound care. Registered Nurse #3 Unit Manager stated Resident #41 was on enhanced barrier precautions so they should have worn their personal protective equipment gown while completing the wound care and it was important to not spread any germs between residents.During an observation on 12/03/2025 at 2:17 PM, Certified Nurse Aide #18 and Certified Nurse Aide #1 were in Resident #41's room, transferring them from their bed to their wheelchair with the Hoyer lift. Neither Certified Nurse Aide had a personal protective gown on.During an interview on 12/03/2025 at 2:19 PM, Certified Nurse Aide #18 stated they had just changed Resident #41 and transferred them to their wheelchair. Certified Nurse Aide #18 stated they should have worn a personal protective gown but forgot to wear one while showering, transferring, and providing incontinent care to Resident #41; it was important to wear personal protective equipment when providing hands on care to Resident #41 because they were on enhanced barrier precautions, and did not want to spread infection or germs around.During an interview on 12/03/2025 at 2:20 PM, Certified Nurse Aide #1 stated they only assisted Certified Nurse Aide #18 with Resident #41's transfer, they did not touch the patient. They stated personal protective equipment should be worn for a resident on enhanced barrier precautions whenever hands on care were performed, because you don't want to spread infection.During an interview on 12/03/2025 at 2:22 PM, Certified Nurse Aide #2 stated they assisted Certified Nurse Aide #18 earlier that day with Resident #41s shower and transfer, did not have on a personal protective gown, and should have. They stated it was important because they did not want to spread anything from resident to resident.During an interview on 12/03/2025 at 2:23 PM, Licensed Practical Nurse #12 stated Certified Nurse Aides #1, #2, and #18 should have all worn a personal protective gown when providing any hands-on care to Resident #41. It was important to prevent the spread of pathogens.During an interview on 12/03/2025 at 2:26 PM, Registered Nurse #3 Unit Manager stated Certified Nurse Aides #1, #2, and #18 should have all worn a personal protective gown when providing any hands-on care to Resident #41. It was important to prevent the spread of bacteria or infection.During an interview on 12/05/2025 at 1:16 PM, Regional Educator and Quality Assurance stated all staff were trained on enhanced barrier precautions in general orientation, annually, and as needed. Staff were trained to wear a gown and gloves whenever providing hands on care was performed on a resident, staff should have worn a gown when transferring, showering, providing incontinent care and wound care to Resident #41 or any resident on enhanced barrier precautions. Regional Educator and Quality Assurance stated there was a risk for contamination and infections if personal protective equipment was not worn.During an interview on 12/05/2025 at 3:08 PM, Director of Nursing/Infection Preventionist stated they expected all staff caring for resident on enhanced barrier precautions to wear gloves and a gown, tied firmly around the waist, during wound, incontinent, or any hands-on care provided to a resident on enhanced barrier precautions. Staff should have worn gowns when providing care to Resident #41. It was an infection control issue. They stated there should always be a barrier placed for soiled linens/dressings; things should never be placed on the floor; it was an infection control issue.3. During an observation and interview on 12/03/2025 at 9:53 AM, [NAME] unit, the [NAME] Drive medication cart had a personal pink insulated beverage container and a personal disposable cup with an open lid present on top of the medication cart during medication administration. During medication observation of medications to Resident #19, Licensed Practical Nurse #7 dispensed medication from containers directly into the palm of their hand prior to placing them into a medication cup. During transfer of medication from the palm of their hand into the plastic med cup, medication fell onto the top of the medication cart, was picked up by Licensed Practical Nurse #7 ungloved fingers and placed into the medication cup. Licensed Practical Nurse #7 was prepared to administer the medications to Resident #19 when the surveyor stopped them. Licensed Practical Nurse #7 stated they had cleaned the top of the medication cart prior to the start of their medication pass that morning and had sanitized their hands prior to the initiation of Resident #19's medication pass. Licensed Practical Nurse #7 stated they did touch the outside of the medication cart and items within the medication cart prior to dispensing the medications into the palm of their hand. They stated they should not have dispensed the medications into the palm of their hand or utilized the medication that dropped onto to medication cart due to germs and infection control. They stated they should have dispended the medication directly into the medication cup or utilized a glove prior to utilizing their hand to handle the medication. Licensed Practical Nurse #7 stated they were not supposed to have personal beverages on the medication cart due to infection control, but they forgot.During an observation on 12/04/2025 at 9:13 AM, [NAME] Unit, [NAME] Drive medication cart, had a staff member's personal [NAME] Horton cup present on top of the medication cart while Registered Nurse #5 was administering medications.During an interview on 12/04/2025 at 9:18 AM, Registered Nurse #5 stated their personal beverage should not have been present on the medication cart for infection control reasons. They stated they forgot.During an interview on 12/05/2025 at 7:20 AM, the Director of Nursing/Infection Preventionist stated medications should not be handled by a nurse's bare hands due to infection control. They stated any medication that encounters the surface of the medication cart should be discarded and dispensed again as the surface of the medication cart is not considered clean. The Director of Nursing/Infection Preventionist stated there should not be any personal items, including coffee or water bottles on the medication cart for infection control purposes.4. During intermittent observations from 12/01/2025 to 12/05/2025 between 7:00 AM - 3:00 PM, there was no conspicuous signage throughout the facility offering COVID-19 vaccinations/boosters.During an interview on 12/05/2025, Unit Clerk #1 stated they have not observed any signage in the facility related to the COVID vaccinations being available.During an interview on 12/05/2025 at 10:16 AM, Licensed Practical Nurse #11 stated they were not aware of any COVID vaccination signage posted in the facility.During an interview on 12/05/2025 at 8:48 AM, the Director of Nursing/Infection Preventionist stated they did not have any signage posted in the facility regarding COVID vaccinations.During an interview on 12/08/2025 at 2:08 PM, the Director of Nursing/Infection Preventionist stated they were not aware that signage needed to be posted throughout the facility offering COVID-19 vaccinations/boosters. They stated they would be responsible to take care of that, and had they known they would have posted signage. 10 NYCRR 415.19 (a) (1-3)

Based on observation, interview, and record review conducted during a Standard survey completed on 12/09/2025, the facility did not ensure a resident was assessed by the interdisciplinary team to determine a resident's ability to safely administer their own medications if clinically appropriate for one (1) (Resident #77) of one (1) resident reviewed for medication self-administration. Specifically, Resident #77 was observed with medications in their room, and they self-administered the medications without being evaluated as to whether they could safely do so. The finding is:The policy titled Self-Administration of Medications dated 12/01/2017 documented residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. Staff shall identify and give to the Unit Manager/Nurse Supervisor any medications found at the bedside that are not authorized for self-administration and return to the family or responsible party.1.Resident #77 had diagnoses including fracture (partial or complete break in a bone) of right femur (long thigh bone), atrial fibrillation (irregular heart rate) and anxiety disorder. The Minimum Data Set (resident assessment tool) accepted on 09/19/2025 documented Resident #77 was understood, understands and was cognitively intact.The Careplan Report dated 09/16/2025 documented Resident #77 was independent for decision making ability. The general orders documented Diphenhydramine Hydrochloride (antihistamine) oral tablet 25 milligrams, 2 tablets by mouth at bedtime started 09/03/2025. There was no documented evidence that Resident #77 was assessed for the ability to self-administer any medications.The undated Medications Profile for Resident #77 documented Diphenhydramine Hydrochloride (antihistamine) oral tablet 25 milligrams, 2 tablets by mouth bedtime for sleep management with a start date of 09/03/2025. There were no physician's orders for Resident #77 to self-administer medications or to leave medications at the bedside. Review of Progress Notes Report dated 09/03/2025 to 12/03/2025, there was no documented evidence that Resident #77 was assessed by the interdisciplinary team to determine if they could safely self-administer their medications and keep them at their bedside. There was no documentation that the resident had self-administered any medications or that any medications were removed from their bedside. Review of medical provider notes dated 10/14/2025 to 11/26/2025 revealed no notes that addressed the resident could self-administer their medications or keep them at the bedside. During an observation on 12/02/202 at 9:14 AM, Resident #77's had an opened clear bottle of soft gel capsules labeled max strength sleep aide, diphenhydramine hydrochloride (antihistamine) 50 milligrams, on their tray table visible from the doorway of their room. During an observation and interview on 12/03/2025 at 9:41 AM, Resident #77 was in bed, an opened clear bottle of labeled soft gel capsules, max strength sleep aide, diphenhydramine hydrochloride (antihistamine) 50 milligrams, remained on their tray table visible from the doorway of their room. Resident #77 stated they take the diphenhydramine hydrochloride occasionally to go to sleep. They stated they brought it from home and the facility prescribed it for them. Resident #77 stated the facility lets them take it by themselves and they had taken it last night. Resident #77 stated the staff knew they had the diphenhydramine hydrochloride on their tray table and had not said anything. Resident #77 then placed bottle of diphenhydramine hydrochloride in their nightstand drawer.During an interview on 12/03/2025 at 9:53 AM, Licensed Practical Nurse #7 stated residents cannot self-administer medications unless it was ordered. They stated they were not aware of any residents having medications ordered to be at their bedside. They stated if medications were observed at the bedside, they would check for orders, remove medications if not ordered and notify whoever was in charge. Licensed Practical Nurse #7 stated having medications at a bedside was a safety concern, residents could self-administer the wrong dose, the medication may not react with other medications they are prescribed, and another resident may gain access to them.During an interview on 12/04/2025 at 9:53 AM, Registered Nurse #5 stated Resident #77 did not have an order to self-administer medications or keep mediations at their bedside. They stated Resident #77 had an order for Benadryl (antihistamine) 50 milligrams every night that has been ordered since 09/03/2025 that is administered by nursing staff. They stated they were not aware Resident #77 had medication at their bedside. They stated it was important to know what medications a resident is taking to monitor for any drug-to-drug interactions. They stated if they observed any medications at a resident bedside, they would confiscate them to avoid safety concerns; and inform the nurse manager and provider.During an interview on 12/04/2025 at 12:07 PM, Resident #77 stated their bottle of sleep aid was removed from their room by an unknown nurse that morning. Resident #77 stated they took a gelcap, diphenhydramine hydrochloride, from their bottle last night, 12/03/2025, to help them sleep.During an interview on 12/04/2025 at 12:13 PM, Licensed Practical Nurse #2, Charge Nurse, stated residents are not supposed to have medications kept at their bedside or should they be self-administering medications to themselves without an order. They stated it was a safety concern because they would not know when the resident is taking it or if it was contraindicated with any of the other medications being administered to them. Licensed Practical Nurse #2, Charge Nurse stated they were not aware of Resident #77 having medication at their bedside until they were notified by Registered Nurse #5 that day.During an interview on 12/5/2025 at 7:20 AM, the Director of Nursing stated there is a process that must be followed for a resident to self-administer medication. They stated a medical provider would have to determine if a resident was capable and write an order to self-administer and keep medications at bedside. They stated a consent would have to be signed, education would have to be provided to the resident and a lock box provided. The Director of Nursing stated they knew nothing about Resident #77 having medications at their bedside. They stated they would expect nurses to remove any medication found at a resident's bedside, educate the resident, and call the responsible party.10 NYCRR 415.3(f)(1)(vi)

Based on observation, interview and record review conducted during a Standard survey completed on 12/09/2025, the facility did not ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent new ulcers from developing for one (1) (Resident #4) of four (4) residents reviewed. Specifically, the Physician Wound Consultant recommendation dated 10/31/2025 for an air mattress (a mattress that provides air flow to relieve pressure) was not implemented, and Resident #4 developed a new pressure ulcer. The finding is:The facility policy and procedure titled Pressure Ulcers -Risk Assessment and Maintenance of Skin Integrity dated 02/01/ 2018 documented the facility would identify residents at risk for skin breakdown to implement interventions to maintain skin integrity and ensure that residents with pressure ulcers were appropriately assessed and treated. Interventions for reduction of pressure included positioning/protective devices as indicated and all pressure relieving devices will be immediately implemented as per facility policy. Resident #4 had diagnoses that included congested heart failure, diabetes mellitus, and pressure ulcer of sacral (area above the tail bone) region unspecified stage. The Minimum Data Set (a resident assessment tool) dated 10/31/2025, documented Resident #4 was understood, understands, and was cognitively intact. The Minimum Data Set documented Resident #4 required partial/moderate assistance (helper does less than half the effort) for bed mobility and transfers. Resident #4 was at risk of developing pressure ulcers, and had one (1) Stage 3 (full thickness tissue loss) pressure ulcer present on admission. The Comprehensive Care Plan dated 10/28/2025 documented impaired skin integrity related to decreased mobility/strength, diabetes, and Stage 3 pressure ulcer to coccyx (tail bone). The planned interventions included: encourage resident to reposition self every two (2) hours and as needed, pressure relief chair cushion/mattress, skin care as ordered, and weekly skin checks by nurse. The comprehensive care plan was revised on 11/27/2025 to include a Stage 3 pressure ulcer to the left posterior (back) thigh and did not reflect the use of an air mattress until 12/05/2025. The care plan documented the resident had a history of non-compliance and refusing wound care. The undated Care Profile (guide used by staff to provide care) documented Resident #4 was at high risk for skin breakdown. Interventions include routine skin checks, preventative skin care, and turn and position every two (2) - three (3) hours. The Care Profile was not revised to reflect the use of an air mattress. Review of the initial wound and assessment plan dated 10/31/2025 documented by the Physician Wound Consultant revealed Resident #4 had a Stage 3 pressure ulcer on their coccyx. Wound measurements were 4.5 centimeters (length) x 1.3 centimeters (width) x 0.3 centimeters (depth). Preventative wound recommendations included an air mattress and pressure reduction cushion. Review of the wound and assessment plan dated 11/28/2025 documented Resident #4 pressure ulcer to the coccyx had declined and they had developed a new Stage 3 pressure ulcer to the left posterior thigh. The wound onset date was documented as 11/27/2025 and the wound measurements were 0.8 centimeters (length) x 4 centimeters (width) x 0.2 centimeters (depth). The 12/05/2025 wound and assessment plan note documented the pressure ulcer to the left posterior thigh was healing and the pressure ulcer to the coccyx had declined with wound measurements documented as 6 centimeters (length) x 1.3 centimeters (width) x 0.2 centimeters (depth). Review of the nursing progress note dated 11/06/2025 written by the Director of Nursing, documented Resident #4 was seen by the wound physician on 10/31/2025 and a treatment order for Santyl ointment to be applied every day was initiated. There was no documentation in the progress note regarding the recommendations made for an air mattress. Review of all interdisciplinary progress notes from 10/31/2025 - 12/04/2025 revealed no documented evidence that an air mattress had been implemented to Resident #4, and there was no resident refusals documented. Review of the physician progress notes from 11/03/2025 - 12/01/2025 completed by Medical Doctor #1 documented Resident #4 was high risk for skin issues, had a sacral pressure ulcer, pressure relief mattress, and wound care was to continue. There was no documentation in the progress notes that addressed the recommendations made by the Physician Wound Consultant. During an observation and interview on 12/01/2025 at 08:31AM, Resident #4 was observed in bed with a regular standard mattress in place. Resident #4 stated they had reported to the nurse a few days ago they needed a new mattress because it dipped down in the middle, and they would get stuck. Resident #4 stated it was difficult for them to turn and sit up. During intermittent observations made on 12/02/2025 at 09:11AM, 12/03/2025 at 08:25AM, and 12/03/2025 at 03:36 PM, Resident #4 was observed in bed and there was no air mattress present on bed. During an observation on 12/04/2025 at 11:16 AM, Licensed Practical Nurse #6 provided pressure ulcer care to Resident #4's pressure ulcers, they removed the soiled dressings dated 12/03/2025 from both wounds located on the coccyx and the left upper posterior thigh, both areas remained open with a moderate amount of yellow drainage observed from wounds. Licensed Practical Nurse #6 cleansed both wounds with acetic acid solution (wound cleansing solution used to kill bacteria) and treatments were applied as ordered. There was no air mattress present on the bed during the wound care observation. During an interview on 12/04/2025 at 11:29AM, Licensed Practical Nurse #6 stated Resident #4 had two pressure ulcers, was seen by the wound doctor weekly, and often refused to turn and position and to get out of bed. They stated Resident #4 did not have an air mattress and they were unaware how the facility determined which residents were issued air mattresses. During an interview on 12/05/2025 at 10:53 AM, the Physician Wound Consultant stated they completed wound rounds at the facility weekly with the Unit Managers, new recommendations were documented in their notes, and they would print a copy for the facility on the day of the visit. They stated they would expect their recommendations to be followed unless the facility provider did not approve them. The Physician Wound Consultant stated they recommended an air mattress for Resident #4 on 10/31/25 and could not recall if they had seen an air mattress on their bed. They stated air mattresses were recommended for any Stage 3 or Stage 4 pressure ulcers to keep sustained pressure off the wound. The Physician Wound Consultant stated Resident #4 had a Stage 3 pressure ulcer to their coccyx that was present on admission and had developed a new in-house Stage 3 pressure to the left posterior thigh on 11/27/2025. They stated there was no documentation that Resident #4 had refused an air mattress and was unaware the air mattress was not placed. The Physician Wound Consultant stated Resident #4 was quite mobile and was able to turn and position themselves, the air mattress would have been beneficial to relieve pressure but may not have prevented the new wound from occurring. During an interview on 12/05/2025 at 1:16 PM, the Director of Nursing stated they were unaware of the Physician Wound Consultant's recommendation that was made on 10/31/2025 for Resident #4 to have an air mattress. They stated the recommendation was overlooked and should have been implemented. The Director of Nursing stated that the Unit Manager or Charge Nurse were responsible to review the recommendations, have them approved by the provider, and implement the new orders. The Director of Nursing reviewed the wound consult dated 10/31/2025 in the electronic medical record and verified Licensed Practical Nurse #2 Charge Nurse initialed and dated the wound consult on 11/04/2025 and Medical Doctor #1 signed the consult. They stated when Medical Doctor #1 signed the recommendation that indicated they had agreed for the air mattress to be placed on Resident #4's bed. The Director of Nursing stated air mattresses promoted wound healing. During an interview on 12/08/2025 at 11:16 AM, Licensed Practical Nurse #2 Charge Nurse stated when they received recommendations from the Physician Wound Consultant, they would confirm the recommendations with the facility provider and then enter the new orders into the electronic medical record. They stated when an air mattress was recommended, they would contact the maintenance department by phone to request them. Licensed Practical Nurse #2 Charge Nurse stated they had initialed the wound consult for Resident #4 but could not recall why the air mattress was not placed. They stated at times they would be told by the maintenance department that air mattresses were on backorder but was unsure if that was the reason for Resident #4 recommendations not being followed. During a telephone interview on 12/09/2025 at 9:51AM, the Medical Director stated they typically agreed with the Physician Wound Consultants recommendations. They stated if there was a recommendation for an air mattress, they would expect the facility to follow that recommendation and order an air mattress. The Medical Director stated air mattresses were beneficial to prevent new pressure ulcers, it was a protective device especially when residents laid in bed for long periods of time, would be helpful to prevent skin breakdown. 10 NYCRR 415.12 (c) (2)

Based on observation, interview and record review conducted during a Standard survey completed on 12/09/2025, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming for two (2) (Residents #44 and Resident #5) of two (2) residents reviewed for nail care. Specifically, Resident #44 had long fingernails on their right hand, and Resident #5 had long fingernails with brown debris underneath. The findings are:The policy titled Care of Fingernails dated 06/26/2018 documented the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care included daily cleaning and regular trimming on resident assigned bath/shower day. Unless otherwise permitted, do not trim the nails of diabetic residents or residents with circulatory impairments. Only Licensed Nurses will cut diabetic nails. If a resident does not receive a bath/shower or refused on the scheduled bath or shower day, nail care is still to be provided. If the resident refused the procedure, the reasons why and interventions taken were to be documented on the Activities Daily Living record and/or the medical record.1. Resident #44 was admitted to the facility with right hemiplegia (paralysis on the right side of the body), a cerebral infarction (stroke) and aphasia (ability to speak affected). Review of the Minimum Data Set (a resident assessment tool) dated 05/15/2025 documented that the resident was moderately cognitively impaired, was understood by others, understands others, and the resident required some assistance with activities of daily living. Review of the undated certified nurse aide care profile documented that Resident #44 had a shower day on Monday day shifts.Review of the comprehensive care plan dated 7/16/2025 documented that Resident #44 has an impaired self-care function. The care plan did not address nail care.Review of a progress note dated 08/19/2025 at 11:53 AM, documented that Resident #44 had long, thick fingernails and the Assistant Director of Nursing trimmed them. Review of nursing progress notes from July 2025 to December 2025 revealed no documentation the resident refused nail care.During an observation and interview on 12/02/2025 at 9:07 AM, Resident #44 had one-inch-long fingernails on their right hand. The resident stated that they could not cut their own nails due to their stroke. They also stated that the length of the nails bothered them.During an observation on 12/03/2025 at 8:22 AM, Resident #44's right hand was observed to have an 1/2 inch long nail on the right thumb. The right hand is contracted and observed were three fingers with one-inch-long nails. During this observation, the resident put their thumb out and stated, cut this and made a scissor cutting motion with their left hand.During an interview on 12/03/2025 at 10:15 AM with Certified Nurse Aide #2, they stated that Resident #44's nails should not be that long. They stated that the nurses usually trimmed the nails once a week. They stated if a resident refuses, they are supposed to report it to their nurse.During an observation and interview on 12/3/2025 at 10:30 AM, Registered Nurse Supervisor #1 observed Resident #44's nails and stated that the resident's nails should not be that long. They stated that if the resident refuses to get their nails cut, staff should reapproach them. They stated that the nails could dig into Resident #44's skin and cause open areas. During this interview, Registered Nurse Supervisor #1 asked the resident if they wanted to have their nails trimmed and they replied yes.During an interview on 12/09/2025 at 8:39 AM with the Registered Nurse Regional Educator, they stated that if the resident refuses nail care, staff should document it and report it to their nurse. They stated that activities of daily living are part of grooming and staff are taught to complete these tasks.2. Resident #5 had diagnoses that included diabetes mellitus, chronic kidney disease and congestive heart failure. The Minimum Data Set, dated [DATE] documented Resident #5 was understood, understands and had moderate cognitive impairment. The resident required substantial/maximal assist (helper does more than half the effort) for personal hygiene and was dependent (helper does all the effort) on staff for shower/bathing. There were no refusals of care documented.Review of the comprehensive care plan dated 10/24/2025 documented Resident #5 had a diagnosis of diabetes mellitus, and they preferred to be showered on Wednesday on the day shift (7:00AM -3:00PM). The care plan did not document the resident's nails were to be trimmed and cleaned by a nurse.Review of the undated care profile (a guide used by staff to provide care), identified as current by the Director of Nursing, documented Resident #5's bathing schedule was one time a week on Wednesdays during the day shift (7:00AM - 3:00PM). The activities of daily living assessment on the care profile dated 12/03/2025 documented Resident #5 required moderate assistance of one (1) staff member for shower/bathing and personal hygiene. The care profile did not document Resident #5 was a diabetic and nails were to be trimmed and cleaned by a nurse.Review of the Physician Order Form dated as of 12/05/2025 revealed there was a physician order for licensed nurse to cut fingernails weekly every Wednesday one time a week with a start date of 10/24/2025.The Treatment Administration Record dated 11/01/2025 - 11/30/2025 and 12/01/2025 - 12/31/2025 documented on 11/12/2025 and 12/03/2025 Resident #5's fingernails were not cut and there were no refusals documented. The Daily Shower Review sheet dated 12/03/2025 documented Resident #5 had refused their shower, received a bed bath and nail care was not signed off as being completed. Review of Resident #5's progress notes dated 11/01/2025 through 12/03/2025 revealed there was no documented evidence the resident refused nail care.During intermittent observations on 12/01/2025 at 9:05 AM, 12/03/2025 at 8:53 AM, and 12/04/2025 at 8:52 AM, Resident #5's fingernails were observed to be long beyond the finger pads on both hands, approximately 1/2 - 1 inch long, jagged and had thick dark brown debris present under nails.During an interview and observation on 12/03/2025 at 4:40 PM, Resident #5 was sitting up in bed eating a soft dinner roll using their right hand. Resident #5's fingernails remained long and extended over pads of fingers, dark brown debris noted around nail beds and under nails. Resident #5 stated they would be ok if staff cut and cleaned them. During an interview on 12/04/2025 at 10:25 AM, Certified Nurse Aide #10 stated nail care was to be completed on shower days or whenever nails were too long or dirty. They stated the certified nurse aides were responsible to cut the resident's nails unless a resident had a diagnosis of diabetes, then the nurse would be responsible for the resident's nail care. Certified Nurse Aide #10 stated they had just provided care to Resident #5 and assisted them out of bed. Certified Nurse Aide #10 entered Resident #5's room at 10:29 AM and stated the resident's fingernails were too long and had thick debris built up under the nails. They stated Resident #5's shower day was last evening, and their nails should have been cleaned and trimmed. Certified Nurse Aide #10 stated they did not notice Resident #5's nails when they provided care to them today and were unsure if they had a diagnosis of diabetes.During an observation and interview on 12/04/2025 at 5:26 PM, Certified Nurse Aide #11 stated they were assigned to Resident #5 last evening, they refused their shower and had requested a bed bath. Certified Nurse Aide #11 stated resident's nails were to be cut on shower days by the certified nurse aides unless the resident was diabetic then it was the nurse's responsibility. Certified Nurse Aide #11 observed Resident #5's fingernails and stated their nails were long and had dirt underneath their nails. They stated while providing a bed bath to Resident #5 last evening they had fecal matter on their hands, they were focused on cleaning their hands and did not look underneath their nails or notice the length. They stated Resident #5's nails should have been cut and cleaned. Certified Nurse Aide #11 stated nail care was important for cleanliness and dignity. During an interview on 12/04/2025 at 10:37 AM, Registered Nurse #5 stated nurses were responsible to cut resident's nails if they had a diagnosis of diabetes. They stated nail care should be done on shower days and documented on the Treatment Administration Record. Registered Nurse #5 observed Resident #5's nails and stated they were long with thick dirty debris underneath the nail. They stated the length of Resident #5's nails appeared to be more than one week growth. Registered Nurse #5 stated Resident #5 was a diabetic and their nails should have been cut yesterday by the nurse after their shower. They stated nail care was important for personal hygiene and safety.During an interview on 12/04/2025 at 10:48 AM, the Director of Nursing stated they expected resident's nails to be cut and cleaned on their shower day and anytime it was needed. They stated the nurses were responsible for nail care for residents with a diagnosis of diabetes, the certified nurse aides completed nail care for all other residents. The Director of Nursing observed Resident #5's nails and stated they were long with yellow discoloration and had thick brown debris under the nail that may be skin build up. They stated the length of the Resident #5's nails was possibly more than one week's growth. They stated they would have expected the nurse to have soaked Resident #5's nails to remove all the debris and trimmed their nails. The Director of Nursing stated nurses were to sign out on the Treatment Administration Record when nail care was completed and would expect refusals to be documented. They stated an X on the Treatment Administration Record indicated care was not provided. The Director of Nursing stated they would have expected staff to notice when nail care was needed, it was important for infection control.10 NYCRR 415.12 (a) (3)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #2609916) during the Recertification Survey completed on 12/09/2025, the facility did not ensure that all residents receive treatment and care in accordance with professional standards of practice for two (2) (Resident #8 and #145) of five (5) residents reviewed. Specifically, there was a delay in obtaining an order for pain management and an x-ray for a resident who sustained a fall and subsequently had a clavicle fracture (break in the S-shaped bone connecting your shoulder blade (scapula) to your breastbone (sternum) (#145). Additionally, there was no assessment or treatment initiated to a skin tear on Resident #8's right forearm. The findings are:The policy and procedure titled Accidents and Incidents- Investigation and Reporting revised 12/10/2021, documented all incidents involving a resident shall be documented on at the time of the incident. Whenever an incident/accident occurs, the involved staff will immediately notify the Unit Manager and Nurse Supervisor.1. Resident #145 had diagnoses including Alzheimer's disease (a progressive brain disorder, characterized by memory loss, impaired thinking, and behavioral changes, stemming from abnormal protein buildup (plaques and tangles) that kills brain cells over time), repeated falls and type two (2) diabetes mellitus (a chronic condition where the body doesn't use insulin properly). The Minimum Data Set (a resident assessment tool) dated 12/23/2024 documented that Resident #145 had moderate cognitive impairment, was sometimes understood, and usually understands others. The resident had no rejection of care and required supervision/touch assist with transfers. The Careplan Report established 12/23/2024 documented Resident #145 was at risk for pain. Interventions included to administer pain meds as ordered, use adjunctive pain-relieving measures as indicated- repositioning, reassurance, emotional support and distraction when appropriate, and use verbal or non-verbal pain scale before and after interventions. The goal was that the resident's pain would be recognized, assessed and treated appropriately through next review.The undated Care Profile (a guide used by staff to provide care) documented Safety Precautions: Fall; skid socks at all times, as tolerated; encourage shoes/sneakers out of bed; encourage proper footwear out of bed; and bed in lowest position. A Full QA (quality assurance) Report completed by the Director of Nursing dated 12/23/2024 at 4:15 PM documented Resident #145 had an unwitnessed fall in their bedroom and was found lying on their left side on the floor which resulted in bruising to the back of their left scapula (shoulder blade). Resident #145 provided a statement tht was documented as I was trying to get into bed and slipped. The report documented ice was applied and Acetaminophen was given per resident request as an immediate intervention/first aide. Nurse Practitioner was notified on 12/23/2024 at 4:33 PM and no new orders were received. The report conclusion documented that an x-ray was completed, and Resident #145 sustained a left non-displaced clavicle fracture. There was no identified abuse or mistreatment. The Progress Notes completed by Registered Nurse #2 Supervisor dated 12/25/2024 documented at 8:43 AM, Resident #145 complained of pain on a scale of (one)1- (ten)10 as being a 10 (ten). They documented that the bruising was in different stages of healed and when pressing in, on/around shoulder joint Resident #145 experienced pain. At 9:02 PM on 12/25/2024 Registered Nurse #2 Supervisor documented Resident #145 complained of pain in left shoulder, and they were requesting an x-ray. Registered Nurse #2 Supervisor documented they had informed Resident #145 that it was a holiday, and x-rays were not being done. There was no documented evidence the medical provider was notified of the resident's pain level and had requested an x-ray.The Daily Unit Report (nursing twenty-four report sheets) dated 12/25/2024 Registered Nurse #2 Supervisor on the evening shift documented that Resident #145 was status post (after) day two (2) from fall and wanted an x-ray of their left shoulder. Further review revealed on 12/26/2025 the day shift nurse documented the resident received Tylenol with positive effect.The Monthly MAR (Medication Administration Record)- TAR (Treatment Administration Record) documented an order dated 12/26/2024 for Acetaminophen (Tylenol) 325 milligrams two (2) tablets every six (6) hours as needed for pain management. Resident #145 received Acetaminophen (Tylenol) 325 milligrams, 2 tablets (650 milligrams) on 12/26/2024 at 11:35 AM, 12/27/2024 at 5:29 AM, 12/28/2024 at 4:54 PM and 12/29/2024 at 5:37 AM. Additionally, prior to the order dated 12/26/2025 there were no physician orders for pain management.The Provider note signed by the Physician Assistant #1 dated 12/27/2024, documented Resident #145 was being seen per staff reports of a left shoulder contusion (bruise) after a recent fall. The Physician Assistant documented left shoulder contusion was diffuse but more posteriorly (toward the back of the body), range of motion was restricted with reported pain. New order for left sided shoulder x-rays for further evaluation and pain management as needed. The Final Radiology Report dated 12/27/2024 documented recent fracture of the distal (outer) clavicle.During a telephone interview on 12/08/2025 at 12:55 PM, Registered Nurse #2 Supervisor stated residents have the right to request an x-ray no matter what, even if they do not see anything wrong. They stated if a resident requested an x-ray, they would notify a medical provider because it was important to honor the resident's rights. Registered Nurse #2 Supervisor stated they kind of remembered writing progress note on Resident #145 on 12/25/2024 regarding their request for an x-ray. But they did not know if an x-ray had been completed prior to that and could not recall if they looked to see if Resident #145 already had an x-ray. Registered Nurse #2 Supervisor stated they could not recall if they notified a medical provider of Resident #145's request for an x-ray or about their pain level. Registered Nurse #2 Supervisor stated they believed but could not recall if they spoke with the Director of Nursing or a medical provider and they told them to wait on getting an x-ray. They stated they should have documented who they spoke with, and the recommendations given so it showed they reported it to somebody. During an interview on 12/08/2025 at 2:08 PM, the Director of Nursing stated x-rays could be completed at the facility. They stated on a holiday the facility was at the mercy of the x-ray provider, because the x-ray company was limited and completed x-rays on a case-to-case basis. They stated if Resident #145 requested an x-ray on 12/25/2024 it should have been honored, and a provider should have been notified. If an x-ray could not have been done on a holiday, then the provider should have been updated, and if needed the resident could have been sent to the hospital for evaluation. The Director of Nursing stated they did not know why an x-ray of Resident #145's left shoulder wasn't ordered until 12/27/2024. The Director of Nursing also stated they did not recall receiving a message or being notified of Resident #145's request for an x-ray. The Director of Nursing stated they expected residents to be medicated for pain as ordered and for a provider to be contacted if pain was not controlled. During a telephone interview on 12/09/2025 at 8:08 AM, the Physician Assistant #1 stated they expected staff to give what was available for pain then contact provider if pain was not relieved. They stated that it was not appropriate to tell a resident who was having pain and requesting x-ray that an x-ray could not be done on a holiday. They stated they expected staff to call a medical provider to let them know and they would send the resident out to hospital for an x-ray if it couldn't be done in a timely manner. They stated that they were not aware the resident was in that much pain as it was not relayed to them.During a telephone interview on 12/09/2025 at 8:16 AM, the Customer Service Representative for the portable x-ray service company stated they were open on Christmas and Christmas eve. They stated all the facility staff would have had to do was call, and they would have sent someone out as soon as they could.During an interview on 12/09/2025 at 8:44 AM, the Registered Nurse Regional Educator stated if staff could not get an x-ray completed on a resident in house, then the staff should send the resident out. They stated they would expect staff to update the provider and the Director of Nursing.During a follow up interview on 12/09/2025 at 8:51 AM, Registered Nurse #2 Nursing Supervisor stated if a resident complained of pain ten out of ten, they would tell the cart nurse so the cart nurse could administer pain medication, the cart nurse may not always click it off. Registered Nurse #2 Nursing Supervisor stated they could not remember if they gave Resident #145 any pain medication on 12/25/2024 or if they told Licensed Practical Nurse #3 to administer pain medication to Resident #145. They stated it would be documented in Resident #145's medical administration record if it was administered.During a telephone interview on12/09/2025 at 9:20 AM, Licensed Practical Nurse #4, stated after the fall on 12/23/2025 Resident #145 had pain to their left shoulder and that was what prompted the facility to get the x-ray. They stated that they did not recall what the resident's pain level was, but that the resident was complaining of pain, and they recall giving the resident something for pain. They stated they remember Resident #145 only having Tylenol ordered for pain. They stated Resident #145 had bruising to their left shoulder area. They stated that it should be documented in the medication administration record if pain meds were given, and/or in the progress notes. During an interview on 12/09/2025 at 10:15 AM, the Administrator stated they had no knowledge of the situation with Resident #145 and was not aware of the delay in treatment, if there was one. During an interview on 12/08/2025 at 11:14 AM with the Medical Director, they stated that if the resident requested to be sent to the hospital, the resident should be sent to the hospital. They stated that it is the resident's right to go to the hospital. They stated that they expect staff to call them if the resident's pain was not managed and to get new orders for stronger pain medication. 2. Resident #8 had diagnoses that included right femur fracture (break in the long leg bone), dementia and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 09/08/2025, documented Resident #8 was severely cognitively impaired, rarely/never understood and rarely/never understands others. The Minimum Data Set documented, Resident #8 was dependent for transfer and bed mobility, and a maximal assist for toileting, dressing, bathing. The Careplan Report dated 10/24/2025 documented Resident #8 was at risk for impaired skin integrity. Interventions included to apply skin barrier ointment after each episode of incontinence as needed, dietary assessment, pressure relief cushion and mattress, skin care as order. The undated Care Profile (a guide used by staff to provide care) documented Resident #8 was at high risk for skin breakdown and staff were to check skin with routine care each shift. The Daily Shower Review [NAME] Unit dated Tuesday 11/25/2025 documented Resident #8's room number and documented shower given by Certified Nurse Aide #12. Registered Nurse #5's nursing initials were documented on the daily shower sheet indicating a skin check was completed. The Daily Order Report between 8/18/2025 and 11/30/2025 revealed there was no documented evidence a treatment order was initiated to Resident #8's right forearm skin tear. During an observation and interview on 12/02/2025 at 8:49 AM, Resident #8 was in bed and had a skin tear to their right posterior (back) forearm, approximately six (6) centimeters by one (1) centimeter. The wound bed was pale yellow and moist in appearance. There was no drainage noted. Resident #8 stated they did not know what happened but that it was healing. During an observation and interview on 12/04/2025 at 8:02 AM, Resident #8 was in bed with skin tear was still visible to their right forearm that was dry and presented as healing with scab formation. The assigned Certified Nurse Aide #12 stated Resident #8 had a skin tear to their right arm. They stated Resident #8 obtained the skin tear last week on their shower day during a transfer. Certified Nurse Aide #12 stated they reported the skin tear to a nurse and believed it was Registered Nurse #5. They stated it was important to report any resident injuries to a nurse so an accident/incident report could be completed and a proper treatment completed. Review of Progress Notes dated 11/04/2025 through 12/02/2025 revealed there was no documented evidence of an assessment or a treatment to skin tear of Resident #8's right forearm. The Physician's Order Form as of 12/04/2025 documented treatment order to right forearm skin tear: cleanse with 0.9 percent normal saline, pat dry, apply xeroform gauze to the wound bed, dry clean dressing and kerlix wrap daily and as needed. During an interview on 12/04/2025 at 8:14 AM, upon Registered Nurse #5 observing the skin tear present to Resident #8's right forearm they stated they were not aware of this skin tear and should have been informed. Registered Nurse #5 stated an assessment of the skin tear should have been completed, a treatment ordered, area monitored for infection and family notified. They stated a skin check is to be completed weekly on the resident's shower day by a nurse and documented. They stated they did not know why an accident/incident report was not completed but an accident/incident report should have been completed if it was a new injury. During an interview on 12/04/2025 at 8:28 AM, the Director of Nursing, covering as Unit Manager on [NAME] Unit, stated there was no required nursing documentation with weekly skin checks, unless there was a concern. They stated skin tears should be reported to the nurse, who would then notify them. They stated a measurement should be taken of skin tears, a house treatment implemented, and the provider and responsible party notified. The Director of Nursing stated an accident/incident report should be completed for tracking and investigation reasons. They stated they were not aware of the skin tear to Resident #8's right forearm and there was no assessment, treatment or accident and incident report completed.10 NYCRR 415.12 (a)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 12/09/2025, the facility did not ensure that the resident can make choices about aspects of his or her life that is important to them. Specifically, two (Residents #82 and Resident #7) of four (4) residents reviewed for choices had issues with not receiving a shower per their preference (Resident #82) and the facility did not honor the resident's preference to get out of bed before breakfast (Resident #7). The findings are:The policy titled Care Plans -Comprehensive revised on 02/01/2018, documented an individualized comprehensive care plan that includes measurable objectives and timetables to meet the residents medical, nursing and psychological needs is developed for each resident. Each resident's care plan is designed to reflect the residents expressed wishes regarding care and treatment and will incorporate the residents personal and cultural preferences in developing goals of care.The policy titled Resident Rights dated 03/01/2017, documented employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility which include the residents right to self-determination and to be informed of and participate in their care planning and treatment.The policy titled Bathing and Showering dated 3/1/2017, documented that the resident will be offered the frequency, days of the week, and location of their showers.1. Resident #82 was admitted to the facility with diagnoses of peripheral vascular disease, cellulitis (infection) of the leg, and chronic pain syndrome. Review of the Minimum Data Set (a resident assessment tool) dated 11/4/2025 documented that the resident was cognitively intact, understood others, understood by others, and it was somewhat important for them to choose between a bed bath or a shower. Resident #82 was dependent on staff for bathing and showering.Review of an undated Certified Nurse Aide Care Profile for Resident #82 documented that the resident was to receive a shower once a week on Wednesdays during the afternoon 3:00 PM to 11:00 PM shift. The care profile documented that the resident was dependent on staff for showering and bathing including washing, rinsing and drying.Review of the comprehensive care plan dated 10/30/2025 documented that the resident bathing and self-care was per Occupational Therapy's recommendations.Review of the Occupational Therapy Evaluation dated 10/30/2025 documented that the resident required a maximal assist of two staff members for bathing due to Resident #82 only able to perform 25% of the bathing task. Further review of the occupational therapy evaluation documented that the resident would need to use a shower chair for bathing.Review of Resident #82's daily shower sheets dated 11/5/2025, 11/12/2025, 11/26/2025, and 12/3/2025 documented that the resident received bed baths or refused bathing.Review of Resident #82's chronological progress notes dated 10/29/2025 to 12/7/2025 revealed no documentation of any resident refusals to take a shower.During an interview on 12/2/2025 at 10:26 AM with Resident #82, they stated that they asked staff when they get a shower, and it was supposed to be on Wednesdays. They stated that they have not received a shower since they have been admitted . They stated that no one asked for their preference to take a shower. They stated that it bothered them as they took a shower every night when they were at home.During an interview on 12/5/2025 at 11:50 AM with Certified Nurse Aide #4, they stated that they never gave a shower to Resident #82. They stated they did not offer a shower to Resident #82 because they thought that the resident could not fit the shower bed, and they didn't think Resident #82 could fit the shower chair. They stated that they did not tell anyone about not getting a shower done.During an interview on 12/5/2025 at 12:10 PM with Certified Nurse Aide #3, they stated they have never given a shower to Resident #82. They stated that Resident #82 was a two assist for a shower so if they don't have enough staff then Resident #82 could not get a shower.During an interview on 12/5/2025 at 1:13 PM with the Physical Therapist, they stated that they were never approached by nursing staff about Resident #82's shower. They stated that if they had known, they could have given showers to Resident #82 as part of therapy time.During an interview on 12/8/2025 at 8:38 AM with Licensed Practical Nurse Charge Nurse #2, they stated that they were not aware that Resident #82 was not getting a shower. They stated that they expect staff to report when residents were not getting showers. They stated that they expected staff to document when residents refused a shower and the reason why. They stated that the resident could be lifted into a shower chair and given a shower that way.During an interview on 12/9/2025 at 8:42 AM with the Registered Nurse Regional Educator, they stated that if a resident wanted a shower or their preference was a shower, staff should give the resident a shower as long as the resident was safe. 2.Resident #7 had diagnoses that included congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease (progressive lung disease). The Minimum Data Set, dated [DATE] documented Resident #7 was understood, understands and was cognitively intact. Resident #7 had upper extremity functional limitation to one side and required supervision or touching assistance (helper provides verbal cues and/or touching and or contact guard assistance) with transfers. There were no behavioral symptoms or refusals of care documented.The comprehensive care plan identified as current by the Director of Nursing documented Resident #7's preferences were initiated on the care plan on 09/16/2020 and their preferred time to rise varied. There were no revisions made to Resident #7's preferred rise time.The undated care profile (guide used by staff to provide care) identified as current by the Director of Nursing, documented Resident #7's preferred time to rise was on night shift (11:00PM - 7:00AM) by 7:00 AM.Review of the Resident Care Profile (V.3) Form created on 10/08/2025 by the Director of Nursing, documented Resident #7's preferred rise time was on the night shift by 7:00AM.Review of nursing progress notes from 11/05/2025 through 12/05/2025 revealed there was no documented evidence Resident #7 refused to get out of bed at their preferred rise time.During an observation and interview on 12/01/2025 at 1:26 PM, Resident #7 was observed in their room sitting up in wheelchair. They stated they were not given the choice on what time they could get out of bed in the morning. Resident #7 stated they preferred to be up early before breakfast and have expressed their preferences to the Unit Manager. They stated when they asked the certified nurse aides to get up before breakfast, they were told either they had to wait until other resident's had been provided care or needed to wait until there was a second certified nurse aide to help. During observation and interview on 12/03/2025 at 8:56 AM, Resident #7 was lying in their bed and stated it was important to them to be out of bed early, they were independent once in their wheelchair and attended several activities and therapy throughout the day.During intermittent observations made on 12/02/2025 at 9:43 AM and 12/04/2025 at 9:06 AM, Resident #7 was observed to be lying in bed.During an interview on 12/04/2025 at 9:10 AM, Certified Nurse Aide #6 stated they were assigned to Resident #7 and were informed from other staff they preferred to get out of bed between 10:00 AM - 11:00 AM. They stated the resident care profile specified what time a resident preferred to go to sleep but was unsure if it specified a preference time to get out of bed. Certified Nurse Aide #6 stated the nurses communicated to them what residents needed to be up for therapy or had early appointments and those resident's received care first. Certified Nurse Aide #6 stated Resident #7 did not request to be up before breakfast.During a telephone interview on 12/04/2025 at 4:56 PM, Certified Nurse Aide #15 stated they worked the night shift (11:00PM - 7:00AM) and were familiar with Resident #7, they stated they were not assigned to Resident #7 and had not provided care to them. Certified Nurse Aide #15 stated the nurse would inform the certified nurse aides which residents were to be up early on their shift and Resident #7 was not an early get up.During a telephone on 12/04/2025 at 5:11PM, Licensed Practical Nurse # 5 stated they worked the night shift (11:00PM- 7:00AM) and there were two (2) residents scheduled to be up early on their shift. They stated the Unit Manager determined what residents were to be up early and Resident #7 was not an early get up. Licensed Practical Nurse #5 stated Resident #7 had requested in the past to be up early but due to staffing they sometimes worked with only one or no certified nurse aides and were unable to get Resident #7 out of bed.During an interview on 12/05/2025 at 2:53 PM, Certified Nurse Aide #16 stated they provided care to Resident #7 today and had assisted them out of bed between 9:00 AM - 10:00 AM. They stated Resident #7 had not requested to be out of bed earlier and were unsure if the care profile listed a resident's preferred rise time. Certified Nurse Aide #16 stated they would be verbally informed by other staff members if a resident needed to be up early otherwise, they worked their way down the hall to get every resident up.During an interview on 12/05/2025 at 2:59 PM, Licensed Practical Nurse Manager #1 stated resident preferences were listed on the care plan and care profile, they were reviewed and updated quarterly or when a resident requested a change. They stated if a resident had a preference to be up early it would be documented on their care plan and care profile and expected staff to follow the care plan. Licensed Practical Nurse Manager #1 stated Resident #7 had expressed to them in the past they preferred to be up before breakfast, they were independent in their wheelchair and liked to travel around the facility. They stated the night shift currently assisted two (2) residents out of bed in the morning and Resident #7 was not one of those residents. Licensed Practical Nurse Manager #1 pulled up Resident #7's care profile in the electronic medical record and reviewed their preference for rise time. They stated they were aware Resident #7 was to be out of bed by 7:00 AM but was not being followed due to staffing. Licensed Practical Nurse Manager #1 stated they were responsible to ensure certified nurse aides followed the care plan, it was important to honor resident preferences because this was their home.During an interview on 12/05/2025 at 4:28 PM, the Director of Nursing stated resident preferences were obtained on admission and could be updated anytime the resident requested to make a change. They stated certified nurse aides would know a resident's preferred rise or bedtime by looking at the care profile and would expect them to review the care profile prior to care and honor the resident's preferences because it was their home. During the interview the Director of Nursing reviewed Resident #7's care profile and stated the residents preferred time to rise was on night shift by 7:00 AM. They stated staff should have honored Resident #7's preference and attempted to get them out of bed at their preferred time.10 NYCRR 415.5 (b)(1)(3)

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00341704 and #NY00350496) completed on 1/27/25, the facility menus and nutritional adequacy did not meet the nutritional needs of residents in accordance with established national guidelines and be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy. Specifically, two (lunch and dinner) of two meal entrees observed revealed proper amount of protein was not being provided to meet adequate nutritional needs of the residents. The finding is: Review of the facility's policy titled Food and Nutrition Services dated 11/02/17 provided by the Corporate Quality Assurance Nurse revealed the facility is to provide each resident with a nutritious, palatable, well-balance diet that meets daily nutritional and special dietary needs, considering the resident's preferences. Food and nutrition staff will inspect meal trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive. During a lunch observation on 1/21/2025 at 11:55 AM, the Dietary Supervisor #2 and [NAME] #2 plated the food while the Acting Dietary Department Director #1 oversaw the tray line and placed all the foods on each resident's individual tray. The lunch menu consisted of tacos (consisting of ground beef in a flour tortilla), the primary vegetable was corn, the alternate vegetable was peas and carrots, and rice or mashed potatoes. The plated food appeared monochromatic (same color or hue) and unappetizing. [NAME] #2 placed a blue scoop in the ground taco meat which was later identified as a 2 oz portion. During the tray line [NAME] #2 stated they use any recipes and the facility did not have recipes for the foods being served. [NAME] #2 stated they just knew how to cook them from their training. Continued observation revealed that [NAME] #2 and Dietary Supervisor #2 plated approximately 60 lunch trays with tacos consisting of a 2 oz portion of ground meat. The Acting Dietary Department Director #1 did not intervene. While calling out the food preferences during the tray line the Acting Dietary Department Director #1 stated Resident #1 and Resident #2 did not want the main meal or choose the alternate and the Acting Dietary Department Director #1 made the decision to provide them alternates, which was fish for the entree. During an observation on 1/21/2025 at 4:20 PM, [NAME] #3 stated they just got through making the dinner meal which was chicken salad sandwiches. They stated they used the blue scoop to prepare them. [NAME] #3 was pureeing mixed vegetables in the blender and added water. When asked to see the recipe for the pureed vegetable, [NAME] #3 stated there wasn't one and they just knew how to make them. During the observation a chicken salad sandwich was checked for the protein measurement. The amount of chicken salad was measured even on the blue scoop. During an interview on 1/22/2025 at 12:05 PM Dietician #1 stated the cooks prepare the foods based on their training and was not aware of any recipe booklet utilized by the facility. In addition, they were not aware of how the cooks were trained and assumed by word of mouth that the cooks knew how to cook. Regarding portion sizes Dietician #1 stated that the facility utilizes scoops, and the dietary staff should know the proper scoop sizes for plating food. Dietician #1 stated that normally residents should receive 3 - 4 ounces of protein at lunch and dinner per normal dietary guidelines; however, was not aware of any written nutrient guidelines maintained in the facility. Dietician #1 stated that receiving 2 oz of protein at lunch and dinner was not a sufficient daily serving for protein. During a follow up interview on 1/27/2025 at 12:40 PM, the Dietician #1 stated that the facility utilizes the corporate menus which were last reviewed in the Summer of 2024. The Dietician stated for some reason when the menus were done the nutritive value of the foods was omitted and had been on previous facility menus. The Menus are posted on the unit; however, they are not provided to each resident individually. Upon admission Dietician #1 goes over the resident's food preferences and the meals are delivered based these food preferences. Dietician #1 stated when a resident does not like the entree of the alternate, staff should find out what the resident desires rather than making an independent decision however, the choices are somewhat limited and stated in the future they hope to offer more alternatives. Alternates are leftovers or what's in the refrigerator and stated nursing staff should know the daily alternatives so the residents could have choices During a telephone interview on 1/27/2025 at 3:22 PM, the Regional Registered Dietician stated that they try to meet with all the regional facility Food Service Directors quarterly to address menus, alternatives and always available food items to mainstream facility practices for food service delivery. Nutritive analysis of menus should be maintained by the facility personnel. The rest of the facilities utilize a software that provides that information; however, this facility utilizes a program that currently does not have that feature. They stated it can be purchased as an add on and they'll have to get it. The Regional Registered Dietician stated in absence of the computerized program the facility could have obtained the information without it and maintained their records. The Regional Registered Dietician stated that an average meal intake for maintenance consist of a 2000 calorie with 85-95 grams of protein per day and stated that the 2 oz observed for each meal was not an adequate amount of protein for an average diet. 415.14 (d)(1)(2)

Based on observation, interview and record review conducted during a Complaint (#NY00350496) investigation the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice for one (Resident #7) of three residents reviewed. Specifically, Resident #7 did not receive Levothyroxine Sodium (Synthroid medication used to treat thyroid conditions) as ordered and there was a lack of physician notification. The finding is: The policy titled Administering Medications/Treatments dated 12/1/17 documented medications shall be administered in a safe and timely manner, and as prescribed; and if a drug is withheld, refused, or given at a time other than the scheduled time the individual administering the medication will initial and document the electronic medical administration record space provided for that drug and dose and notify the Registered Nurse Supervisor and attending physician. In addition, medication refusal or omission - notify the provider of 2 consecutive missed doses of medication regardless of reason. Resident #7 was admitted to the facility with diagnoses that included hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), celiac disease (an immune reaction to eating gluten, a protein found in wheat, barley and rye), and chronic kidney disease and dialysis dependent. The Minimum Data Set (MDS, resident assessment tool) dated 1/7/25 documented Resident #7 was cognitively intact. The Physician's Order Form as of 1/22/25 documented Levothyroxine Sodium (Synthroid) oral tablet 88 microgram capsule by mouth every day early morning for hypothyroidism with a start date of 1/4/25. The Comprehensive Care Plan dated 1/6/25 documented Resident had diagnosis of hypothyroidism with interventions including medications as per the physician's order. Review of Resident #7's Medication Administration Record dated January 2025 revealed Levothyroxine Sodium (Synthroid) oral tablet 88 micrograms scheduled at 6:30 AM was not initialed as given as ordered on the following dates: January 6, 7, 8, 9, 10, 11, 16, 20, 21, and 22 and documented it was on hold on January 17th, 2025. Review of Resident #7's Progress Notes as of 1/27/25 revealed there was no documented evidence why the Levothyroxine Sodium (Synthroid) was not administered or that the physician had been notified on January 6, 7, 8, 9, 10, 11, 16, 17, 20, 21, and 22, 2025. During an interview on 1/21/25 at 10:45 AM, Resident #7 stated they have not received their Synthroid every morning as ordered. They stated they were to get it first thing in the morning every day. On many days the nurse will tell them they can't find it and believe it may not have come in from the pharmacy. Other nurses have given it to them, so they did not know why they were not getting the Synthroid as ordered. During a telephone interview on 1/23/25 at 10:36 AM, Resident #7's family member stated they were very concerned that Resident #7 was not receiving their Synthroid as ordered. They stated they believed on Tuesday January 14, 2025, a nurse, whom they could not identify, told them they believed the medication had not been delivered from the pharmacy. During an interview on 1/23/25 at 12:30 PM, Licensed Practical Nurse #1 stated Resident #7 had a physician's order for Synthroid 88 micrograms and it was to be administered every day at 6:30 AM. Resident #7 goes to Dialysis three (3) days a week at 5:00 AM and does not know if the Synthroid was rescheduled on those days. Upon review of the Medication Administration Record and Progress Notes Licensed Practical Nurse #1 stated there was no evidence the Synthroid was rescheduled and administered on the dates identified; January 6, 7, 8, 9, 10, 11, 16, 17, 20, 21, and 22, 2025. Licensed Practical Nurse #1 observed the Synthroid package from pharmacy and stated the fill date was January 6, 2025, with a dispensing amount of 25 tables and 15 tablets were remaining; therefore Resident #7 had not received the Synthroid as ordered. During an interview on 1/23/25 at 12:39 PM, Registered Nurse #2 stated upon review of Resident #7's Medication Administration Record, progress notes and the Synthroid medication package Resident #7 had not been receiving the Synthroid as ordered. During an interview on 1/23/25 at 12:58 PM, Unit Manager Licensed Practical Nurse #2 stated they were not aware Resident #7 was not receiving the Synthroid as ordered. Upon review of the Medication Administration Record and Progress Notes they stated there is no evidence Resident #7 received their Synthroid on the identified dates January 6, 7, 8, 9, 10, 11, 16, 17, 20, 21, and 22, 2025 as ordered and expected the nurses to notify them and the physician if a medication was not provided, and document the reason in the progress notes. During an observation and interview on 1/27/25 at 6:32 AM, Licensed Practical Nurse #3 stated they were responsible to administered Resident #7's medications at 6:30 AM on January 9 and 10, 2025 and upon review of the Medication Administration Record they stated they do not recall why the Synthroid was not administered. During an observation of the medication administration on 1/27/25 at 6:32 AM for Resident #7, Licensed Practical Nurse #3 stated they were unable to locate the Synthroid 88 micrograms on the medication cart and would have to obtain the medication from the facility's (name locked computerized medication dispensing system that stores and tracks medications). During an interview on 1/27/25 at 7:09 AM, Registered Nurse #5 stated the facility's (name of locked computerized medication dispensing system that stores and tracks medications) had Synthroid 25 micrograms and 125 micrograms but doesn't have the 88 micrograms Resident #7 requires and they would notify the Nursing Supervisor. During an interview on 1/27/25 at 7:16 AM, Registered Nurse Supervisor #3 stated they were the Nursing Supervisor on the following mornings, January 7, 9, 10, 16, and 17th and were not aware Resident #7 was not receiving their Synthroid as ordered. They stated 3 days ago (1/24/25) Licensed Practical Nurse #4 was unable to locate Resident #7's Synthroid, and they had asked Licensed Practical Nurse #5. Licensed Practical Nurse #5 told them the Synthroid was not in a blister package but in a smaller plastic labeled bag stored in the top drawer of the medication cart. Nursing Supervisor Registered Nurse #3 reviewed Resident #7's Medication Administration Record and Progress Notes and stated there was no documented evidence Resident #7 received Synthroid as ordered on the dates identified, January 6, 7, 8, 9, 10, 11, 16, 17, 20, 21, and 22, 2025 and there was no documentation why it was not administered. They stated since the medication was scheduled to be administered at 6:30 AM they would have expected the nurse to notify them the medication was not available, so they could assist in locating the medication or notify the physician and pharmacy that it isn't available. During an observation on 1/27/25 at 7:25 AM Nursing Supervisor Registered Nurse #3 showed Licensed Practical Nurse #3 where Resident #7's Synthroid 88 micrograms was in the top drawer of the medication cart. During an interview on 1/27/25 at 10:30 AM, the Director of Nursing stated the facility's (name of locked computerized medication dispensing system that stores and tracks medications) does not contain Synthroid 88 micrograms. They stated all medications should be administered as ordered and if a nurse was unable to locate a medication, they should inform the Nursing Supervisor or Unit Manager and follow their direction. They stated on the night shift (11 PM - 7AM), the Nursing Supervisor should have been notified and they would have contacted the physician for further direction. They stated the nurses should not be leaving the Medication Administration Record blank or indicating a medication was on hold without a physician's order to hold it. Upon review of Resident #7's Progress Notes and Medication Administration Record they stated there was no documented evidence Resident #7 received the Synthroid as ordered on January 6, 7, 8, 9, 10, 11, 16, 17, 20, 21, and 22, 2025; there was no documented evidence the medication was not available and no evidence the physician was notified. During a telephone interview on 1/27/25 at 11:42 AM, Medical Doctor #2 stated the facility notified them on 1/24/25 Resident #7 had missed a couple doses of Synthroid because they were gone to dialysis. They adjusted the administration time to accommodate the early pick up for dialysis. Medical Doctor #2 stated they were not aware Resident #7 had not received the Synthroid as ordered on January 6, 7, 8, 9, 10, 11, 16, 17, 20, 21, and 22, 2025 or that the nurses couldn't find it in the medication cart. They stated they expected the nurses to notify them any time a medication was unavailable and not able to be administered as ordered. During a telephone interview on 1/27/25 at 2:51 PM, Licensed Practical Nurse #4 stated they were unable to find Resident #7's Synthroid on January 6, 7, 8, 16, 17, and 20 2025, they did not notify the Nursing Supervisor, pharmacy or the physician and should have. They stated they left the Medication Administration Record blank except on 1/17/25 they documented it was on hold and had not called a physician, so it really wasn't on hold. Licensed Practical Nurse #4 stated they didn't know what to do when they couldn't find the medication. 10 NYCRR 415.12

Based on observation, interview, and record review conducted during a Complaint investigation (#NY00341704 and #NY00350496) completed on 1/27/25, the facility did not ensure each resident received food that accommodated their allergies, intolerances, and preferences for three (Resident #1,2 and 7) of three residents reviewed. Specifically, Resident #7 was ordered a no added salt renal, gluten free diet and was not being provided gluten free products and food preference choices. Resident #1 and Resident #2 did not receive their food preference choices. The findings are: The Facility assessment dated [DATE] and 9/18/17 identified as current by the Administrator documented the intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person - centered care and services the residents require. Resident support/care needs under General Care for Nutrition, documented individualized dietary requirements, liberal diets and specialized diets. The facility policy and procedure titled Food and Nutrition Services dated 11/02/17 documented each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Additionally, food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident. The facility policy and procedure titled Procurement of Dietary Items dated 2/10/17 documented it is the policy of the Food and Nutrition Director responsibility for the ordering of food and supplies. Work closely with dietary employees and have a thorough understanding of the menu to ascertain which products are most appropriate for the food prepared. The facility policy and procedure titled Therapeutic Diets dated 6/26/18 documented therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his/her goals and preferences. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. 1. Resident #7 was admitted to the facility with diagnoses that included hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone), celiac disease (an immune reaction to eating gluten, a protein found in wheat, barley and rye), and chronic kidney disease, stage 5 dialysis dependent. The Minimum Data Set (resident assessment tool) dated 1/7/25 documented Resident #7 was cognitively intact. Therapeutic diet on admission and while a resident. During an observation on 1/21/25 at 12:27 PM Resident #7's meal tray was delivered with a small bowl of tuna fish with a large amount of mayonnaise mixed in it. The meal ticket on the tray documented, Renal Gluten Free, meal - Chicken breast. Additionally in red ink, handwritten on the meal ticket documented, ALT (alternate) and ALT (alternate) Veg - no rice. Resident #7 stated they wanted the chicken breast and doesn't know why someone is writing ALT on their meal ticket and they were not asked if they wanted an alternate and were not offered choices. The Physician's Order Form as of 1/22/25 documented diet - no added salt renal, fluid restriction 1500 milliliter, gluten free with a start date 1/6/25. The Comprehensive Care Plan dated 1/6/25 documented Resident #7 is allergic to rice and wheat (needs to be on a gluten free diet) and resident is at risk for gastric intestinal discomfort related to diagnosis of celiac disease with interventions including provide a strict gluten free diet. Additionally, Resident is alert and oriented x 3, independent for decision making ability with goals including making decision regarding preferences in activities of daily living such as food preferences, and interventions including offer food choices to Resident. Review of the Progress Notes dated 1/4/25 through 1/27/25 revealed the following: -1/4/25 at 7:25 PM Registered Nurse #6 documented, dietary preferences Gluten Free Serious Celiac Disease. -1/4/25 at 11:04 PM Registered Nurse #6 documented, resident arrived at 5:30 PM, resident family member extremely concerned as to what Resident #7 was going to have to eat as they were extremely hungry at 6:40 PM and they were unable to eat the served meal which included breaded fish and then two peanut butter and jelly sandwiches. Family member stated they would go and get something the resident could eat today, but unable to bring in three meals a day plus snacks for the resident. Additionally, it is documented the family, and the resident were reassured the facility will accommodate their diet. Family member requested kitchen help (dietary) to be educated as to what is acceptable for a special diet, since breaded fish and peanut butter and jelly was not an acceptable meal for them. -1/5/25 at 1:08 PM Registered Nurse # 7 documented, Resident states they might have to leave because the facility doesn't have fresh vegetables, and needs a no added salt, renal and gluten free diet. -1/6/25 at 2:15 PM Director of Nursing documented, they met with Resident #7 and family member, and all appreciated the Registered Dietician clarify and initiating the gluten free diet as resident has a gluten allergy. -1/8/25 at 2:39 PM Registered Dietician documented, resident offers concerns regarding in-house diet related to Celiac's, maintaining food items with renal diet. -1/21/25 at 3:19 PM (late note from 1/20/25) Registered Dietician documented, received a call from Resident #7 over the weekend regarding food items on trays. Registered Dietician spoke with the resident on 1/20/25 stating they do not like how they are constantly getting tuna fish in a bowl despite this being an original preference. Education was given regarding renal and gluten free diet and how many items need to be restricted. Additionally, the kitchen staff are educated on renal diet, providing resident with tuna verses meal at that time per Resident's preference. Resident requested tuna be removed from their meal items and preferences updated. -1/22/25 at 3:10 PM Registered Dietician documented they spoke with Resident #7 regarding tonight's meal tonight and lunch/ dinner for 1/23/25. Choices per resident obtained for these meals. Explained chicken breast has been ordered and will be arriving on 1/23/25. Review of Resident #7's Meal Pattern identified by Registered Dietician as current revealed Gluten Free with chicken breast at lunch and dinner. Review of Resident #7's meal tray tickets (identifies what the resident is scheduled to receive for their meals) dated 1/18/25 through 1/21/25 revealed lunch and dinner chicken breast to be served. Review of the dietary Purchase Order slips dated 1/2/25 through 1/22/25 revealed chicken breast was ordered on 1/2/25 and 1/22/25. During an interview on 1/21/25 at 10:45 AM Resident #7 stated they have Celiac's disease and required a gluten free diet and the facility refuses to order gluten free crackers and breads. They stated they had received a bowl of tuna fish loaded with mayonnaise for lunch and dinner for several days and they talked to the Registered Dietician concerning their preferences multiple times but nothing changes. They stated they are to receive chicken breast every lunch and dinner as their preference, but they are told the facility had run out of chicken breast on 1/18/25 and it still had not come in. They stated the tuna fish is not appealing to eat out of a bowl and would prefer to have gluten free crackers or gluten free bread to spread it on. In addition, they had requested fresh fruit and vegetables but does not receive them. Resident #7 stated when they were admitted and discussed their diet preferences they were informed the facility was unable to provide gluten free breads and crackers and fresh fruit and vegetables; therefore their family had been providing the gluten free breads, but doesn't think they should have to bring it in since gluten free breads are readily available in stores and doesn't understand why the facility will not provide them with their dietary needs. During a follow up interview on 1/22/25 at 2:18 PM Resident #7 stated they were served breaded fish on 1/21/25 for dinner and they sent it back and then received a hamburger with cheese without a bun because they do not have gluten free rolls, and it bothers them. 2. During an interview on 1/21/2025 at 1:20 PM Resident #1 stated they did not like the tacos and did not like the fish. They stated their family ordered them a lunch meal from an outside source. Review of Resident #1's Nutritional assessment dated [DATE] revealed under the food preference the resident dislikes tacos. 3. During an interview on 1/21/2025 at 1:25 PM Resident #2 stated the vegetables were not good and it wasn't their favorite meal. They stated, I'm used to it. Review of Resident #2'sNutritional assessment dated [DATE] revealed under food preference the resident dislikes spicy foods, rice and fish. During an interview on 1/21/25 at 2:38 PM the Acting Dietary Department Director #1 stated they are unable to order gluten free crackers or breads because of budget reasons. They stated dietary does not have set alternates and the residents are not notified of what is available or offered choices because what is provided to them is left over from the previous day or foods available in the refrigerator. Every day might be something different. They stated Resident #7 was provided an alternate because they ran out of chicken breast and do not have any at this time. During a follow up interview on 1/23/25 at 9:20 AM the Acting Dietary Department Director #1 stated they had not attempted to purchase gluten free breads or crackers because they believed the facility would not allow them to purchase the items. They stated they didn't know someone could go to the store to purchase gluten free breads and they didn't notify the Administrator Resident #7 was requesting gluten free breads. They stated they are responsible for ordering food for the planned meals for the week and didn't know Resident #7 had chicken breast every lunch and dinner on their meal plan. They stated they do not look at the resident's meal tickets to know if there are specific items that need to be purchased, they order based on the week's menu not specific resident request. During an interview on 1/22/25 at 7:42 AM the Nursing Supervisor Registered Nurse #1 stated when Resident #7 was admitted they were informed by the evening Nursing Supervisor that dietary told them they cannot accommodate and provide gluten free bread products according to the Resident's choice. They stated they informed the Director of Nursing of Resident #7's preferences, and the Director of Nursing informed them the resident could be provided their choices of gluten free products and would follow up. During an interview on 1/22/25 at 8:55 AM the Registered Dietician stated Resident #7 had requested gluten free breads on 1/6/25, but the facility did not have any gluten free breads. The family offered to provide the gluten free breads, and the facility had not made any arrangements to provide the gluten free crackers or breads. They stated they should have informed the Director of Nursing, Dietary Department Director and the Administrator that Resident #7 was requesting gluten free breads because it is the responsibility of the facility to provide specialized dietary products for residents. Additionally, they stated Resident #7 requested chicken breast daily at lunch and dinner. The facility ran out of chicken breast and had not been providing Resident #7 with their dietary preferences and have not been offering food alternate choices. During an interview on 1/22/25 at 2:45 PM Medical Director #1 stated the facility is responsible to ensure all residents are provided with an appropriate nutritional diet and provide food products that accommodate a resident's preferences within means. They stated prior to admission the facility should have either ensured the resident they were able to accommodate or not accommodate the resident's diet so that the resident was able to make an educated decision whether to be admitted here or not. They stated if a resident wants gluten free breads and crackers then it is the Administrator's responsibility to ensure the facility obtains the products. Additionally, if Resident #7 wanted chicken breast every lunch and dinner meal the Dietary Department Director should know what is needed and had ensured the chicken breast was ordered timely and provided to meet their preferences and dietary needs. During an interview on 1/23/25 at 9:27 AM the Regional Administrator stated they oversee all aspects of the facility and stated gluten free products have never been denied and should have been ordered to accommodate the resident's dietary needs. If Resident #7 was planned to have chicken breast every lunch and dinner, then the Acting Dietary Department Director should have ensured it was ordered to accommodate their meal plan. They stated it is the facility's responsibility not the family to ensure specialized diet products such as gluten free breads and crackers are provided. They stated residents should be offered alternative choices for meals not the dietary staff deciding what they are going to send to the resident. They stated they believe all kitchen staff need additional training. During an interview on 1/23/25 at 10:36 AM Resident #7's family member stated upon admission they were informed the facility doesn't provide gluten free crackers and breads and had brought some in for Resident #7. During an interview on 1/23/25 at 1:30 PM the Director of Nursing stated they met with Resident #7 on 1/6/25 and was informed by Resident #7 they were gluten free and had concerns with their diet. They informed Registered Dietician #1 of Resident #7's request for preferences and the Registered Dietician met with the resident. They stated if Resident #7 requested gluten free breads and crackers and chicken breast daily at lunch and dinner then they should have been receiving them. They stated the Acting Dietary Department Director should have ensured the gluten free products and chicken breast were ordered. The Registered Dietician #1 should have ensured the resident was receiving their diet and preferences. They stated it is the facility's responsibility to ensure resident's nutritional diet and preferences are provided. During an interview on 1/27/25 at 9:00 AM Dietary Supervisor #1 stated if a resident's meal ticket documents a product that they know they are out of then they write ALT on the meal ticket meaning alternate and then dietary decides what to send up depending on what is available in the kitchen. They do not offer food choices because of limited amount of food available. During an interview on 1/27/25 at 9:20 AM [NAME] #2 stated they know what to make for each meal by following the Production Sheet the Dietary Supervisor develops the day before. They stated they do not look at the resident's meal tickets and didn't know Resident #7 had chicken breast listed on their meal plan for lunch and dinner every day. They stated if they were to ensure a chicken breast was to be cook then the Production Sheet should have the chicken breast identified on it. During an interview on 1/27/25 at 9:41 AM Dietary Supervisor #2 stated they complete the production sheet and do not know how the cooks know to cook a chicken breast. They stated they list the menu items on the production sheet and count the residents who are receiving regular meals but do not look at specific meal tickets for specific food items. They stated if a resident is listed to receiving anything else other than the regular menu then they count that resident to receive an alternate, and alternates are whatever is available in the kitchen. During an interview on 1/27/24 at 10:59 AM the Administrator stated they were unaware Resident #7 had requested gluten free crackers and bread and should have been informed so they could ensure the products were available according to their diet and preferences. They were not aware the facility was out of chicken breast and stated the Acting Dietary Department Director should have known Resident #7 meal ticket documented chicken breast for both lunch and dinner meal and ordered it before running out. The Administrator reviewed the identified production sheet dated 1/27/25 and stated it doesn't reflect a chicken breast is to be cooked therefore would not be able to ensure Resident #7's meal plan preferences were going to be followed. The Administrator stated there needs to be improvement in the kitchen with processes and education provided. 10 NYCRR 415.14(d)(4)

Based on observations, record review, and interviews conducted during the Standard survey completed on 4/26/24, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for one (Residents #61) of 2 residents reviewed for resident choices. Specifically, Resident #61 was given a bed bath instead of a shower as planned and per their stated preference. The finding is: The policy and procedure titled Quality of Life- Accommodation of Needs, dated 9/1/17, documented the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. In order to accommodate individual needs and preferences, adaptations can be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. The policy and procedure titled Care of the Bariatric Resident, dated 5/10/21, documented the facility will use an interdisciplinary care approach to care for residents with severe obesity, and the facility will ensure appropriate equipment is available and in good repair. Resident #61 had diagnoses including severe morbid obesity, multiple sclerosis (a progressive disease, involving nerve cells in the brain and spinal cord, that can cause numbness, impairment of muscular coordination), and fragile X syndrome (a genetic condition causing intellectual disability). The Minimum Data Set (a resident assessment tool) dated 11/30/23, documented Resident #61 was moderately cognitively impaired, always understood and always understands. The Minimum Data Set documented that it was very important for the resident to choose between a shower and a bed bath, and the resident was dependent on staff for showers. The care plan dated 3/15/21 documented Resident #61 preferred a shower twice a week, every Monday and Thursday on the day shift, with a goal that staff would honor the resident's preferences/choices as able. Resident #61's, undated, Care Profile (guide used by staff to provide care) documented the resident was to receive a shower one time per week on Mondays. The undated, Yellow Unit shower schedule documented Resident #61 received showers on Thursdays. The facility was unable to provide evidence that showers were provided per the resident's care plan and that only bed baths were provided. During an interview on 4/22/24 at 9:43 PM, Resident #61 stated they had not had a shower since they were transferred from the second floor to the first floor. They could not recall how long that had been. They were given bed baths, but they preferred a shower. They stated that staff told them it was unsafe for them to be in the shower chair due to their size. Resident #61 stated they told several staff they preferred a shower over a bed bath. During an interview on 4/25/24 at 8:21 AM, Certified Nurse Aide #1 stated that Resident #61 got a bed bath instead of a shower because the shower chair was unsafe for them due to their weight. During an interview on 4/25/24 at 8:28 AM, Registered Nurse #1 stated that Resident #61 received a daily bed bath instead of a shower. They did not think the shower chair on the unit would be safe for Resident #61 due to their weight. During an interview on 4/25/24 at 9:19 AM, Licensed Practical Nurse Unit Manager #1 stated that showers were put on the schedule based on the resident's preferences. They stated that if a resident was scheduled for a shower, they would expect them to get it. The Unit manager stated they were aware that Resident #61 had been receiving bed baths instead of showers. They stated the resident's wheelchair would not fit into the shower room and the shower chair would not be safe for their weight. The Unit Manager stated that the previous administration had been aware of the situation, and nothing had been done about it. The Unit Manager stated the Resident's care plan should be changed to a bed bath instead of a shower. During an interview on 4/25/24 at 10:02 AM, the Environmental Director stated the larger shower chair on the Yellow unit would hold up to 375 pounds, however, there was a bariatric shower chair on the second floor that held up to 750 pounds. During an interview on 4/26/24 at 8:07 AM, the Director of Activities stated they completed the preference portion of the Minimum Data Set, on admission, if there was a significant change, and annually. They stated that they reviewed each question with the resident during each interview. The Director of Activities stated if there was a change in a resident's preference, they would update the unit manager. During an interview on 4/26/24 at 12:22 PM, the Director of Nursing stated if Resident #61's preference was to have a shower it should have been care planned and staff should have provided a shower. 10 NYCRR 415.5 (b)(3)

Based on observation, interview, and record review during the Standard survey completed on 4/26/24, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected two (First Floor, Second Floor) of two resident use floors and the Basement. The finding is: The policy and procedure titled Carbon Monoxide Detectors, effective 5/2019, documented carbon monoxide detectors shall be installed, tested and cleaned as per manufacturer's recommendations. Additionally, carbon monoxide detectors are to be vacuumed once monthly to remove any accumulated dust. Observations during the building tour on 4/22/24 from 6:10 PM until 9:00 PM revealed fuel-burning appliances were located in the Basement and First Floor. Resident sleeping rooms were located on the First and Second Floors. Further observation revealed there were Brand A single-station battery-operated carbon monoxide detectors in each of the six resident unit corridors, and also a Brand A single station battery-operated carbon monoxide detector in the Main Kitchen on the First Floor and the Laundry Room in the Basement. There was also a Brand B single-station hard-wired carbon monoxide detector in the Boiler Room in the Basement. 1a. Review of Brand A carbon monoxide detector manufacturer's User Manual revealed, It is recommended that users test the manual key once a month. According to the User Manual, the product will self-test the buzzer circuit every week. Review of online operating instructions for Brand A carbon monoxide detectors revealed the device had three light indicators: green power light, yellow fault light, and red ALARM emergency light. The online operating instructions indicated when powering the device for the first time, press the test/ silence button for five seconds, the green power light will blink once per second, the red ALARM word will appear in the center, and it will make a beeping sound. This is the warm-up state. After 60 seconds, the green power light will blink once every minute, which is the normal working state. Additionally, the whole cover is the test/ silence button. During an interview on 4/22/24 at 7:00 PM, the Environmental Director, Maintenance Supervisor, and Maintenance Assistant stated the Brand A carbon monoxide detectors were installed after the last Life Safety Code survey in 2023 and there was no testing done on them. At this time, the Maintenance Assistant removed one from a corridor wall and stated there was no obvious test button on the front or the back of the device. During an interview on 4/24/24 at 2:45 PM, the Regional Plant Operations Director stated the facility had eight Brand A carbon monoxide detectors, and that brand was chosen by corporate personnel because Brand A devices automatically performed self-tests. Also at this time, the Maintenance Supervisor stated they personally installed the Brand A carbon monoxide detectors in 2023 by pulling the tab on each one, and stated the green light did light up for a few seconds after each tab was pulled. Observation on 4/24/24 at 2:50 PM revealed the Brand A carbon monoxide detectors from the Laundry Room and from [NAME] Hall were brought to the Maintenance Shop for testing. At this time, both were pressed in the center and on the four corners for various lengths of time and neither of them produced a light or sound. Observation on 4/24/24 at 3:15 PM revealed the Brand A carbon monoxide detector in the [NAME] Hall was pushed in the center by the Maintenance Supervisor for various lengths of time and did not produce a light or sound. Observation on 4/24/24 from 3:00 PM to 3:20 PM revealed when the Brand A carbon monoxide detectors in the Lake Hall, [NAME] Hall, Shamrock Hall, [NAME] Hall, and Main Kitchen were pushed in the center by the Maintenance Supervisor or the Environmental Director, the word ALARM appeared in red in the center, several quick beeps were heard, and the green light flashed several times. After that series, the green light flashed once every minute. 1b. Review of the Brand B carbon monoxide detector manufacturer's User's Manual revealed it is important to test this unit every week to make sure it is working properly. The unit can be tested manually by pressing the test/ silence button until the alarm sounds, or by remote control. Additionally, according to the User's Manual, the unit must be cleaned at least once a month by gently vacuuming the outside of the alarm. During an interview on 4/23/24 at 3:40 PM, the Regional Plant Operations Director stated the Brand B carbon monoxide detector in the Boiler Room was hard-wired, but still should be tested per manufacturer's instruction. During an interview on 4/24/24 at 3:20 PM, the Environmental Director stated the Brand A carbon monoxide detectors were installed prior to their employment at the facility and they were not familiar with them. The Environmental Director stated Maintenance staff were not testing the carbon monoxide detectors because there was no task on the automated maintenance work order system that addressed testing them. The Environmental Director stated they were familiar with the Brand B hard-wired carbon monoxide detector in the Boiler Room and tested it once, but did not perform further testing because they did not know if testing it would affect any other system in the facility. At this time, the Environmental Director also stated since learning more about the Brand A carbon monoxide detectors today, they now believed they should beep and flash red ALARM light and the green light when pushed in the center of the unit and they were unsure why three of them did not beep or light up as expected during today's testing. During an interview on 4/26/24 at 1:55 PM, the Environmental Director stated the importance of testing carbon monoxide detectors was to ensure that they would work in an actual carbon monoxide emergency. The Environmental Director also stated Brand A carbon monoxide detectors were not mechanically repairable and the three that did not respond at all to testing on 4/24/24 needed to be replaced. 42 CFR 483.70(b) 10NYCRR: 415.29(a)(2), 711.2(a)(1) 2020 Fire Code of New York State, Section 915: 915.3.1, 915.6

Based on observation, interview, and record review conducted during the Standard survey completed on 1/30/23, the facility did not maintain an effective pest control program so that the facility was free from insects. Specifically, one (Blue Unit) of three units' and one Main dining room multiple black flies were observed. Residents #1, #42, #50, #52, #53, #57, #74, #83, and #88 involved. The findings are: The facility policy and procedure (P&P) titled Pest Control with a revised date of May 2008 documented the facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Windows are screened at all times. During and observation on 1/23/23 at 10:13 AM Resident #1 was observed to be sleeping in their wheelchair (w/c) in their room. Multiple flies were observed flying around the resident and landing on the resident's clothing and their right hand. During an observation and interview on 1/23/23 at 11:11 AM, multiple flies were observed on Resident #83's bottom sheet on their bed and on the nightstand. Resident #83 stated the flies were a pain in the butt and that they have reported this many times. Resident #83 could not recall to whom they reported fly concern to. Additionally, at 4:11 PM, flies were still observed in Resident #83's room and landing on the residents exposed arms. During an observation on 1/23/23 at 11:25 AM and 4:10 PM, multiple flies were observed in Resident # 50's room and landing on residents' head, exposed skin on torso, left hand and bed sheets covering the resident. Resident #50 was unable to be interviewed. During an observation on 1/23/23 at 12:24 PM, flies were observed flying around the Blue Unit hallway while staff were passing meal trays. At 12:47 PM, staff were observed waving a fly away with their hand. During an observation on 1/23/23 at 2:59 PM, Resident #57 was in the Main Dining Room for lunch, the resident was observed to have multiple flies around them. One fly landing on the resident's chest and the other fly circling around the outside of the resident's open mouth. The resident's physical ability prevented the resident from removing the fly's from around them. During an observation and interview on 1/24/23 at 8:36 AM, Resident #42 was observed swatting a fly away, with their hand, while eating their breakfast. Resident #42 stated the flies get very annoying, especially when there are a lot of them. Resident #42 stated it's because they leave their window open and there was no screen. The windows were observed open and without screens in the room and bathroom. During an observation and interview on 1/24/23 at 8:52 AM, flies were observed flying around food on breakfast tray in front of Resident #53 in their room. Resident #53 stated, they're a pain in the ass. There are always 1 or 2 around and they are a nuisance. Additionally, Resident #53 stated they have commented to the staff about the flies. During an observation and interview on 1/24/23 at 9:23 AM, Resident #52 stated the flies have been constant for a while and that their daughter was going to bring in fly paper. On the chair in the resident's room there was a supper meal tray with leftover food from 1/23/23. During an observation and interview on 1/24/23 at 9:48 AM, flies were observed flying around in Resident #88's room. There were no screens on windows. Resident #88 stated the flies bother them and doesn't want them on their food and drinks. Resident #88 stated, the flies, fly around my head and I can hear them. Additionally, Resident #88 stated the flies were really bad a couple of weeks ago and was told by a nurse the facility had an exterminator come in last year. During an observation and interview on 1/24/23 at 11:30 AM, was a fly in the bathroom attached to Resident #1's room. The Maintenance Supervisor stated flies were occasionally seen in the facility. The Maintenance Supervisor stated the facility had a contract with a licensed exterminator and if there was an issue with flies, they would call the exterminator. Additionally, Resident #1 stated they never opened the window in their room, but there were occasional flies in their room, usually around mealtime. During an interview on 1/25/23 at 1:05 PM, the Maintenance Director stated there were three insect light traps in the facility, two in the kitchen and one in the lobby, and they were maintained by a licensed exterminator. The exterminator made regular monthly service visits to the facility, and additional visits as needed. The Maintenance Director also stated they had not personally had any resident complaints regarding flies recently. During an interview on 1/26/23 at 9:10 AM, Certified Nursing Assist (CNA) #2 stated they have noticed flies in residents' room and on residents; especially in Resident #50's and Resident #74's room. CNA #2 stated they have seen flies on Resident #50's face and on their bed. CNA #2 stated they fly the flies away from the residents because they shouldn't be on them. Additionally, CNA #2 stated they had not reported it to anyone because they thought it was kind of normal. CNA #2 stated they were glad surveyor asked them about the flies, in my head, I thought it was odd. By you asking verifies there's an issue. During an interview on 1/26/23 at 9:21 AM, CNA #5 stated they were swatting away the flies, flying at their face while in hallway. CNA #5 stated every time they have worked over the last 2-3 months, they have seen flies in resident rooms and in the hallways of the Blue Unit. CNA #5 stated, the flies are nasty and shouldn't be around the residents and in their food. I wouldn't want them in my house. During an interview on 1/26/23 at 9:25 AM, Licensed Practical Nurse (LPN) #1 stated that there were flies everywhere on Blue Unit. However, they hadn't personally reported the flies to anyone. LPN #1 stated that flies carry bacteria and shouldn't be on the residents. LPN #1 stated, wouldn't want flies on me. During an interview on 1/26/23 at 10:56 AM, the Laundry/Housekeeping Supervisor stated they had noticed flies, especially on the Blue Unit and had reported this to the Administrator and Maintenance Director. Laundry/Housekeeping Supervisor stated they did not like flies being in the facility and thought it was an infection control concern. During an interview on 1/26/23 at 11:06 AM, the Maintenance Director stated they were informed by the Administrator yesterday or the day before of a fly concern. The Maintenance Director stated, told my guys to see if they could catch them with a fly swatter. They found a few of them and killed them. Pest control was notified yesterday. During an interview on 1/26/23 at 11:16 AM, the Administrator stated they were aware of the flies, and had brought it to the attention of housekeeping, nursing, and maintenance. The Administrator stated they have observed them around and were prevalent. The expectation would be for staff to inform them of flies due to sanitation and that they aren't meant to be indoors. 10 NYCRR 415.29(j)(5)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/30/2023 the facility did not ensure that residents who require dialysis, received services consistent with professional standards of practice. Specifically, one (Resident #42) of one resident reviewed for dialysis had an issue involving the lack of the AVF (arteriovenous fistula) access site (a tube or device surgically implanted to create an artificial connection between an artery and a vein) pressure dressing not being removed. The finding is: Review of the facility policy and procedure (P&P) titled Dialysis dated1/19/2019, documented the facility has established standards of care for the dialysis resident. The licensed nurse will evaluate, observe, and/or assess the shunt/fistula site for signs and symptoms (S&S) for bleeding and infection and remove the pressure dressing from the shunt/fistula site upon return from dialysis as indicated. 1. Resident #42 had diagnoses including End Stage Renal Disease (ESRD), anxiety and diabetes mellitus (DM- high blood sugar). The Minimum Data Set (MDS-a resident assessment tool) dated 12/9/22 documented the resident was understood, understands, was cognitively intact, and had dialysis treatments. Review of the Comprehensive Care Plan dated 4/11/22 documented Resident #42 had chronic renal insufficiency/renal failure. Interventions included to monitor their AV fistula every shift and remove the pressure dressing 3-4 hours after return to the facility. Review of the Physicians Orders dated 11/17/22 documented to remove the fistula pressure dressing 3-4 hours after dialysis on the evening shift. Review of the Treatment Administration Record (TAR) dated 1/1/2023 through 1/27/23 documented on 1/23/23 and 1/25/23 at 3:00 PM the pressure dressing was removed. During an observation on 1/24/23 at 8:36 AM, Resident #42's pressure dressing over the right upper extremity (RUE) AV fistula was intact, dry and clean. At the time of this observation, Resident #42 stated they were at dialysis yesterday and the nurse didn't take the dressing off yet. Nobody has looked at it, otherwise they would have taken the dressing off. Resident #42 was then observed to remove the pressure dressing over the fistula site, dried bloody drainage was noted to the dressing with no active bleeding at the site. During an observation on 1/26/23 at 10:35 AM, Resident #42 was lying in bed, the AV fistula dressing over the RUE was dry and intact. At the time of the observation, Resident #42 stated they were at dialysis yesterday; the nurse hadn't taken the dressing off yet and the aides won't do it. The resident also stated they will remove the dressing and leave it on the bedside table for the staff to see. During an observation on 1/26/23 at 1:32 PM, the AV fistula dressing was observed to remain on the resident's RUE. During an interview on 1/27/23 at 11:16 AM, Licensed Practical Nurse (LPN) #6 stated the resident had a fistula in their arm but was unsure when the dressing was supposed to be removed, the site should be check for bleeding and infection. During an interview on 1/27/23 at 1:06 PM, the Director of Nursing (DON) stated they were somewhat familiar with the resident but was unsure of what type of dialysis port the resident had and should probably talk to the Assistant Director of Nursing (ADON). During an interview on 01/27/23 at 1:10 PM with the ADON stated Resident # 42 was on hemodialysis and had a shunt in their arm for access, they were unsure when the resident's dressing was supposed to be removed but it was up to the direction of the dialysis center, sometimes they tell us to take it off or at times the say leave it alone and they care for it. The ADON stated the nurses should follow the MD order for removal. During an interview on 11/27/23 at 1:18 PM, the Dialysis Center RN #2 stated the resident had a fistula in their right arm and the dressing should be removed late evening and the site assessed post dialysis. The resident had a history of bleeding, and the dressing removal should not wait till the next day. During an interview on 1/27/23 at 2:30 PM, the Regional DON stated fistula dressings were usually removed post dialysis 4-6 hours depending on the dialysis center's recommendations. 10 NYCRR 415.12

Based on observation, record review and interview conducted during a Complaint investigation (Complaint # NY00304636) during the Standard survey completed on 1/30/23, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services consistent with professional standards of practice to promote healing for one (Resident #100) of four residents reviewed. Specifically, there were lack of pressure ulcer assessments and ongoing monitoring from a qualified individual for a resident with ankle and Achilles' pressure ulcers to include stage, location, measurements. In addition, the Minimum Data Set (MDS - resident assessment tool), did not reflect pressure ulcers and the comprehensive care plan was not revised to include the use of an air mattress. The finding is: The facility policy and procedure (P&P) titled Pressure Ulcers -Risk Assessment and Maintenance of Skin Integrity dated 2/1/ 2018 documented the facility would identify residents at risk for skin breakdown, maintain skin integrity and would ensure that residents with pressure ulcers were appropriately assessed and treated. When a resident was identified at moderate to high risk for skin breakdown, a plan of care and interventions would be developed by the interdisciplinary (IDT) care plan team according to risk assessment. The Certified Nursing Assistant (CNA) was responsible to observe the residents' skin daily for redness, breaks in skin, and reported changes in integrity to the nurse. Nurses inspected residents' skin weekly on bath day and documented the condition. If an area is noted, the nurse proceeded to wound care protocol per the facility standards. When new pressure ulcer/impaired skin integrity was identified the Licensed Nursing Staff notified the Registered Nurse (RN) Supervisor/Assistant Director of Nursing (ADON) immediately. The RN Supervisor/ADON immediately assessed the resident and completed a wound assessment in the forms section of the medical record. The facility (P&P) titled Braden Risk Pressure Ulcer Risk Assessment Tool dated 11/1/2017 documented an assessment for pressure ulcer risk was completed for residents and aided in the prevention of pressure ulcers. The RN Supervisor completed assessment tools on admission and readmission to the facility. The MDS/Care Plan Nurse completed the Clinical Risk Assessment Form within twenty-four (24) hours of a wound being identified and a Braden Risk Assessment once a week for four (4) weeks after admission whenever indicated. 1. Resident #100 had diagnoses that included pressure ulcers, diabetes mellitus, and depression. The MDS dated [DATE] documented Resident #100 had severe cognitive impairment and had no pressure ulcers. The Comprehensive Care Plan (CCP) dated 6/6/22 documented impaired skin integrity related to diabetes and pressure ulcers. The planned interventions included to keep skin clean and dry, maintain adequate nutrition, provide clean, dry, wrinkle-free linens; weekly skin checks weekly by nurse; and turn and position every 2 hours and as needed while in bed. The CCP was not revised to reflect the use of an air mattress. The Care Profile (guide used by staff to provide care) dated 1/26/23 verified as current by Licensed Practical Nurse (LPN) #8 Unit Manager documented Resident #100 was at high risk for skin breakdown. Interventions include routine skin checks, preventative skin care, turn and position every 1-2 hours, and to float heels while in bed. The Care Profile was not revised to reflect the use of an air mattress. Review of the Resident #100's entire Medical Record from 6/6/22 through 1/30/23 revealed an admission Braden Scale assessment was completed and signed by an RN on 6/7/22. There was no documented evidence of additional Braden Scale Assessments completed. The Daily Unit Report for the Yellow Unit dated 10/9/22 revealed the Podiatrist performed nail debridement with Resident #100's nephew present. The nephew was upset due to the multiple pressure ulcers on Resident #100's ankles and heels and the nursing supervisor was notified. The Nursing Progress Notes documented the following: -10/6/22 Licensed Practical Nurse (LPN) #8 documented at 12:11 PM there was no current wound care at this time. -10/9/22 LPN #9 documented at 9:35 AM that Resident #100 was seen by the podiatrist. Bilateral heels and ankle ulcers were noted. Per the podiatrist Resident #100 cannot wear ankle socks. LPN #9 documented heel booties were in place to free float heels while in bed. -10/9/22 LPN #10 documented they were notified by the nurse on duty that Resident #100 was seen by the podiatrist with the nephew present in the room. Bilateral heel and ankle sores were noted, which resulted in the nephew becoming upset. LPN #10 further documented the Director of Nursing (DON) was notified. -10/10/22, the ADON documented at 2:04 PM they assessed Resident #100 and noted 3 oval scabs to the top of the right and left foot and measure 1.8 centimeters (cm) with a small amount of bleeding. There was no documented RN assessment of the posterior ankles/Achilles or heels to include stage, location, measurement, or drainage. The contracted Podiatry Consult dated 10/9/22 documented that Resident #100 nails were derided. The Podiatry Consult did not document any pressure ulcers. The Wound Physicians Services Consult titled Wound Assessment and Plan documented on 10/11/22 that Resident #100 was seen for a right distal great toe arterial ulcer. There was no documented evidence of a wound assessment and plan for the bilateral ankles/or Achilles', or heel pressure ulcers. Physician's Orders with an as of date of 10/11/22 revealed physician orders for skin prep barrier film daily to the right distal great toe and skin prep was to be applied to the bottom of the right foot pressure (heel) ulcer twice daily. There was no physician's order for treatment to the left and right ankles or Achilles. The Treatment Administration Record (TAR) dated 10/2022 revealed skin prep was to be applied to the bottom of the right foot pressure ulcer (heel) twice daily. There were no documented treatment orders to the left and right ankles/or Achilles. Review of the Weekly Pressure Ulcer Progress Assessment Update revealed there was no documented weekly monitoring for the pressure ulcers to the left and right ankles/ or Achilles. During an interview on 1/30/23 at 9:45 AM, CNA #7 stated they couldn't recall the last time they saw Resident #100's feet. During a telephone interview on 1/30/23 at 10:04 AM, the contracted Podiatrist stated Resident #100's toenails were debrided in the facility on 10/9/22. The Podiatrist, in the presence of Resident #100's nephew removed tight tennis socks from both feet and discovered pressure ulcers to the left and right ankles and Achilles. The podiatrist reported the pressure ulcers to LPN #9. Until seen by the Physician, the Podiatrist recommended avoiding tennis socks and wound prep to both ankles and Achilles. The Podiatrist stated they were Strictly contracted for nail debridement in the facility and retained their own personal wound documentation. The Wound Consult provided by the contracted Podiatrist on 1/30/23 and dated 10/9/22 and revealed left and right anterior, and posterior ankle wounds related to pressure. The Consult documented the following: -Ulcer 1 left anterior ankle: full thickness wound, measured 3 cm x 2 cm x 0.6 cm. -Ulcer 2 left posterior ankle (Achilles): full thickness wound, measured 3.2 cm x 2.8 cm x 0.6 cm. -Ulcer 3 right anterior ankle: full thickness wound, measured 3.4 cm 2.3 cm 0.6 cm. -Ulcer 4 right posterior ankle (Achilles): full thickness wound measured, 3.3 cm x 3.0 cm 0.5 cm. The wounds presented with a moderate amount of serosanguinous (blood and serum) drainage with minimal bleeding. The Podiatrist further documented; Resident #100 was initially scheduled for nail debridement on 10/9/22. However, upon evaluation full thickness wounds were noted to the anterior and posterior ankles. There were low cut ankle socks on both feet. Due to edema was concerned about the posterior wounds over the Achilles tendons, the subcutaneous tissue was exposed. The residents' nephew was in attendance during the evaluation and upset. It was unclear what treatment had been previously provided. However, due to the depth and size of the wounds, the wounds have been present for greater than 4 weeks. During a telephone interview on 1/30/23 at 11:03 AM, LPN # 9 stated the Podiatrist had removed the socks and discovered wounds on both ankles and Achilles. The podiatrist informed LPN #9 that Resident #100 should not wear tight ankle socks. LPN# 9 stated It looked like the wounds had been there for a while and were crusted over. LPN #9 reported the wounds, and the nephews concerns to LPN #10 Nursing Supervisor and documented the findings on the daily unit report. During an observation and interview on 1/27/23 at 1:51 PM, LPN # 7 cleansed Resident #100's left posterior unstageable pressure ulcer and right posterior unstageable pressure with betadine and were left open to air. LPN #7 stated the ankle wounds were resolved. LPN #7 was unaware of how long the wounds have been on the Achilles. During a telephone interview on 1/30/23 at 12:20 PM, the facility Wound MD stated Resident #100 was first seen on 1/3/23 for pressure ulcers on both Achilles (left posterior ankle was a stage IV and the right was a stage II). The Wound MD stated the facility staff who performed wound rounds with them were unfamiliar with the resident skin issues and history. During an interview on 1/30/23 at 9:16 AM, LPN #8 Unit Manager stated LPN's measured wounds. The ADON reviewed the measurements and completed weekly wound assessments with the wound doctor. The ADON documented wound measurements on the weekly wound tracker. LPNs documented on the wound in the Nursing Progress notes and on the 24-hour report. LPN #8 was unaware of the pressure ulcers to Resident #100's ankles and Achilles until Last week, when the Wound doctor mentioned it. The nurses informed LPN #8 of skin issues. A treatment to the left and right ankles should had been ordered on 10/9/22 and I don't see treatment. During an interview on 1/30/23 at 11:55 AM, the ADON stated wound rounds were conducted weekly with the wound doctor and documented on the Wound Tracker Form. The ADON was Shocked to see the pressure ulcers to Resident #100's Achilles on 1/3/23. The Achilles wounds were not assessed or monitored until 1/3/23. The ankle pressure ulcers were resolved. CNAs reported skin concerns to the LPNs, RNs or Unit Managers. I would have expected the CNA to report the pressure ulcers to the nurse. That didn't happen. During an interview on 1/30/23 at 11:48 AM, the Medical Director stated Resident #100 was admitted with the ulcers they healed then they reopened a few months ago. The MD stated nursing staff needed to communicate. During an interview on 1/30/23 at 12:17 PM, the Director of Nursing (DON) stated they would have expected the CNAs reported the irregularity to the nurse after they removed the socks from the residents' feet. Skin checks were expected daily with care and irregularities were reported immediately to the ADON/DON. The ADON or DON measured, assessed, and ensured pressure relieving devices were put in place immediately. The Physician was notified, and a treatment put in place immediately. Not days later. The MDS should be coded correctly to reflect the pressure ulcers. 10 NYCRR 415.12 (c)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/30/23, the facility did not ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with the physician's orders, and the comprehensive person-centered care plan for one (Resident #20) of one resident reviewed. Specifically, there was lack of assessment and dressing changes of a PICC line catheter (peripherally inserted central catheter - a catheter that is inserted through a vein and advanced until the tip enters the central venous system) and flushes were not administered as ordered. Additionally, inaccurate documenting of IV (intravenous) therapy/care/treatment. The finding is: The facility policy and procedure (P&P) titled Central Venous Catheter created 3/14/2019, documented CVC (Central Venous Catheter) dressings are changed every (7) days. If the dressing needs to be changed sooner, it is the responsibility of the primary nurse. All patients admitted with a vascular access dressing in place will have the dressing and components changed upon admission. All dressings should be dated and timed. Vascular access sites should be assessed at least every shift. Facility P&P titled Central Venous and Midline Catheter Flushing created 1/2020, documented no physician order is needed for this procedure; consult state Nurse Practice Act for RN/LPN (registered nurse/licensed practical nurse) scope of practice and functions. Flush catheters at regular intervals to maintain patency and before and after the following: converting from continuous to intermittent therapies. For multi-lumen access devices, each lumen is considered a separate catheter and must be flushed according to established catheter protocols to prevent occlusion. The following should be recorded in the resident's medical record: the condition of the IV site before and after administration. 1. Resident #20 was admitted to the facility with diagnoses including sepsis (severe blood infection), pyocystis (severe lower urinary tract infection), and MS (multiple sclerosis-chronic disease affecting the central nervous system). The Minimum Data Set (MDS-a resident assessment tool) dated 10/8/22 documented Resident #20 was cognitively intact, understands and was understood. A hospital Discharge Summary dated 1/11/23 documented Resident #20 was seen by infectious disease who recommended to continue antibiotics for an additional week, currently has a midline catheter in placed. The comprehensive care plan (CCP) report from 1/11/23 to 1/30/23 documented a treatment/intervention with a start date of 1/13/23 to cleans Resident #20's right arm and change dressing on PICC line once a week/every 7 days and 1/20/23 RX (medical prescription), normal saline (NS) flush IV solution 0.9 % 10 milliliters (ml) IV to right forearm evening shift between 3:00 PM and 10:59 PM for 7 days to keep line free and clear. Review of facility Physician Order Historical Report general orders between 10/1/2021 and 1/26/2023 and Physician's Order Form as of 1/26/23 documented the following: -Order start 1/13/23 -Cefepime (antibiotic) 2 gram IV every (q) 12 hours(hrs.) at 11:00 AM, 11:00 PM for 7 days. Reason: infection. Order stop 1/19/23 11:00 PM. -Order start 1/13/23- NS flush IV solution 0.9 %, 10 ml (milliliters) IV q 12 hours at 11:00 AM and 11:00 PM for 7 days. Order stop: 1/19/23 11:00 PM. -Order start 1/20/23- NS flush IV solution 0.9 % (percent), 10 ml IV to right forearm evening shift between 3:00 PM and 10:59 PM for 7 days to keep line free and clear. Reason: prophylaxis. Order stop: 1/25/23 3:00 PM. -Treatment start date: 1/13/23- Right arm cleans and change dressing on PICC line once a week/every 7 days. Review of the Treatment Administration Record (TAR)/Medication Administration Record (MAR) dated January 2023 documented PICC line care right arm- cleans and change dressing on PICC line once a week at 7:00 AM and was checked as completed by Licensed Practical Nurse (LPN) #1 on 1/18/23 and 1/25/23. The NS IV flush 10 ml IV to right forearm evening shift between 3:00 PM and 10:59 PM for 7 days not signed as completed 1/20/23, and 1/25/23. On 1/22/23 it was documented with a circled X. Additionally, NS IV flushes were signed out by LPNs on 1/23/23, and 1/24/23. Review of the nursing and physician/provider progress notes from 1/11/23 through 1/26/22 lacked documented evidence of PICC line dressing was change upon admission and q 7 days. Intermittent observations revealed the following: -1/23/23 at 10:40 AM, 1/26/23 at 1:38 PM and 1/26/23 at 4:20 PM, Resident #20 had a double lumen PICC line inserted into their RUA (right upper arm). The insertion site was not visible as it was covered with a gauze pad and followed by a secondary intact transparent dressing. The PICC line dressing was dated 1/9/23. -1/27/23 at 11:42 AM the PICC line secondary transparent dressing was lifting away from skin and the PICC insertion site not visible. The physical therapy assistant (PTA #1) was present in the room, observed the PICC line dressing, and stated it was dated either 1/7 or 1/8/23. During interview on 1/23/23 at 10:40 AM, Resident #20 stated they received their last dose of IV antibiotic last week and no one had done anything with the line since. The resident stated the PICC line dressing had not been changed since they were in the hospital. Additionally, on 1/27/23 at 11:42 AM, Resident #20 stated no one had flushed their PICC line in a while, until last night (1/26). During an interview on 1/26/23 at 2:22 PM, Director of Nursing (DON), stated that PICC line dressings should be changed every 7 days by an RN and that PICC flushes were an RN skill at this facility. The DON stated they would expect the LPNs to notify them or an RN Nurse Manager of any PICC line orders. Additionally, the DON stated nursing should be documenting observations of the PICC line for signs/symptoms of infection. During an interview on 1/26/23 at 2:27 PM, LPN #1 stated LPNs were not allowed to change PICC line dressing or flush PICC lines, that it was the responsibility of the RN's or RN Supervisor. During an interview on 1/27/23 at 11:27 AM, the DON stated the PICC line flush should be completed as ordered to maintain patency until it was removed. PICC lines are a source of infection, sepsis and dressing changes were expected so the site can be observed for signs and symptoms of infection. During a telephone interview on 1/27/23 at 11:52 AM, Unit Manager/RNS (Registered Nurse Supervisor) #1 stated they had not changed Resident #20 PICC dressing because they can't remember everything and have not been in. Additionally, RNS #1 stated whoever the nurse (LPN) was on the floor should have notified an RN of the PICC orders. RNs completing task should sign for completion. During a telephone interview on 1/27/23 at 1:09 PM, Medical Doctor (MD) #1, stated PICC dressing changes and flushes (with or without ABT) should absolutely be maintained and would expect PICC line care to be done based on facility policy and procedure. During an interview on 1/30/23 at 9:49 AM, Regional Nurse Educator stated LPNs cannot touch central lines; no flushing or dressing changes. They expect the LPNs to call the RN to complete and sign off. During an interview on 1/30/23 at 10:34 AM, DON stated LPNs should not be signing out PICC dressing changes and PICC flushes, as this was out of their scope of practice and was unacceptable. Additionally, upon review of January 2023 MAR, the DON stated the X indicated on 1/22/23, documented on hold and the LPN should have called an RN to complete the flush order. Blanks on the MAR for 1/20/23 and 1/25/23 would mean not done. During a telephone interview on 1/30/23 at 11:37 AM, RNS #2, stated that RNs were responsible for PICC line dressing changes. RN #2 stated they had never changed Resident #20 PICC dressing and were never asked to change it and the last time they flushed Resident #20 PICC line was while the resident was receiving IV [NAME]. Further stated they thought PICC dressing were usually completed on day shift, once a week. RNS #2 did not notice the date on the PICC dressing and would have changed it if informed. During a telephone interview on 1/30/23 at 9:51 AM, LPN #4 stated the RN was responsible to flush PICC lines and that they have never flushed Resident #20's PICC line. LPN #4 stated they honestly weren't sure if they signed out order for flushing the PICC line. Maybe so because it was on my assignment. I might have signed it off by accident. Additionally, LPN #4 couldn't recall if they informed an RN of flush order on 1/26/23. During a telephone interview on 1/30/23 at 10:00 AM, LPN #3 stated they cannot flush PICC lines. They check the MAR as done and make a note that RN aware to complete. LPN #3 stated they probably shouldn't have checked MAR on, 1/24/23, as completed because they were not the one completing the task and could not verify if task was completed as ordered. Stated they notified RN, but couldn't verify if the RN completed. 10 NYCRR 415.12

Based on observation, interview, and record review conducted during the Extended survey completed on 5/19/16, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Nine (Residents #7, 15, 80, 172, 180, 183, 207, 209, 210) of 20 residents observed for infection control practices during blood glucose monitoring had issues. The facility failed to have an effective system in place for the proper disinfection of shared glucose meters between resident use. Specifically, nursing staff were observed testing fingerstick (sample of blood to determine glucose level) blood glucose levels for multiple residents using a shared glucose meter and failed to disinfect the blood glucose meter with a germicidal (a substance that destroys germs) cleaning agent. There were 30 residents residing in the facility at the time of the survey who received blood glucose testing in the facility using portable glucose meters, including two residents with known communicable bloodborne diseases. This was a pattern of no actual harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. In addition, two (Residents #47, 76) of four residents observed for infection control practices during personal care had issues involving improper hand hygiene during fecal incontinence care. Staff did not remove soiled gloves and wash their hands before touching items in the environment. The findings are: 1. a.) During an observation of the the Green Unit (located on the second floor) on 5/13/16 at 10:30 AM, a Licensed Practical Nurse (LPN #3) approached Resident #210 in a common area in front of the Nurses' Station. Resident #210 has [DIAGNOSES REDACTED]. Review of the medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. Review of physician's orders [REDACTED]. The observation revealed that LPN #3 was pushing a rolling over-the-bed table which contained two clear, unlabeled, disposable plastic cups, a plastic basket that contained several single-use disposable lancets (a device used to puncture the skin to obtain a small blood sample), pre-packaged alcohol pads, a vial of glucose monitor test strips, and a portable blood glucose meter. The LPN was observed wearing a glove only on the left hand and her right hand was ungloved. LPN #3 inserted a test strip into the blood glucose meter; cleansed Resident #210's fingertip with an alcohol pad; punctured the fingertip; and obtained a sample of blood. The LPN disposed of the used lancet in one of the plastic cups and the alcohol pad and packaging in the second plastic cup. LPN #3 then picked up the blood glucose meter in the gloved left hand and touched the tip of the blood glucose test strip to the droplet of blood on the resident's fingertip. Once a glucose reading was obtained on the meter, the nurse disposed of the test strip into one of the plastic cups and placed the glucose meter into the plastic basket of supplies. The LPN documented the glucose reading on a worksheet and then pushed the over-the-bed table with all the items into the Occupational Therapy (OT) Treatment Room located on the second floor. LPN #3 was observed to pick up the glucose meter from the basket, insert a test strip, gathered a new lancet and alcohol pad in her hand, and approached Resident #207 who was in the OT Treatment Room. b.) Resident #207 has [DIAGNOSES REDACTED]. Review of the medical record Face Sheet revealed the resident was admitted to the facility on [DATE]. Review of physician's orders [REDACTED]. Without cleansing the blood glucose meter, LPN #3 was observed to complete blood glucose testing using the same glucose meter used for Resident #210. LPN #3 disposed of the used lancet, glucose test strip, and alcohol pad in the disposable cups. After documenting the glucose reading on a worksheet, LPN #3 placed the glucose meter into the plastic basket of supplies. LPN #3 wheeled the over-the-bed table out of the OT Treatment room and into the Physical Therapy (PT) Treatment Room. LPN #3 approached Resident #80, who was riding a stationary bike. c.) Resident #80 has [DIAGNOSES REDACTED]. Review of the medical record Face Sheet revealed that the resident was re-admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS- an assessment tool) dated 2/25/16 revealed the resident is cognitively intact, understands, and is understood. Review of physician's orders [REDACTED]. LPN #3 was observed to pick up the glucose meter from the plastic basket and completed blood glucose testing on Resident #80 with the same glucose meter used to test Resident #207 and 210's blood glucose. LPN #3 did not clean or disinfect the glucose meter prior to using it for Resident #80. At approximately 10:45 AM, after completing blood glucose testing on Resident #80, LPN #3 was observed to remove the glove on her left hand and wheeled the over-the-bed table out of the PT Treatment Room, back to the medication cart next to the Green Unit Nurses' Station. LPN #3 disposed of the used lancets into the biohazard container and disposed of the cups containing the used lancets, test strips, and used alcohol pads into the garbage. LPN #3 did not clean or disinfect the blood glucose meter and placed the plastic basket of supplies (containing the contaminated glucose meter) back into the medication cart. LPN #3 did not cleanse the over-the-bed table after use and was observed to put it into an alcove area next to the Green Unit Nurses' Station. d.) At approximately 10:46 AM, LPN #3 approached another resident (Resident #180) walking in the immediate area and asked if the resident was ready to have his blood glucose testing completed. LPN #3 gathered the contaminated glucose meter, the vial of test strips, a lancet and an alcohol pad, and accompanied the resident to his room. LPN #3 did not wash her hands between residents after completing blood glucose testing, she did not immediately dispose of contaminated waste in a biohazard container, and placed blood contaminated cups into a non-biohazard waste container. LPN #3 did not disinfect the blood glucose monitor with a germicidal cleansing agent between and after resident use. Review of the CDC (Centers for Disease Control and Infection Prevention) Guideline for Hand Hygiene in Health-Care Settings dated 10/25/02 revealed when hands are visibly dirty or contaminated with proteinacious material or are visibly soiled with blood or other body fluids, health care workers are to wash their hands with either a non-antimicrobial soap and water or an antimicrobial soap and water for at least 15 seconds. If hands are not visibly soiled, health care workers can use an alcohol-based hand rub for routinely decontaminating hands. Review of the CDC Recommended Practices for Preventing Bloodborne Pathogen Transmission during Blood Glucose Monitoring and Insulin Administration in Healthcare Settings revealed Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be share, the device should be cleaned and disinfected after every use, per manufacturer's instruction, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Review of the manufacturer's instructions for cleaning the Ultra Trak Pro blood glucose meter, used to test blood glucose levels in the facility, revealed the Ultra Trak Pro should be cleaned and disinfected between each patient test. Equipment needed includes an EPA (Environmental Protection Agency) registered germicidal or bleach wipe, approved for use in healthcare settings and for surface cleaning, and the disinfecting agent must be effective against HIV (human immunodeficiency virus), HBV (hepatitis B), and the HCV (hepatitis C). When disinfecting the meter, staff are to refer to the product label of the disinfectant wipes to determine how long the liquid from the wipes needs to be on the body of the meter for full disinfecting (also known as contact time). e.) Interviews on 5/13/16, between the hours of 7:00 AM to 3:00 PM, with five (LPNs #1, 2, 3, 9, and 10) of six LPN Medication Nurses assigned to work on 5/13/16 revealed the following: - At 12:26 PM, LPN #1 stated that she uses an alcohol swab to wipe down the blood glucose meter. LPN #1 stated that the facility has Sani-cloths (a germicidal wipe) available but she just uses alcohol. - At approximately 12:30 PM, LPN #2 stated she will occasionally use germicidal wipes to clean the blood glucose meter but she usually will use alcohol wipes to clean the glucose meter between residents. - At 12:28 PM, LPN #9 stated that she cleanses the blood glucose meter with alcohol between residents. - At 12:31 PM, LPN #10 stated that she cleanses the glucose meter with alcohol between residents. - At approximately 3:00 PM, LPN #3 stated that she usually cleans the blood glucose meter with alcohol between residents. When the surveyor stated that no cleansing of the blood glucose meter was observed during observations earlier that morning on 5/13/16, LPN #3 stated I guess I didn't clean the machine, but I usually do. LPN #3 stated that she used disposable cups for contaminated waste and the over-the-bed table to take supplies between residents because she was trying to get ahead with her work. When asked about handwashing between residents, LPN #3 stated I guess I didn't wash my hands between residents. During an interview with the Director of Nursing (DON) and the Administrator on 5/13/16 at 3:26 PM, the DON stated that blood glucose meters should be cleansed with germicidal wipes between resident use. The DON stated she was not sure what the facility policy states and was not sure if the glucose meters used in the facility are for multiple resident use. The DON stated that the facility has been using the current glucose meters for approximately one year. The DON further stated that the facility did not conduct an annual skills evaluation of the nursing staff for the use of the blood glucose meters and did not have documentation of inservice training when the facility first began to use the current glucose meters. During an interview on 5/13/16 at 5:50 PM, the Medical Director stated that the facility should strive for individual equipment for residents of the facility because the facility has known residents with bloodborne diseases. The Medical Director further stated that traditionally, medical equipment could be cleansed with a germicidal wipe but it would be better to have individual glucose meters for the residents. The Medical Director stated that cleansing with alcohol wipes is not an acceptable method to control the spread of disease. f.) Observation on 5/14/16 at approximately 10:12 AM revealed LPN #11 obtained blood glucose readings using a portable glucose meter on two residents (Residents #172 and 209). Between each resident use, LPN #11 used a Sani-cloth wipe (germicidal cleansing cloth) to cleanse the glucose meter by wiping the glucose meter for approximately 20 seconds. Observation on 5/14/16 at approximately 10:41 AM revealed LPN #8 performed blood glucose meter readings on two residents (Residents #183 and 210). Between each resident use, LPN #8 used a Sani-cloth wipe to cleanse the glucose meter by wiping the glucose meter for approximately 20 seconds. Observation on 5/15/16 at approximately 6:24 AM revealed LPN #9 performed glucose meter reading on six residents (Residents #7, 15, 80, 183, 207, and 210). Between each resident use, LPN #9 used a Sani-cloth wipe to cleanse the glucose meter by wiping the glucose meter for two to five seconds. LPN #9 was then observed to use a resident-specific glucose meter for one additional resident and wiped the glucose meter with a Sani-cloth for two to five seconds after its use. Review of the Sani-cloth Plus Germicidal Disposable Cloth container revealed the cleaning procedure stated the following: - All blood and other body fluids must be thoroughly cleansed from surfaces and objects before disinfection by the germicidal wipe. --- - Open, unfold and use first germicidal wipe to remove heavy soil. - The instructions under Contact time stated Use second germicidal wipe to thoroughly wet surface. Allow to remain wet two minutes, let air dry. Although efficacy at a two minute contact time has been shown to be adequate against HIV-1, HBV, and HCV, this time is not sufficient for the other organisms listed on this label. Therefore a three minute wet contact time must be used for other listed organisms. Review of the website for Sani-Cloth Plus, the germicidal wipes have an overall contact time of three minutes. The website revealed that according to the Centers for Disease Control and Prevention Guidelines for Disinfection and Sterilization in Healthcare Settings, the overall contact time is the time it takes the product to disinfect all the microorganisms on the disinfectant's master label. Review of a facility policy and procedure (P&P) entitled Glucose Monitoring revised 5/13/16 revealed the plastic housing of the glucometer (glucose meter) can be wiped clean with a damp cloth and mild soap/ detergent, alcohol swab or germicidal cloth. The P&P did not instruct staff of the need to disinfectant the glucose meter between and after resident use. g.) Review of the facility's Annual Infection Control Inservice Training Attendance Sheets and Competency Examinations for 2015 and 2016 revealed that approximately three of 13 Registered Nurses (RN's), twelve of 25 Licensed Practical Nurses (LPN's), and 21 of 49 CNAs did not have evidence of annual in-service attendance and/or competency examinations. Interview with the DON and RN Assistant DON on 5/19/17 at approximately 3:30 PM revealed that all of the facility staff are not current with Infection Control training. 2. Resident # 76 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident is cognitively intact, understands, and is understood. The MDS documented that the resident requires extensive staff assistance for bed mobility, transfer, and dressing, and supervision for personal hygiene. Observation on 5/17/16 at approximately 7:18 AM revealed two Certified Nursing Aides (CNAs #5 and 6) provided personal care to the resident. After providing fecal incontinence care, CNA # 5 did not remove her contaminated gloves and she was observed to touch the bedside drawer, the resident's wheelchair, and the resident prior to removing the gloves. During an interview on 5/19/16 at approximately 12:00 PM, the DON stated that the Infection Control Nurse position has been vacant for approximately one year and all staff have not completed annual infection control training, which includes Universal Precautions (Standard Precautions - an approach to infection control to treat all human blood and certain human body fluids as if they were known to be infectious for HIV, HBV and other bloodborne pathogens). The DON stated that in addition, all CNA competencies are not up to date due to staff shortages. 3. Resident # 47 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/27/16 revealed the resident has severe cognitive impairment, understands, and is understood. The MDS documented that the resident is frequently incontinent of bowel and bladder. Observation on 5/15/16 at approximately 5:15 PM revealed two Certified Nurse Aides (CNAs #1 and 3) provided urinary and fecal incontinence care to Resident #47, using disposable wipes. The CNAs were observed to repeatedly cleanse the resident's fecal soiled buttocks, hips, groin, and genitalia. While wearing the same gloves used to provide incontinence care, CNA #1 opened the resident's bedside stand and took out a tube of barrier cream. The CNA did not remove the contaminated gloves and she did not wash her hands prior to touching items in the environment. 415.19(a)(1)(2)(4)

Based on observation, interview, and record review conducted during the Extended Survey completed on 5/19/16, the facility was not 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 facility Administrator failed to ensure that an effective system was in place, including a policy and procedure, for the proper disinfection of shared blood glucose meter between resident use and that quality control testing was performed on blood glucose meters. This was a pattern with no actual harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. The findings include but are not limited to: REFER TO: F441 - Infection Control, Prevent Spread, Linens - S/S=K F503 - Laboratory Services - Facility Provided - S/S = D F520 - QAA Committee - S/S = K 1. Nine (Residents #7, 15, 80, 172, 180, 183, 207, 209, 210) of 20 residents observed for infection control practices during blood glucose monitoring had issues. The facility failed to have an effective system in place for the proper disinfection of shared glucose meters between resident use. Specifically, nursing staff were observed testing fingerstick (sample of blood to determine glucose level) blood glucose levels for multiple residents using a shared glucose meter and failed to disinfect the blood glucose meter with a germicidal (a substance that destroys germs) cleaning agent. Subsequently, the facility failed to ensure that adequate infection control procedures were implemented for 30 residents residing in the facility at the time of the survey who received blood glucose testing in the facility using portable glucose meters, including two residents with known communicable bloodborne diseases. During an interview with the Administrator and the Director of Nursing (DON) regarding blood glucose testing in the facility on 5/13/16 at approximately 3:26 PM, the Administrator deferred all questions to the DON. Interview with the DON on 5/13/16 at approximately 3:26 PM revealed that the facility does not conduct an annual skills performance evaluation regarding the use of blood glucose meters nor does the facility have any evidence of education for the use of the blood glucose meters. The interview further revealed that the DON was unsure whether the blood glucose monitors that the facility currently uses are intended for multi-patient use or if the facility policy and procedure addresses the need for disinfection of the blood glucose meters. 415.26

Based on observation, interview, and record review conducted during the Extended survey completed on 5/19/16, the facility failed to provide a Quality Assessment and Assurance (QAA) committee that effectively identified issues with the potential to cause serious harm to residents and did not develop and implement appropriate plans of action. The facility QAA failed to ensure that Infection Control and Quality Control practices were implemented for the use of blood glucose meters. This was a pattern with no actual harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. The findings are: REFER TO: F441 - Infection Control, Prevent Spread, Linens - S/S=K F503 - Laboratory Services - Facility Provided - S/S = D F490 - Effective Administration/Resident Well-Being - S/S = K 1. Nine (Residents #7, 15, 80, 172, 180, 183, 207, 209, 210) of 20 residents observed for infection control practices during blood glucose monitoring had issues. The facility failed to have an effective system in place for the proper disinfection of shared glucose meters between resident use. Specifically, nursing staff were observed testing fingerstick (sample of blood to determine glucose level) blood glucose levels for multiple residents using a shared glucose meter and failed to disinfect the blood glucose meter with a germicidal (a substance that destroys germs) cleaning agent. Subsequently, the facility failed to ensure that adequate infection control procedures were implemented for 30 residents residing in the facility at the time of the survey who received blood glucose testing in the facility using portable glucose meters, including two residents with known communicable bloodborne diseases. During an interview with the Director of Nursing (DON) and the Administrator on 5/13/16 at 3:26 PM, the DON stated that blood glucose meters should be cleansed with germicidal wipes between resident use. The DON stated she was not sure what the facility policy states and was not sure if the glucose meters used in the facility are for multiple resident use. The DON stated that the facility has been using the current glucose meters for approximately one year. The DON further stated that the facility did not conduct an annual skills evaluation of the nursing staff for the use of the blood glucose meters and did not have documentation of inservice training when the facility first began to use the current glucose meters. During an interview on 5/13/16 at 5:50 PM, the Medical Director stated that the facility should strive for individual equipment for residents of the facility because the facility has known residents with bloodborne diseases. The Medical Director further stated that traditionally, medical equipment could be cleansed with a germicidal wipe but it would be better to have individual glucose meters for the residents. The Medical Director stated that cleansing with alcohol wipes is not an acceptable method to control the spread of disease. Review of the Facility Survey Report (FSR), signed by the Administrator on 5/11/16, revealed that the facility's QAA committee meets monthly and the most recent meeting was held on 4/27/16. The FSR documented that the DON and the Administrator are both members of the committee. During the QAA review meeting with the Administrator and the DON on 5/19/16 at approximately 12:20 PM, the DON stated that glucose testing in the facility has not been discussed in the QAA meetings and there was no inservicing when the current glucose meters started being used in the facility. The DON stated that when an 11:00 PM to 7:00 AM shift nursing supervisor retired about one year ago, everything fell through the cracks. The DON stated that due to staffing cuts, nurses have been unable to do quality testing for the glucose meters. During an interview on 5/19/16 at approximately 2:00 PM, a member of the facility's Governing Body stated that he would expect the staff to receive education anytime new equipment is introduced into the facility. In addition, the expectation is for Infection Control and Quality Control practices to be utilized when performing blood glucose meter monitoring per the manufacturer's recommendations. 415.27(a)(c)(3)(v)