Every finding on record at Samaritan Senior Village, Inc

Based on observations and interviews, the facility failed to serve food in accordance with professional standards for food service safety in one of four unit pantries (Unit 4 pantry). Specifically, Food Service Worker Team Lead #12 and Food Service Worker #13 did not change their gloves or perform hand hygiene between tasks and proceeded to touch food with contaminated gloves.Findings include:The facility policy Standards for Sanitary Operation for Food Service Department,' revised 03/2025, documented employees should wash hands between changing gloves, before touching food, and after touching contaminated areas.During a continuous observation on 05/29/2026 at 11:55 AM Food Service Worker Team Lead #12 arrived at the 4th floor pantry, put on gloves, and assisted with meal service. Between 11:55 AM and 12:17 PM they touched the refrigerator door handle then touched food items, including slices of cheese, a hamburger patty, bread, and buns. They changed gloves at 12:18 PM continued to touch the refrigerator door handles then touched turkey and rolls with the contaminated gloves.During an observation in the 4th floor pantry on 05/29/2026 at 12:18 PM, Food Service Worker # changed their gloves without performing hand hygiene then carried dirty dishes to the sink in the pantry. They changed gloves again without performing hand hygiene and resumed serving food and touching food items with the gloves.During an interview on 05/29/2026 at 12:31 PM Food Service Worker Team Lead #12 stated they wore gloves when they touched any food. They should sanitize their hands and change gloves in between changing tasks and food items to prevent cross contamination. They stated they did not change their gloves when they changed tasks while in the 4th floor pantry and touched different food items because they just did not think about it.During an interview on 05/29/2026 at 12:51 PM Food Service Director #14 stated if staff touched the refrigerator or food items, they should perform hand hygiene and change gloves before touching different food. Staff needed to wash their hands before putting on clean gloves to prevent cross contamination of food. 10 New York Codes, Rules and Regulations 415.14(h)

Based on observations, record review, and interviews, the facility failed to ensure residents received respiratory care consistent with professional standards of practice for one of one resident (Resident #21) reviewed. Specifically, Resident #21 had a physician order for oxygen at 2 liters per minute as needed to keep oxygen saturations (amount of oxygen in the blood stream) above 90% (the order did not include the oxygen delivery method) and the resident received continuous oxygen via nasal cannula, the Medication Administration Record did not include oxygen administration, oxygen saturations were not ordered or obtained to determine if the oxygen was needed, and the care plan did not include oxygen therapy. Findings include:The facility policy Oxygen Delivery, last reviewed 06/18/2025, documented a nasal cannula was used for residents that only needed low flow supplemental oxygen at a rate of 1-6 liters per minute. After an order was obtained and oxygen was applied, oxygen saturations were monitored. The oxygen tubing was changed every 7 days. Resident #21 had diagnoses including atrial fibrillation (irregular heartbeat), high blood pressure, and heart failure. The 03/18/2026 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact, did not reject care, and did not receive oxygen therapy. Physician orders documented:-On 05/11/2026 oxygen 2 liters to keep saturation above 90% every 24 hours as needed for shortness of breath.-On 05/29/2026 change oxygen tubing and humidifier every night shift on Sundays. There was no documented evidence of an order for the frequency of oxygen saturations to determine if oxygen needed to be administered. The Comprehensive Care Plan did not include an individualized respiratory care plan with the use of oxygen. Resident #21 was observed wearing oxygen via an undated nasal cannula with a portable oxygen tank set to 2 liters per minute at the following times:-On 05/27/2026 at 7:42 AM seated in a recliner chair in the dining room. At 8:50 AM, 9:04 AM, and at 10:50 AM seated in their recliner chair in the common television area.-On 05/28/2026 at 9:04 AM and 11:30 AM, seated in their recliner chair in the common television area.-On 05/29/2026 at 8:40 AM, seated in their recliner chair in the dining room and at 9:04 AM seated in their recliner in the common television area. The May 2026 Medication Administration Record did not document administration of oxygen from 05/11/2026-05/31/2026. The May 2026 oxygen saturation summary documented:-On 05/03/2026 at 9:24 PM 97% on room air.-On 05/11/2026 at 5:17 PM 97% on oxygen via nasal cannula.-On 05/12/2026 at 8:04 AM 95% on room air, at 11:01 AM 93% on room air, and at 5:12 PM 94% on room air.-On 05/13/2026 at 1:33 PM 93% on room air and 5:59 PM 94% on room air.-On 05/14/2026 at 7:11 AM 93% on room air and at 10:09 AM 98% on room air. There was no documented evidence the resident's oxygen saturation was checked from 05/14/2026-05/31/2026 to determine the need for 2 liters per minute of oxygen as needed to keep the oxygen saturation above 90%. During an interview on 06/01/2026 at 1:09 PM, Certified Nurse Aide #11 stated the care instructions told them if a resident required oxygen. Resident #21 wore oxygen all the time for the past 2-3 weeks. During an interview on 06/012026 at 1:18 PM, Licensed Practical Nurse #10 stated Resident #21 had an order for oxygen as needed, but the resident wore oxygen all the time. The resident did not have a routine order for oxygen saturation monitoring so they would only check the resident's oxygen saturations if they became short of breath and then it was documented under vital signs. Oxygen therapy should be on the resident's care plan. Registered Nurse Manager #9 was responsible for ensuring the care plans were updated. During an interview on 06/01/2026 at 1:29 PM, Registered Nurse Manager #9 stated if a resident needed oxygen, it was ordered and charted. They did not know if the nurses signed off on the Medication Administration Record when a resident was wearing oxygen. The delivery method should be in the order. If there was not an order to check oxygen saturations it was only done if a resident was short of breath. Oxygen tubing was changed weekly but they were not sure if it was documented anywhere, the nurses just knew. Resident #21 had pneumonia a couple weeks ago and now required continuous oxygen. They stated the current Medication Administration Record did not reflect the resident used oxygen and the order did not make sense. The care plan should include oxygen use because it was part of the resident's care needs. Resident #21's care plan did not include the use of oxygen because it was new. During an interview on 06/01/2026 at 2:37 PM, Physician Assistant #8 stated oxygen use required an order. They did not always include nasal cannula in the order because it was implied. There was not always an order to check the oxygen saturation but if oxygen was ordered for an acute situation, the nurses were pretty good at monitoring the saturations. Resident #21 had been on oxygen intermittently over the past month and was treated for heart failure and pneumonia. They relied on the nurses to tell them if a resident was wearing oxygen intermittently or continuously. They reviewed the resident's oxygen saturations to determine if the oxygen could be weaned. If there was no documentation of oxygen saturations, they would not know how the resident was doing with or without oxygen. 10 New York Codes, Rules, and Regulations 415.12(k)(6)

Based on record review and interviews the facility failed to ensure each resident was seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter for one of one resident (Resident #9) reviewed. Specifically, Resident #9 was not seen by a medical provider (physician, physician assistant, or nurse practitioner) every 30 days for the first 90 days after admission and did not have an admission assessment completed by a registered nurse. Findings include:Resident #9 had diagnoses including diabetes, seizures, and cancer. The 03/25/2026 admission Minimum Data Set assessment (a health status assessment tool) documented the resident had moderately impaired cognition, required substantial to maximum assistance with most activities of daily living, and was admitted from a short-term hospital. The comprehensive care plan initiated 03/23/2026 documented the resident was admitted to the facility with a plan for long term placement. Interventions included the interdisciplinary team would continue to work with the resident to obtain the highest practicable level of functioning. The 03/19/2026 at 2:57 PM former Licensed Practical Nurse Assistant Manager #17 progress note documented the resident was admitted from the hospital. There was no documented evidence the resident was assessed by a registered nurse on admission. The actual nursing staffing for 03/19/2026 documented there were three registered nurses working when Resident #9 was admitted to the facility. Registered Nurse Manager #9, the Assistant Director of Nursing, and the Director of Nursing were working. The 03/19/2026 History and Physical completed by Physician #15 documented the resident was admitted with multiple medical problems and comorbidities and would be a long-term resident for long-term care. There was no documented evidence the resident was seen for their mandated 30 day or 60 day physician visits. The Physician #15 progress note documented a date of service of 04/23/2026 and was electronically signed on 06/02/2026 (the same day as survey exit). During a telephone interview on 06/01/2026 at 4:37 PM, former Licensed Practical Nurse Assistant Manager #17 stated anything out of a licensed practical nurse's scope was completed by a registered nurse. Registered Nurse Manager #7 mostly completed the registered nurse portions of an admission for all admissions at the facility. The registered nurse assessment was documented electronically in the record. Registered Nurse Manager #9 was responsible for the unit the resident was admitted to. Physician Assistant #8 usually assessed the resident the same day of admission, and Physician #15 usually assessed the resident within their first week. During an interview on 06/02/2026 at 8:50 AM, Registered Nurse Manager #9 stated when a resident was admitted to the facility all the nurse managers came to help. The clinical admission was the head-to-toe assessment that was completed by a registered nurse. They looked in the electronic record and did not see any evidence the resident was assessed by a registered nurse. They were not sure if they worked the day that Resident #9 admitted . Physician #15 saw the resident either the same day or the next day. They did not see any evidence in the chart the resident was seen by a medical provider since then. During an interview on 06/02/2026 at 9:11 AM, the Assistant Director of Nursing stated when a resident was admitted all the unit managers kicked in to help. On the 3rd floor Registered Nurse Manager #9 was ultimately responsible, but all the nurses pitched in and usually Registered Nurse Manager #7 handled the admissions. They performed a double check and ensured the registered nurse assessment was completed. They looked in Resident #9's electronic chart and saw the clinical assessment was started by former Licensed Practical Nurse #17 but it was not completed by Registered Nurse Manager #9. A registered nurse needed to complete an assessment on admission because it was the resident's baseline when they came in. Physician Assistant #8 always saw the residents on admission and Physician #15 received a call that a new resident was admitted and would see them within a few days. Residents had to be seen by a physician at 30 days, 60 days, and 90 days after admission and then 60 days thereafter. Physician Assistant #8 documented their progress notes electronically, but they did not see any notes from them in the resident's electronic medical record. Physician #15 documented in the hard chart. At 9:29 AM, the Assistant Director of Nursing looked in the hard chart and did not find any progress notes. During an interview on 06/02/2026 at 9:41 AM, Physician Assistant #8 stated they usually saw residents on admission. It was very overwhelming; they saw many residents a day. They did not always have the time to document progress notes. They know they saw Resident #9 on 04/23/2026 but they did not document a progress note. They stated Physician #15 was responsible for seeing the residents for their 30, 60, and 90 day visits. During a telephone interview on 06/02/2026 at 12:23 PM, Physician #15 stated the facility had called them and they just dictated a note that Resident #9 was seen on 04/23/2026. The notes did not get dictated right away. The notes were completed in their office and then were sent over to the facility and put in the residents' chart. The resident was due to be seen again next week (06/02/2026 was 40 days past 04/23/2026). They were trying to catch up, another team was supposed to be taking over but they had not yet. 10 New York Codes, Rules, and Regulations 415.15(b)(2)(ii)

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of seven residents (Resident #117) reviewed. Specifically, Resident #117 had conflicting isolation precautions signage and orders, and staff were observed not wearing appropriate personal protective equipment while in the resident's room. Findings include: The facility policy Enhanced Barrier Precautions, last reviewed 03/06/2026, documented use of personal protective equipment. It did not replace the guidance for contact precautions. A gown and gloves were to be worn for high contact care activity such as indwelling medical devices and wound care. Instructions for contact precautions, included a resident who had active or colonized Methicillin-resistant Staphylococcus aureus infection, a gown and gloves were to be worn any time staff entered the room.Resident #117 had diagnoses including methicillin-resistant staphylococcus aureus (multi-drug resistant bacteria) infection in a left knee surgical wound, a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer, and bladder dysfunction. The 05/15/2026 Minimum Data Set assessment documented the resident had full cognition, was dependent on all activities of daily living except eating, had an indwelling urinary catheter, was always incontinent of bowels, had two coccyx Stage 4 pressure ulcers, and received an antibiotic. The 05/12/2026 physician order documented enhanced barrier precautions related to indwelling urinary catheter.The 05/15/2026 physician order documented contact precautions due to methicillin-resistant staphylococcus aureus infection in the left knee.The 05/26/2026 comprehensive care plan documented the resident had an indwelling urinary catheter, was on enhanced barrier precautions, required activities of daily living assistance, had a coccyx Stage 4 pressure ulcer, and had a left knee infection post-surgery. Interventions included direct staff and residents to follow enhanced barrier precautions, utilize gowns and gloves for all personal care, and educate staff on enhanced barrier precautions. The 05/27/2026 comprehensive care plan documented the resident had methicillin-resistant staphylococcus aureus infection in the left knee and was on contact precautions. Interventions included bag and transport used linen according to protocol, wear gowns and gloves when changing linens, and provide antibiotics.During an observation and interview on 05/29/2026 at 12:22 PM, Resident #117 returned to the facility via stretcher and transport personnel. Licensed Practical Nurse #5 and Certified Nurse Aide #6 washed their hands and donned gloves prior to entering the room and did not put on gowns. There were contact precautions and enhanced barrier precautions signs on the left side of the doorway. The nurse closed the door. At 12:26, the door was opened, the resident was in bed, and Licensed Practical Nurse #5 and Certified Nurse Aide #6 did not have gowns on. They removed their gloves, washed their hands, and exited the room. Certified Nurse Aide #6 and an unidentified staff put on a gown and gloves. Certified Nurse Aide #6 stated they were about to reenter the room to provide direct resident care and were donning the gown and gloves as the resident had methicillin-resistant staphylococcus aureus in their left leg. During an interview on 05/29/2026 at 12:27 PM, Licensed Practical Nurse #5 stated Resident #117 was on contact precautions for a left leg wound that had methicillin-resistant staphylococcus aureus germs and the resident also had an indwelling urinary catheter. A gown and gloves should be worn for any type of direct care. The nurse stated they and Certified Nurse Aide #6 did not put on a gown prior to transferring the resident back to bed and was unsure if a gown should have been worn then. The nurse stated the resident was on contact and enhanced barrier precautions per the signs on the doorway and a gown and gloves should be donned prior to entering the room. They stated the signs were confusing as to what personal protective of equipment was to be put on in what instances. During an interview on 05/29/2026 at 12:36 PM, Certified Nurse Aide #6 stated personal protective equipment should be donned as directed by the precaution signs on the doorway. There was an equipment station hanging on the resident's door. The purpose of the personal protective equipment was to prevent cross contamination of germs from one individual to the next. The resident was on precautions due to an indwelling urinary catheter. They stated they did not wear a gown when they transferred the resident back to bed as they were not going to come in direct contact with the catheter. They stated they should have worn a gown per the contact precautions sign, but they thought enhanced barrier precautions was a higher level precaution than contact precautions.During an interview on 05/29/2026 at 12:45 PM, Registered Nurse Manager #7 stated Resident #117 was on contact precautions due to active methicillin-resistant staphylococcus aureus) infection in their left leg. The resident was also on enhanced barrier precautions for an indwelling urine catheter. Staff should don a gown and gloves prior to entering the room at any time due to the contact precautions. Staff were expected to read the precautions sign outside the room to determine what equipment should be worn prior to entering the room. During an interview on 06/01/2026 at 4:05 PM, the Infection Preventionist stated gowns and gloves should be donned prior to entering the room at any time for a resident on contact precautions. A gown and gloves were only needed when providing direct care for residents on enhanced barrier precautions. The designated precautions sign was posted outside the resident's room by the Assistant Director of Nursing. Those signs documented what personal protective equipment was required and when. The type of precautions was determined by the Assistant Director of Nursing and the Director of Nursing. There should not be more than one type of precaution sign on the doorway. During an interview on 06/01/2026 at 4:47 PM, the Director of Nursing stated there was a difference between contact and enhanced barrier precautions. Contact precautions required gown and gloves to be worn prior to entering the room no matter what the purpose of entering the room was. Enhanced barrier precautions only required a gown and gloves when performing direct resident care. Normally, the medical provider or Infection Preventionist determined the type of precautions a resident should be on. The facility should abide by the Center for Disease Control and New York State Department of Health regulations and guidelines for transmission based precautions. Housekeeping placed the ordered precautions signs and the personal protective equipment stations once they were made aware by nursing. Nursing could also put up the appropriate signs. If a resident was on enhanced barrier precautions and then was placed on contact precautions, both signs were on the resident's door until the resident came off contact precautions. Staff should know which level of precautions had a higher priority, and that was the sign they were to read and abide by. The purpose of personal protective equipment was to prevent cross contamination of germs from one person to the other. 10 New York Codes, Rules and Regulations 415.19(a)(b)

Based on observation, record review, and interview during the recertification survey conducted 8/12/2024-8/16/2024 the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in the main kitchen. Specifically, potentially hazardous foods were not cooled properly in the main kitchen, and there was insufficient lighting in the walk-in cooler and walk-in freezer. Findings include: The facility policy, Food Procurement Receiving Handling Storing Preparing, revised 7/12/2024, documented the facility ensured proper cooling of food, and proper sanitation and food handling practices to prevent the outbreak of foodborne illness. 1) Improperly Cooled Potentially Hazardous Foods The facility document Temperature-Time Cooling Log did not document any food products cooled on 8/12/2024. One item was documented as cooled on 8/13/2024, but it did not identify what the food was on the form. The log documented when cooling any stock, sauce, or potentially hazardous food, the use of the log would enable one to monitor and document the total time for cooling by taking a reading every 30 minutes until it reached 45 degrees Fahrenheit or lower. Remember to cool from 120 degrees Fahrenheit to 70 degrees Fahrenheit in the first 2 hours, and an additional 4 hours may be used to get the item to 45 degrees Fahrenheit. During an observation on 8/13/2024 at 11:23 AM, the bottom shelf of Refrigerator #2 in the main kitchen had a pan of cooked beef covered by plastic wrap that measured 68 degrees Fahrenheit. During an observation on 8/13/2024 at 11:28 AM, four covered hotel pans of cooked pasta were double stacked on two lower shelves in Refrigerator #2 in the main kitchen. The bottom pans had metal lids that enabled the double stacking and all four were covered with plastic wrap. The bottom pans of pasta measured 49 degrees Fahrenheit, and the top pans measured 46 degrees Fahrenheit along the outside edge. During an interview on 8/13/2024 at 11:28 AM, [NAME] #40 stated the pasta was cooked yesterday by Dietary Supervisor #41. The pasta should have been cooked, rinsed in an ice bath until it was cooled to 34-36 degrees Fahrenheit, and then put away in the cooler. They stated they had cooked the beef that morning which was to be used for tomorrow's dinner. They stated the proper cooling of potentially hazardous food requirements were four hours to get down to 34-36 degrees Fahrenheit and the beef should have been left uncovered to allow it to cool quicker. During an observation and interview on 8/13/2024 at 11:45 AM, Dietary Supervisor #41 stated they cooked the pasta the previous day. To cool it, they drained the cooked pasta, refilled with cool water and ice, drained again, portioned the pasta into the four hotel pans, then covered and labeled the pans and placed them into Refrigerator #2. They did not measure the temperature of the pasta before it was portioned because they did not know they were supposed to. They stated the cooling requirements required a four-hour window during which the product had to go from hot to cold and get below 40 degrees Fahrenheit. They thought they followed that requirement for the pasta and was not sure how it was warmer than the other items in that cooler. Cooling was documented for meats, but not for pastas. The temperature of the pasta was checked again in the middle of each pan and measured between 48-53 degrees Fahrenheit. At 11:59 AM, the beef remained covered on the bottom shelf of Refrigerator #2 and was measured at 68 degrees Fahrenheit. During an interview on 8/16/2024 at 11:18 AM, Food Service Director #42 stated the cooling requirement was to get to temperature within six hours. Cooling occurred in the walk-in cooler or walk-in freezer and should not be done in the upright cooler (Refrigerator #2). Proper cooling was important to prevent food borne illness, the growth of bacteria, and to ensure the safe quality of food. 2) Improper Lighting During an observation on 8/13/2024 at 11:22 AM, both the walk-in cooler and walk-in freezer had very limited lighting and required the use of a flashlight to see the contents. During an interview on 8/13/2024 at 11:28 AM, [NAME] #40 stated there was not enough light in the coolers and they often needed to use their cell phone flashlight to see inside. During an interview on 8/16/2024 at 11:18 AM, Food Service Director #42 stated there was not enough lighting in the walk-in coolers, there needed to be more lighting, and the lighting had always been a challenge. 10NYCRR 415.14(h)

Based on observations, record review, and interview during the recertification and abbreviated (NY00344344, NY00344487, and NY00347064) surveys conducted 8/12/2024-8/16/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 3 residents (Residents #59, #67 and #86) reviewed. Specifically, Resident #59 did not have their palm protectors (contracture management device) applied as care planned; Resident #67 did not have their elastic tubular compression bandage (Tubigrip) applied as ordered; and Resident #86 had a skin tear (a wound resulting from separation of the top layer of skin from the second layer) and initial treatment orders were not obtained, and the wound dressing was unclean. Findings include: The facility policy, Rehab-Splints-Upper Extremities-SSV reviewed 3/11/2024 documented the occupational therapist evaluated the resident's upper extremities and provided an appropriate splint/orthotic to meet the individual resident's needs if indicated and established an appropriate wearing schedule. The results of the occupations therapy evaluation and recommendations were documented in the medical record. The splint was fitted to the resident and issued for use on the unit; the care plan was updated; and nursing staff were educated on the application and use of the splint. The facility policy, Skin Tear Protocol, reviewed 11/10/2023 documented all skin tears were evaluated by nursing and the qualified medical provider was notified. Treatment was applied per provider orders; all skin tears were documented upon occurrence and with every dressing change until closed; and the order was discontinued when the area was healed with a provider order. 1) Resident #59 had diagnoses including functional quadriplegia (a condition that causes complete immobility), contracture (tightening of the muscles, tendons, and joints) of the left hand, and contracture of the right hand. The 5/22/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, had functional limitation in range of motion for both upper and lower extremities, was dependent for dressing upper body and did not reject care. The Comprehensive Care Plan initiated 3/7/2024 and revised 7/29/2024 documented the resident required assistance with self-care and mobility related tasks. Interventions included palm protector to left and right hand at all times, off for hygiene as resident allowed. The undated Kardex (care instructions) documented a palm protector to left and right hand at all times, off for hygiene as resident allowed. The 7/15/2024 Occupational Therapist #21 Discharge Summary documented discharge recommendations included hand roll to the right hand and palm protector to the left hand at all times. There was no documented evidence of a physician order for left or right hand palm protectors or a palm roll. The 8/2024 Treatment Administration Record did not document the use of palm protectors or palm rolls. Resident #59 was observed without a palm protector to the left and right hands or a hand roll to the right hand at the following times: - on 8/12/2024 at 11:25 AM in their room sitting in their positioning chair; at 12:30 PM in the dining room while being assisted with their lunch meal; and at 4:02 PM in the common television area sitting in their positioning chair. - on 8/13/2024 at 11:01 AM in their room sleeping in their positioning chair; at 11:17 AM in the dining room sitting in their positioning chair. - on 8/14/2024 at 9:24 AM and 11:18 AM in their room sleeping in their positioning chair - on 8/15/2024 at 9:25 AM in their room sleeping in their positioning chair. During an interview on 8/15/2024 at 10:57 AM, Occupational Therapist #20 stated Resident #59 had left and right hand palm protectors initiated upon therapy discharge on 7/15/2024 by former Occupational Therapist #21. This information was located on the care plan and the certified nurse aides were responsible to ensure the palm protectors were placed. Prior to therapy discharge the occupational therapist educated the certified nurse aides on the use of the palm protectors and how they were put on and taken off. It was verbalized to the licensed practical nurse on the floor that the resident required them. If a resident was not wearing the palm protectors as recommended, their contractures could get worse and there could be skin issues or infections. During an interview on 8/15/2024 at 11:26 AM, Certified Nurse Aide #22 stated they were assigned to Resident #59 that day. Palm protectors prevented skin breakdown and contractures from getting worse. Placement or refusal was not documented anywhere. If they were refused, they reported to the licensed practical nurse on the unit. Resident #59 had contracted hands and they knew they had splints ordered but they did not put them on today because it slipped their mind. They did not tell anyone they did not put the splints on. They stated they should have put the splints on, so the resident did not get any skin breakdown, or so their hand contractures did not get worse. During an interview on 8/15/2024 at 11:40 AM, Licensed Practical Nurse #19 stated directions for palm protectors were located on the Kardex and the certified nurse aides looked at it every day. The certified nurse aides reported any refusals to them. Resident #59 had palm protectors because of contracted hands, and they were responsible to verify the placement of the palm protectors. There should be an order and placement should be documented in the treatment administration record. The order should have been entered in the computer when therapy discharged the resident and provided the certified nurse aides with the palm protectors. They did not know why there was not an order that placement of the palm guards was checked, or why they were not verifying the palm protectors were placed. During an interview on 8/15/2024 at 1:57 PM, Registered Nurse Unit Manager #18 stated Resident #59 had bilateral palm protectors listed on their Kardex that was referenced every shift by the certified nurse aides. They stated if there were any issues or refusals they should be reported to the licensed practical nurse. Without somewhere to document the placement of the palm protectors, the licensed practical nurse would not have known the placement needed to be checked. 2) Resident #67 had diagnoses including chronic congestive heart failure (heart does not pump efficiently), venous insufficiency (the veins in the legs have trouble returning blood to the heart), and edema (swelling caused by excess fluid). The 6/4/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was dependent for dressing lower body/putting on and taking off footwear and did not reject care. The 3/5/2024 physician order documented Tubigrips to bilateral lower extremities for edema, to be on at all times, off only for care, and verify every shift. The comprehensive care plan and the undated certified nurse aide care instructions did not document the resident had edema or required the use of Tubigrips. Resident #67 was observed without their Tubigrips on at the following times: - on 8/13/2024 at 10:55 AM sleeping in their room in their positioning chair wearing black socks and their legs were bare. - on 8/15/2024 at 9:50 AM awake in the common area in their positioning chair with their legs exposed. The August 2024 Treatment Administration Record documented Licensed Practical Nurse #19 verified the Tubigrips were on during the day on 8/13/2024 and 8/15/2024. During an interview on 8/15/2024 at 1:38 PM, Licensed Practical Nurse #19 stated there was an order for Tubigrips and they were on the care plan. If they documented as completed in the Treatment Administration Record it meant the Tubigrips were on. They usually signed them off as completed and then attempted to go back into the chart at the end of their shift and correct any documentation that was incorrect. The certified nurse aides sometimes put the Tubigrips on, but it was ultimately their responsibility they were on as ordered. They should not have documented the Tubigrips as completed in the Treatment Administration Record because they had not verified they were on. They were not sure if the resident had them on at all this week because they had not looked. If Resident #67 did not wear the Tubigrips as ordered, they could have increased swelling and because they were also for the resident's skin protection, they could have skin injuries if not worn. During an interview on 8/15/2024 at 1:47 PM, Registered Nurse Unit Manager #18 stated if something was documented as completed it meant it was done. It was not appropriate to document before a task was completed because it was falsification of documentation. Staff were expected to follow orders as they had an intended medical purpose. If the licensed practical nurse trusted the certified nurse aides placed the Tubigrips, the licensed practical nurse should have verified placement before it was documented. If the resident was not wearing the Tubigrips they could have increased edema that could lead to further clinical issues. 3) Resident #86 had diagnoses including repeated falls, anemia (not enough oxygen rich blood), and venous insufficiency. The 6/17/2024 Minimum Data Set assessment documented the resident was cognitively intact, required substantial/maximum assistance with bathing and dressing, received an anticoagulant (blood thinner), and did not reject care. The comprehensive care plan initiated 7/28/2024 and revised 8/13/2024 documented the resident had potential/ actual impairment to skin integrity related to fragile skin, advanced age, and anticoagulation therapy. A skin tear to the left forearm was documented on 8/11/2024. Interventions included facility protocols for treatment of injury were followed and the location, size, and treatment of skin injury was monitored and documented. The 8/11/2024 at 10:26 AM Registered Nurse #6 progress note documented they were notified the resident had a skin tear to their left forearm approximately 4 centimeters by 4 centimeters V-shaped with scant bleeding noted. The area was cleansed and steri-strips (thin, sticky bandages that hold wound edges together) were applied. The family and the provider were notified. The 8/12/2024 at 6:53 PM Assistant Director of Nursing progress note documented the resident had aging, fragile skin and was on Eliquis (blood thinner medication). The resident sustained a skin tear when bumped while staff assisted with transferring. Skin care as scheduled and medical was aware. The 8/12/2024 at 8:46 PM Nurse Practitioner #17 progress note documented the resident was seen today for follow up of a skin tear reported by nursing on 8/11/2024. Nursing applied steri-strips, the on call provider was notified and no new orders were given. Steri-strips were intact and there was no drainage or signs of infection. There were no documented physician orders from 8/11/2024- 8/12/024 for a treatment for the skin tear. A physician order dated 8/13/2024 documented left arm skin tear, steri-strips in place. Monitor daily and report any adverse findings to the charge nurse until healed. The order was discontinued on 8/16/2024. The August 2024 Treatment Administration Record documented the left arm skin tear with steri-strips were in place, the skin tear was monitored, and adverse findings were reported to the charge nurse until healed daily from 8/13/2024-8/16/2024. Resident #67 was observed on 8/12/2024 at 1:16 PM and 3:57 PM; on 8/13/2024 at 11:22 AM; and on 8/14/2024 at 9:30 AM sitting in their recliner chair in their room. They had 3 steri-strips in place on their left forearm/elbow area that were brown in color. There was a moderate amount of dark colored dried blood in an approximately 3-4-inch area distal (toward the hand) from the elbow: The 8/14/2024 at 1:49 PM Registered Nurse Unit Manager #18 progress note documented per Licensed Practical Nurse #23 the resident's steri-strips had fallen off the left forearm/ elbow area skin tear, the scab was intact, and there were no signs of drainage or infection. During an observation and interview on 8/15/2024 at 9:09 AM Resident #67 was sitting in their recliner chair in their room with an undated Kerlix (gauze bandage roll) wrap to their left elbow. They stated the steri-strips had fallen off during the day yesterday and when an unidentified certified nurse aide assisted them to get ready for bed last night, their scab had rubbed off their elbow when they were putting on a hospital gown for bedtime. The wound started bleeding and an unidentified nurse came in and placed the kerlix wrap and told them it was just temporary because there was no order for it. There was no documented evidence of a physician order for a treatment dressing or Kerlix wrap to the left forearm/elbow through 8/16/2024. During an interview on 8/16/2024 at 11:24 AM, Licensed Practical Nurse #23 stated in the event of a new skin tear they contacted the Nursing Supervisor who determined the appropriate dressing to be placed. Wound treatments required orders. Wounds and dressings should be clean even if they were steri-strips, they should not be discolored, and dried blood around the area should be cleaned as this was an infection control issue. They contacted Registered Nurse Unit Manager #18 on 8/14/2024 after the steri-strips fell off and told them the area was gookey looking. They reported dried blood but no active drainage, and Registered Nurse Unit Manager #18 came and looked at the wound and told them to keep it open to air and it would heal. During an interview on 8/16/2024 at 11:46 AM, Registered Nurse Unit Manager #18 stated Licensed Practical Nurse #23 notified them Resident #86's steri-strips had fallen off a couple days ago. An order was always needed for a wound treatment. Dressings should be clean and that included steri-strips. There should not have been dried blood around the area, and each nurse that signed off that the resident's wound was monitored should have seen that and cleaned it. They recalled a scab yesterday but did not recall any dried blood. They stated medical had seen the resident yesterday and there were no new orders. They had rounded on the resident today, saw the Kerlix wrap, and the resident reported the wound had reopened. There were no new orders. Whoever wrapped the wound should have contacted the provider and entered the appropriate order. Without orders to new, open wounds, the nurses could not monitor or change the dressing. There should have been a progress note and treatment order documented when the Kerlix was placed. 10NYCRR 415.12

Based on observation and interview during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 3 of 5 medication carts (Second floor B side and Fourth floor A and B sides), and 1 of 4 medication rooms (First floor B side). Specifically, the First floor B side medication room was missing medication refrigerator temperatures; the Fourth floor B side medication cart was unlocked and unattended; the Second floor B side and the Fourth floor A side medication carts had eye drops that were not labeled after they were opened. Findings include: The facility policy, Storage of Medication Policy, last reviewed 3/4/2024, documented all medications and biologicals were stored safely, securely, and properly, and followed manufacturer's recommendations or those of the supplier. Medication rooms, carts, and medication supplies were locked when they were not attended by persons with authorized access. All medications were maintained within the temperature ranges noticed in the United States Pharmacopeia (USP) and by the Centers for Disease Control (CDC). The facility maintained a temperature log in the storage area and recorded temperatures at least once a day. Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from inventory. Medication Room Refrigerator Temperatures: During an observation on 8/14/2024 at 9:16 AM the First floor B side medication room's refrigerator log did not have documented temperatures for 8/4/2024 and 8/9/2024. During an interview on 8/14/2024 at 9:16 AM, Licensed Practical Nurse #5 stated medication refrigerator temperatures were taken daily by the night shift and documented on the log. If there was no documented temperature, it was not done. They stated it was important the temperature was taken and recorded because medications like insulin required proper storage and if not stored properly, they were not as effective. During an interview on 8/14/2024 at 11:10 AM Registered Nurse Unit Manager #6 stated refrigerator temperatures were completed by the night shift. The temperatures were documented in a log in the front of the narcotic book to make sure medications that required refrigeration were held at the proper temperature. They stated if medications were not held at the proper temperature, they may not be effective. During an interview on 8/16/2024 at 1:34 PM the Director of Nursing stated refrigerator temperatures should be checked daily on the night shift and documented on the medication log in the medication room to ensure medications were maintained at the proper temperature. Medication carts: During an observation and interview on 8/15/2024 at 1:21 PM the medication cart on the Fourth floor B side was unlocked and unattended in an alcove across from room [ROOM NUMBER]. Licensed Practical Nurse #10 stated it was unlocked for at least 20 minutes. They had not locked it after they last administered medications because they got pulled away to assist another staff member. They stated the medication cart contained medications that were dangerous if ingested accidently. They stated the unit had residents that wandered, and they should have locked the cart when they stepped away. During an interview on 8/16/2024 at 1:34 PM the Director of Nursing stated the standard of practice was the medication cart was always locked when out of view. They stated the medication cart contained medications that should not be taken if not prescribed. Eye drops not labeled: During an observation and interview on 8/14/2024 at 9:26 AM the Fourth floor A side medication cart contained the following eye drops that were not labeled with an opened date: - latanoprost 0.005% (used to treat glaucoma) for Resident #103. - brinzolamide (used to treat glaucoma), Alphagan 0.15% (used to treat glaucoma), and latanoprost 0.005% for Resident #82. - brimonidine/timolol 0.2/0.5% (used to treat glaucoma), latanoprost 0.005%, and Combigan 0.2/0.5% (used to treat glaucoma) for Resident #2. Licensed Practical Nurse #12 stated they were not sure how long eye drops were good for once they were opened. If they noticed a bottle of eye drops that did not have an opened date on them, they looked at the date dispensed or called the pharmacy and got the dispensed date. They stated they used that date as the date opened. They stated it was important not to administer expired medications because they may not be effective. They started to put the medications in the cart and stated, I should not put them back. During an observation and interview on 8/14/2024 at 10:04 AM the Second floor B side medication cart contained the following eye drops that were not labeled with an opened date: - 2 fluorometholone ophthalmic suspension 0.1% (used to treat inflammation) for Resident #126. - latanoprost ophthalmic solution 0.005% for Resident #20. Licensed Practical Nurse #11 stated they used both medications earlier in the day. Resident #126 received fluorometholone ophthalmic suspension 0.1% in their left eye from a bottle that was not labeled when opened. Eye drops were labeled when opened and discarded after 28 days. They stated if the resident received the expired medication they could get an infection, have vision changes, and eye irritation. They stated Resident #20 also had two bottles of eyedrops, one was not labeled, and one was labeled 7/17/2024. That medication was used for glaucoma and expired 42 days after being opened and they were not sure if they used the one that was labeled. If the resident was administered the expired medication, it may not be as effective, and the resident could have increased pressure in their eyes. During an interview on 8/16/2024 at 1:34 PM the Director of Nursing stated eye drops were stored according to manufacturer's recommendations and should be labeled with an opened date. If there was no opened date on the eye drops, they expected staff to look at the dispensed date and put that on the label. If there was no date on the label, staff were trained to discard the medication and reorder it from the pharmacy. 10NYCRR 483.45 (g)(h)

Based on record review, observation, and interview during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, attractive, and at safe and appetizing temperatures for 1 of 2 meal test trays (the 8/13/2024 First floor A side lunch meal); for 2 of 2 residents (Residents #22 and #31) reviewed; and for 7 of 7 anonymous residents present at the Resident Council meeting. Specifically, food was not served at palatable and appetizing temperatures for the First floor A side lunch meal on 8/13/2024; and Residents #22, #31, and the attendees of the Resident Council meeting stated the food did not taste good and was not hot. Findings include: The facility policy, Food Procurement Receiving Handling Storing Preparing, revised and reviewed 7/12/2024 documented food above 41 degrees Fahrenheit and below 135 degrees Fahrenheit allowed the rapid growth of pathogenic microorganisms that could cause foodborne illness. The facility policy, Adequate Diet and Menu Planning to Accommodate Resident Needs and Choice, reviewed 7/20/2024, documented food was to be attractive, palatable, and served at the appropriate temperature. During an interview on 8/12/2024 at 11:06 AM, Resident #22 stated they did not each much of the food because it was always cold. During a Resident Council group meeting on 8/12/2024 at 12:58 PM, 7 anonymous residents stated the food did not taste good, the hot foods were not always hot, the cold foods were not always cold, and they often were missing food items from their meal trays. During an interview on 8/12/2024 at 2:05 PM Resident #31 stated the food was not good. It was not hot and had no flavor. During an interview and observation on 8/13/2024 at 10:46 AM, Resident #31 stated there was no hot food on their breakfast tray, only a muffin and fruit which they ate. The coffee was cold, and they did not drink it. During a lunch meal observation on 8/13/2024 at 12:20 PM on the First floor A side, Resident #119 was served their lunch meal tray. Their lunch tray was tested , and a replacement meal was requested. The chicken tender's temperature was measured at 127.8 degrees Fahrenheit and was soggy on the bottom; the potatoes measured temperature was 117.3 degrees Fahrenheit and had no flavor; the asparagus measured temperature was 146.1 degrees Fahrenheit and was mushy and had no flavor; and the peaches measured temperature was 39 degrees Fahrenheit. Licensed Practical Nurse #28 was present for the temperature readings of the lunch tray. During an observation and interview on 8/13/2024 at 12:34 PM, Resident #31 was seated in the dining room for the lunch meal. They ate a few bites of the grilled chicken tender and 1/2 of the broccoli and stated the chicken was warm, not hot enough to eat and the broccoli was cold. They ate 3/4 of the buttered noodles. They stated they would have eaten more if the food was hot and had more flavor. During an observation and interview on 8/13/2024 at 12:39 PM, Resident #22 ate 1/2 of their pork and stated it was ok, 1/4 of the asparagus and stated it was mushy and had no flavor, and one bite of the mashed potatoes and gravy and stated, it was not hot. During an observation and interview on 8/14/2024 at 8:59 AM, Resident #22 ate one bite of the bacon and none of the eggs on their breakfast tray and stated they were cold. They would have eaten them if they were hot. During an interview on 8/14/2024 at 9:37 AM, Certified Nurse Aide #31 stated residents often complained that food was cold and had no flavor. When residents said food was cold, they heated it in the microwave for an undetermined time and did not use a thermometer for testing the temperature of the food because there was not one available. During an interview on 8/15/2024 at 1:49 PM, Food Service Worker #32 stated food was cooked in the main kitchen and brought to the unit in a hot box. They placed the food from the hot box in the steam table. They stated hot food was served at 140-160 degrees Fahrenheit with the ideal temperature of 165 degrees Fahrenheit. They heard residents complained the asparagus was soggy and the French fries were not cooked because French fries do not hold their temperature very long. They did not do test trays anymore because they were short staffed. Chicken tenders should not have been served at 127.8 degrees Fahrenheit and the potatoes should not have been served at 117.3 degrees Fahrenheit. They stated if foods were served at inappropriate temperatures residents might not eat or could get food poisoning. During an interview on 8/15/2024 at 4:47 PM, the Food Service Director #33 stated all entrees were prepared and temperatures were taken in the main kitchen. They stated test trays were done weekly; however they did not have any documentation. They attended Resident Council meetings and heard complaints about the food. They stated serving temperatures for hot foods should be 140-165 degrees Fahrenheit. They stated chicken tenders should not have been served at 127.8 degrees Fahrenheit and the potatoes should not have been served at 117.3 degrees Fahrenheit. During an interview on 8/16/2024 at 11:37 AM, Registered Nurse Unit Manager #6 stated residents complained that food was not hot, or they did not like what they ordered. If they did not like what they ordered, staff offered another option and if it was not warm enough, staff heated it in the microwave. They were not sure if the kitchen did test trays. During an interview on 8/16/2024 at 1:34 PM, Director of Nursing #2 stated when food was not hot it was heated in the microwave. They were unsure if test trays were being completed regularly. 10NYCRR 415.14(d)(1)(2)

Based on observation, interview, and record review during the recertification and abbreviated (NY00347064) surveys conducted 8/12/2024-8/16/2024, the facility did not ensure each resident had the right to a safe, clean, comfortable, and homelike environment for 1 of 1 resident (Resident #92) reviewed. Specifically, Residents #92's electric wheelchair was unclean. Findings include: The facility policy, Wheelchair/Transport Chair Cleaning Protocol, revised 9/10/2017 documented the facility ensured the resident was provided a sanitary and pleasant environment, equipment was cleaned and disinfected once a month and daily as needed, and each unit had a designated week of cleaning throughout the month. The undated facility document Skilled 4A Side Wheelchairs (wheelchair cleaning log) did not document the resident's chair was cleaned. Resident #92 was admitted to the facility with the diagnoses including left hemiplegia and hemiparesis (weakness and paralysis of the left side of the body) following a cerebral infarction (stroke). The 7/18/2024 Minimum Data Set documented the resident had intact cognition and used a manual or electric wheelchair. During observations on 8/12/2024 at 3:50 PM, and 8/13/2024 at 11:32 AM Resident #92's wheelchair had a significant amount of dried debris underneath and around the footrest and on the front middle portion of the seat. The debris was dried on the surface and embedded in the crevices. During an interview on 8/14/2024 at 11:25 AM, Office Manager #27 from an outside medical office stated during the resident's office appointment on 6/27/2024 the resident's electric wheelchair was filthy. There was dried, unidentified material on it. During an interview on 8/14/2024 at 12:37 PM, Resident #92 stated housekeeping usually cleaned their chair. They were unsure what the cleaning schedule was or when the chair was last cleaned. They felt their chair took extra asking to get it cleaned and they once wheeled themselves into License Practical Nurse Manager #9's office to express how dirty it was just so it would be cleaned. They preferred to sit in a clean chair and had never refused to have their chair cleaned. During an observation on 8/15/2024 at 11:11 AM Resident #92's wheelchair had a significant amount of dried debris underneath and around the footrest and on the front middle portion of the seat. The debris was dried on the surface and embedded in the crevices. During an interview on 8/15/2024 at12:58 PM, Certified Nurse Aide #13 stated wheelchairs were deep cleaned by housekeeping on the night shift, but they were unsure what the schedule was. Housekeeping had to be reminded sometimes as quite a few chairs were missed. They had not seen Resident #92's wheelchair recently, but typically it was dirtier than others because the resident dropped a lot of food. Sitting in a dirty chair was undignified, and in the case of an electric chair, uncleanliness could cause an electrical short. During an interview on 8/15/2024 at 1:09 PM, Housekeeper #14 stated the housekeeping department cleaned the wheelchairs on the overnight shift but was unsure what the schedule was. If they found a dirty wheelchair they would clean it. Resident #92's chair was usually dirty, especially the footrest area. The resident had not refused to have their chair cleaned and thought if they asked the resident, the resident would let them wash their chair. It was important for chairs to be clean, otherwise it would be unsanitary. During an interview on 8/16/2024 at 11:07 AM, License Practical Nurse Manager #9 stated wheelchairs were cleaned weekly by the environmental services staff on the day shift, but they were unaware if there was a particular schedule. Anyone could clean a chair anytime. If they noticed a soiled wheelchair, they should clean it or contact environmental services. They did not have a process to monitor wheelchair cleanliness. Resident #92's wheelchair got very dirty, and the resident had brought it to their attention in the past. A clean wheelchair was important as a dirty chair could smell bad and affect a resident's dignity. During an interview on 8/16/2024 at 12:26 PM, Environmental Services Supervisor #15 stated wheelchairs were cleaned by their staff monthly on Sunday nights. Nursing staff brought any chairs that needed to be cleaned out into the hallway. Housekeeping staff then took the chairs to the spa room to clean, and then returned the chairs to the hallway once cleaned. If a chair was not brought out to the hallway it was not cleaned. The process was the same for electric wheelchairs. The wheelchair cleaning log was filled out with the date the chair was cleaned. A blank on the log indicated that the chair had not been cleaned. Anytime there was a dirty chair, they expected their staff to either clean it or notify them so they could do it regardless of the cleaning schedule. Resident #92's chair was never brought out into the hall, and they were not sure why. They had not spoken with the Nurse Manager about it. They checked the log and spot-checked wheelchairs periodically to ensure chairs were being cleaned. Clean chairs were important for overall resident health, wellness, and dignity. During an interview on 8/16/2024 at 1:34 PM, Director of Nursing #2 stated they did not know the process for wheelchair cleaning but thought environmental services performed the cleaning. If a wheelchair was dirty, it should be spot cleaned, and a work order should be put in for further cleaning. Staff were trained to follow the wheelchair cleaning schedule. 10 NYCRR 415.29(j)(1)

Based on record review and interviews during the recertification and abbreviated (NY00344487) surveys conducted 8/12/2024-8/16/2024, the facility did not ensure that prompt efforts were made to resolve grievances for 1 of 1 resident (Resident # 26) reviewed. Specifically, Resident #26's family member sent an electronic message to the facility's Administrator regarding their concerns and their concerns were not addressed timely. Findings include: The facility's policy, Complaint Grievance and Recommendation, revised 7/28/2024 documented that residents' next of kin or designated representatives were provided a method by which to express complaints and/or recommendations, both verbally and in writing, and that such complaints and/or recommendations would be responded to as soon as possible. Resident #26 was admitted to the facility with diagnoses including transient ischemic attack (mini stroke), abnormalities of gait and mobility, and muscle weakness. The 6/20/2024 Minimum Data Set Assessment documented the resident had intact cognition, did not reject care, and required partial/ moderate assistance with most activities of daily living. A 6/4/2024 electronic mail from Resident #26's family member addressed to the facility's Administrator expressed their concerns over long call bell wait times and other various issues. On 6/5/2024, the facility's Administrator replied to the family member's electronic mail and acknowledged the family member's email and poor experience. The Administrator documented they could not read the sender's attachment and asked for it to be sent again in another manner. On 6/6/2024, Resident #26's family resent an electronic message along with an attachment, they asked to be notified if the attachment could not be opened. There was no documented evidence facility staff responded to Resident #26's family members concerns in a timely manner. During an interview on 8/13/2024 at 11:17 AM Resident #26 stated staff did not respond to call bells in a timely manner and they had to call their family member who then called the Assistant Director of Nursing to have someone respond to their call bell. During an interview on 8/13/2024 at 2:36 PM Resident #26's family member stated call bell wait times could take longer than 1 hour before being answered. They sometimes had to contact the Assistant Director of Nursing who sent staff to answer the call bell. They felt their issues were not being addressed. They sent an electronic mail to the Administrator on 6/4/2024 regarding their concerns over long call bell wait times and other issues but they never received any follow up from the facility other than the electronic message documenting attachments could not be opened. During an interview on 8/15/2024 at 11:49 AM the Assistant Director of Nursing stated If a resident or family member had concerns with care, they could alert the Nursing Supervisor or Unit Manager. They provided the residents and family members with their personal cell phone so they could also call them when issues arose. Concerns with care should be addressed as quickly as possible and all concerns should be acknowledged. During an interview on 8/15/2024 at 3:46 PM the Administrator stated if a resident or family member reached out to them and expressed concerns with care, they would get back to them and try to tackle the problem as quickly as possible. They did not consider complaints to be grievances. They stated grievances were unresolved issues. They stated Resident #26's family member reached out to them by an electronic mail on 6/4/2024 and they could not open the attachment that was provided. They responded and asked for the information to be sent again. The family member replied on 6/6/2024, but they were still unable to open the attachment. They did not follow up with the family member or resident. They were unaware of any unresolved issues. During a follow up interview on 8/16/2024 at 11:51 AM the Assistant Director of Nursing stated Resident #26's family member did not call them a lot and they had not received any calls from them recently. If they received complaints of long waits for call bells to be answered, they followed up with staff. They were unaware of any issues that were outstanding with Resident #26. During an interview on 8/16/2024 at 12:27 PM the Director of Social Services and Grievance Officer stated grievances and complaints were the same thing. The facility should follow up with any complaints and grievances reported to staff. If a family member or resident expressed issues with long call bell wait times that was considered a complaint, and the nursing department heads should be made aware so the issue could be investigated. Residents and family members could express their concerns via electronic messages, verbally, or in writing. It was important to follow up with resident concerns. During a follow up interview on 8/16/2024 at 12:43 PM the Administrator stated they should have reached out to Resident #26's family member. It was important to follow up with resident concerns. 10NYCRR 415.3(C)(1)(ii) 49448

Based on observation, record review, and interviews during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 1 of 2 residents (Resident #125) reviewed. Specifically, Resident #125's comprehensive care plan did not include a diagnosis of Type 2 diabetes (the body is unable to use insulin properly causing high blood sugar). Findings include: The facility policy, Comprehensive Care Planning, revised 10/1/2023, documented the facility would ensure that an individualized care plan was initiated for all residents, and chronic, active diagnoses would be care planned for. The facility policy, Diabetes Management, revised 2/3/2020 documented staff would identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia (low blood sugar). Resident #125 was admitted to the facility with a diagnosis of diabetes mellitus. The 7/19/2024 Minimum Data Set documented the resident had moderately impaired cognition, had a diagnosis of diabetes, and received a hypoglycemic (used to lower blood sugar) daily. Physician orders documented: - on 7/17/2023 the resident was to receive Metformin 500 milligrams (a hypoglycemic) twice daily for diabetes. - on 10/23/2023 the resident was to receive a no concentrated sweets diet. - on 7/30/2024 HGBA1C every 3 months (a lab test that measures average blood sugar level over 2-3 months). A 6/24/2024 Physician Assistant #45 progress note documented the resident had been eating and drinking less lately and was not as interested in food. There was no documented evidence the Comprehensive Care Plan included a diagnosis of diabetes with associated interventions. During an interview on 8/16/2024 at 10:14 AM, Certified Nurse Aide #7 stated the nurse aides had access to resident care plans. It was important to know if a resident was diabetic as it would make them more alert for symptoms of high or low sugar levels such as headaches, dry mouth and dizziness. Resident #125 was a diabetic but was not listed as a diabetic in their care plan or their resident care instructions. During an interview on 8/16/2024 at 10:57, Licensed Practical Nurse Unit Manager #9 stated care plans were done on admission and updated quarterly and as needed. They tried to match diagnoses and medications with care plan problems. If a resident was diabetic, there should be a care plan problem with interventions such as monitoring labs, monitoring finger sticks, and monitoring for signs of abnormal glucose levels. This was important as abnormal glucose levels could lead to coma and even death. Resident #125 was a diabetic and took an oral hypoglycemic daily. They should have a related care plan but did not. During an interview on 8/16/2024 at 1:34 PM, Director of Nursing #2 stated nursing care plans were initiated by the Unit Manager or Supervisor and the Licensed Practical Nurses Managers could update them. Care plans should reflect if someone had diabetes mellitus so that residents could be monitored for changes in condition such as hyperglycemia/hypoglycemia (abnormally high and low glucose levels). If a resident did not have a care plan, the resident should still be monitored. 10NYCRR 415.11(c)(1)

Based on observation, record review, and interview during the recertification and abbreviated (NY00344344, NY00344487, and NY00347064) surveys conducted 8/12/2024-8/16/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 8 residents (Resident #26) reviewed. Specifically, Resident #26 was not assisted out of bed as requested. Findings include: The facility policy, Activities of Daily Living, revised 4/2024 documented activity of daily living tasks included personal hygiene, toileting, feeding, bed mobility, transfer, walking in the room and corridor, locomotion on and off the unit and dressing. Certified nurse aides documented activity of daily living support and performance. Resident #26 had diagnoses including transient ischemic attack (mini stroke), abnormalities of gait and mobility, and muscle weakness. The 6/20/2024 Minimum Data Set Assessment documented the resident had intact cognition, did not reject care, and required partial/ moderate assistance with most activities of daily living including bed mobility. The 3/5/2024 Comprehensive Care Plan documented the resident required substantial/ maximum assistance of 1 for rolling left to right, sitting to lying, and lying to sitting; substantial/maximum assistance of 2 with mechanical lift for sitting to standing and chair to bed transfers. The undated care instructions documented the resident required substantial/ maximum assistance of 1 for lying to sitting on side of bed, sitting to lying, and rolling left to right. On 6/1/2024 at 1:33 PM, a progress note by Licensed Practical Nurse #36 documented the resident stayed in bed. There was no documentation of a reason why the resident stayed in bed. During an interview and observation on 8/13/2024 at 11:17 AM, Resident #26 was seated in their electric wheelchair and stated at times they had been asked to stay in bed because there was not enough staff to get them up. During an interview on 8/13/2024 at 2:36 PM, Resident #26's family member stated the resident called them when their call bell wait times were long and they in turn called the Assistant Director of Nursing to have someone answer the resident's call bells. They had attempted to reach out to the facility's Administrator on 6/4/2024 to discuss their concerns regarding the weekend of 6/1/2024 when the resident was left in bed all day, but no one from the facility had gotten back to them. During an interview on 8/16/2024 at 10:03 AM Licensed Practical Nurse #36 stated residents should not be asked to stay in bed. If a resident requested to get out of bed and staff was unable to, they should let the nurse know so they could assist. At times the unit was staffed with 3 certified nurse aides and 2 licensed practical nurses so staff might not be able to get the resident up at that moment they were providing care to other residents, but the resident should be assisted as soon as possible. They stated they usually worked the overnight shift, but on 6/1/2024 they were mandated to stay over for the day shift. Resident #26 did not refuse care and they did not recall being asked to assist with resident care. During an interview on 8/16/2024 at 12:58 PM Certified Nurse Aide #35 stated sometimes on the weekends only 2 certified nurse aides were scheduled. The weekend of 6/1/2024 was tough. On Saturday 6/1/2024 there were only 2 certified nurse aides until 10:00 AM. Staff had to prioritize who they got up as some residents needed to be up for breakfast. Any residents that did not have to be assisted with meals were not gotten up until after the breakfast meal. Resident #26 was not happy about having to stay in bed but was understanding. They stated they provided care to the resident as fast as they could, but it was almost lunch time when they were able to get to the resident. They washed the resident up and provided assistance as needed. Staff documented the care provided to the residents and they typically did not get to their charting until the end of the day. They stated the 2 licensed practical nurses were aware it was a tough weekend. During an interview on 8/16/2024 at 1:48 PM the Assistant Director of Nursing stated staff was expected to document the care provided each shift. If there was no documentation it was assumed the care did not happen. It was unacceptable for staff to ask a resident to stay in bed because there was not enough staff. They did not recall being notified the unit was short staffed on 6/1/2024 and they expected to be notified about those types of issues. 10NYCRR 415.12(a)(3) 48446 49448

Based on observation, record review, and interview during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure ongoing provision of programs to support each resident in their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 2 residents (Resident #137) reviewed. Specifically, Resident #137 was not assisted to attend an activity that was meaningful to them and met their interests and preferences. Findings include: The facility policy, Activities, effective 4/19/2024 documented the activities program appealed to each resident's interests and enhanced the resident's highest practicable level of physical, mental, and psychosocial wellbeing based upon the resident's comprehensive assessment. Activities were relevant to the specific needs, interests, cultural, background, etcetera of the individual. The facility's August 2024 Recreational Therapy Calendar documented on 8/14/2024 at 2:00 PM there was a Petting Zoo activity on the front lawn. Resident #137 had diagnoses including dementia, muscle weakness, and need for assistance with personal care. The 1/31/2024 Minimum Data Set assessment documented the resident felt it was very important to go outside to get fresh air when the weather was good. The 6/26/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required substantial/ maximum assistance with transfers, and was dependent for locomotion with a wheelchair. The comprehensive care plan initiated 2/1/2024 and revised 4/3/2024 documented the resident did not wish to attend activity programs and was content watching television, resting and visiting with family. Interventions included the resident was allowed to change their mind about attending activity programs. The 1/30/2024 Admission Activity Assessment completed by Activity Coordinator #29 documented the resident got around by wheelchair with assistance. The resident was able to make their needs known and made their own decisions about activity preferences. The resident enjoyed pets and their communication method was verbal. The activities One to One (Room Visits Form) documented the resident was invited to the zoo activity on 8/14/2024 by Activity Coordinator #29. During a telephone interview on 8/15/2024 at 8:40 AM the resident's family member stated the resident was excited to attend the zoo activity yesterday and they were surprised because the resident rarely had an interest in attending the facility's activities. They stated they were visiting with the resident in their room, the resident was ready in their wheelchair and was added to the list of residents that wished to attend. They left around 2:00 PM because the resident was supposed to attend the zoo activity. They stated they called the resident on the telephone around 4:00 PM to ask about the zoo activity and the resident stated they were never picked up to attend the activity. During an observation and interview on 8/15/2024 at 9:02 AM Resident #137 was in their room lying in bed. They stated they wanted to attend the zoo event, but staff never came to take them to the activity. They stated that was life and it was not always fair. During a telephone interview on 8/15/2024 at 2:26 PM Activity Coordinator #29 stated Resident #137 wanted to attend the zoo activity but did not. They stated Certified Nurse Aide #30 was supposed to get the resident ready to go. When they came to the floor to pick up the resident, the resident was not ready by the elevator. The resident was not able to get themself to the elevator and required staff to get them there. The resident should have been able to attend the activity because they rarely came out of their room and was excited to attend. It was important for the residents to get fresh air, to socialize, and to have pleasure and enjoyment. They loved to see the residents smiling and happy at activities and this was important for their quality of life. During an interview on 8/16/2024 at 10:45 AM Certified Nurse Aide #30 stated Activity Coordinator #29 let them know who wanted to attend the zoo activity and they got them ready and then took them over to the elevator to be transported to the activity. Resident #137 wanted to attend the zoo activity and they got them ready to go but did not take them to the elevator because the resident was visiting with family in their room. They stated Activity Coordinator #29 was going to come back to get the resident when they were ready. They should have taken the resident to the elevator. They had not communicated to Activity Coordinator #29 the resident was ready but was still in their room. Attending activities of preference was important for the residents' quality of life and mental health, and it was important for residents to get fresh air. During an interview on 8/16/2024 at 10:54 AM Social Worker #25 stated it was important for residents to attend activities of their preference for their quality of life. Resident #137 should have attended the zoo activity if they wanted to go. It was not acceptable they were left behind. The resident was getting older and may not have another opportunity for a zoo activity. After the resident voiced they wanted to attend the activity and was not picked up, it could have negatively affected their mood. If the resident wanted to attend the activity, they should have. 10NYCRR 415.5(f)(1)

Based on observation, record review, and interview during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not ensure that residents who required dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services received such services consistent with professional standards of practice for 1 of 1 resident (Resident #37) reviewed. Specifically, Resident #37 received hemodialysis treatments at a community-based dialysis center and did not have ongoing assessments of their condition and monitoring for complications before and after dialysis treatments. Additionally, there was not consistent ongoing communication and collaboration between the facility and the dialysis center. Findings include: The facility policy, Dialysis, effective 4/19/2024 documented the facility maintained proper standards related to dialysis protocol and good communication was maintained with the facility that provided dialysis. A communication book went with the resident each time they went to dialysis. The purpose of the book was to share information/ ask questions with the dialysis center. The policy did not document what specific information was included in the communication book, pre or post dialysis assessments to be completed, or dialysis access site monitoring. Resident #37 had diagnoses including end stage renal (kidney) disease with dependence on renal dialysis, hypotension (low blood pressure), and hypertension (high blood pressure). The 7/16/2024 Minimum Data Set assessment documented the resident was cognitively intact, did not reject care, and required hemodialysis treatments. The Comprehensive Care Plan initiated 7/12/2024 documented the resident needed dialysis related to renal failure. Interventions included a dialysis book went with resident to dialysis appointments, dialysis was on Tuesday, Thursday, and Saturdays, and signs/symptoms of infection to the access site were monitored. The Comprehensive Care Plan did not include the type of dialysis access site the resident had. The 7/13/2024 physician order documented the resident attended dialysis on Tuesday, Thursday, and Saturday. The order did not include pre or post dialysis assessments or access site monitoring. The 8/5/2024 Registered Nurse #6 admission progress note documented the resident was readmitted from the hospital. The resident had a left chest permacath (a catheter placed into a blood vessel in the chest and threaded to the heart, used for dialysis access). The August 2024 Treatment Administration Record documented the resident attended dialysis on 8/6/2024, 8/8/2024, 8/10/2024, 8/13/2024 and 8/15/2024. There was no documented evidence the dialysis access site was monitored daily or pre or post dialysis assessments were completed. During an observation and interview on 8/12/2024 at 1:43 PM, Resident #37 was sitting in their room in their recliner chair. They stated they started dialysis less than 6 months ago and attended 3 times weekly. A dual lumen (tubes) left chest permacath was observed with a dry, intact, white border gauze and the lumens were wrapped with a dry, intact, white dressing. The resident stated facility staff never looked at their dialysis access site. A registered nurse at the dialysis center looked at the access site and changed the dressing. They also had an arteriovenous fistula (a surgically created connection between an artery and a vein for dialysis access) to the left arm, but it was not yet in use. They did not believe any assessments or vital signs were obtained pre or post dialysis at the facility. During a follow up interview on 8/14/2024 at 11:28 AM, the resident confirmed they had dialysis on 8/13/2024 and there were no pre assessment or vital signs taken, and there was no post assessment, or vital signs taken. No facility staff looked at their permacath access site. The resident's dual lumen left chest permacath had a dry, intact, white border gauze and the lumens were wrapped with a dry, intact, white dressing. During an interview on 8/15/2024 at 4:05 PM Unit Clerk #39 stated Resident #37 kept their dialysis communication book with them in their room. The certified nurse aides took the post dialysis weight from the book and documented it in the electronic medical record. During an observation and interview on 8/15/2024 at 4:07 PM, Resident #37 was sitting in their room in their recliner chair. Their dialysis communication book was in a bag they took with them to dialysis. The book contained various post-it notes that documented a date and a weight. The dialysis treatment sheets in the book were dated May 2024 or older. The active medication list was dated 2/22/2024. Resident #37 stated they kept the dialysis communication book with them. The certified nurse aides were the only staff that looked at their communication book and they just wanted the weight out of the book to document it. During an interview on 8/16/2024 at 11:17 AM Licensed Practical Nurse #23 stated the dialysis communication binder had order sheets and current medications. The purpose was for communication between the facility and the dialysis unit. They were not sure who was responsible to ensure the communication binder was updated. A medication list from February 2024 was not a current list. It was important for dialysis to know what medications the resident was taking; they were on heart medications and could have a drop in blood pressure. The dialysis center should know what medications they were on so any side effects could be monitored. They did not know what type of dialysis access site the Resident #37 had. They looked in the electronic record and stated the resident had a left arm dialysis port. They were unsure if they had a fistula or a permacath. They had cared for the resident this week and they had not looked at the dialysis site or the communication book. They stated there was no pre or post dialysis assessments. They were unsure if a permacath site should be monitored. During an interview on 8/16/2024 at 11:39 AM Registered Nurse Unit Manager #18 stated the dialysis communication book should include vital signs, weights, orders, and any changes. It should also include a current medication list. A medication list from February was not current and the resident's medications had likely changed in the past 6 months. Dialysis should know what medications the resident was on because they could have adverse reactions. The licensed practical nurse should look at the book when the resident returned from dialysis to know if dialysis had any information they wanted to relay. Dialysis sites should be monitored for swelling, redness, pain, bleeding, and any leakage as there could be complications and negative outcomes. Nurses were expected to know what type of a dialysis access site the resident had. If dialysis access sites were monitored, the nurses would have known what type of access site the resident had. The access site should be monitored and documented on routinely. If there was nowhere to document, it would not have triggered the nurse to monitor the site. Pre and post dialysis assessments should have been completed so any changes could be monitored. During an interview on 8/16/2024 at 1:48 PM the Assistant Director of Nursing stated the dialysis book had weights documented in it. Resident #37 had a fistula that was not being used and a port that was being used. The port (permacath) should be monitored that it was clamped. They did not think the dialysis facility needed a current medication list because the dialysis facility had their phone number and could call with questions. A medication list from February was not current and should not have been in the book. If a medication list was going to be in the book it should have been current. There should be documentation of the permacath site being monitored, and if the permacath site was not monitored, the resident could bleed out. 10NYCRR 415.12(k)

Based on observation, record review, and interview during the recertification survey conducted 8/12/2024-8/16/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #54) reviewed. Specifically, Licensed Practical Nurse #23 did not maintain infection control precautions when administering medications to Resident #54 who was on transmission based precautions (contact precautions) and staff were not aware why the precautions were in place. Findings include: The facility policy, Infection Prevention and Control Plan/ Program, revised 2/16/2024 documented transmission-based precautions were additional infection control precautions in health care for residents who were known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens (highly contagious germs). The infection preventionist was responsible and all staff was educated and monitored for compliance and periodic observations of nursing units were completed to assure transmission-based precautions were maintained. Resident #54 had diagnoses including history of methicillin resistant staphylococcus aureus (a resistant bacteria) infection (site not specified) and obstructive and reflux uropathy (poor urine flow). The 7/3/2024 Minimum Data Set assessment documented the resident required modified independence with daily decision making, was independent or required set-up assistance with most activities of daily living, had an indwelling urinary catheter (removes urine from the bladder), and did not have multi-drug resistant organisms. The 7/28/2024 physician order documented the resident was on contact precautions for methicillin resistant staphylococcus aureus. The 8/1/2024 Nurse Practitioner #17 progress note documented the resident was seen for a positive COVID-19 test, and this was communicated with facility staff. There was no documentation the resident had methicillin resistant staphylococcus aureus or was on transmission-based precautions. The 8/1/2024 at 9:24 PM nursing progress note by the Assistant Director of Nursing documented the resident was COVID-19 positive and an order for droplet precautions was obtained. The Comprehensive Care Plan initiated 8/2/2024 documented the resident had methicillin resistant staphylococcus aureus in the urine. Interventions included the resident/ family/ caregivers were educated on the importance of hand washing, family/ visitors/ caregivers were instructed to wear disposable gown and gloves during physical contact with the resident, gown/gloves were discarded in the appropriate receptacle, and hands were washed before leaving the room. The Comprehensive Care Plan did not document the resident had COVID-19. The August 2024 Medication Administration Record documented the resident was on strict respiratory and contact isolation for COVID-19 precautions for 10 days from 8/2/2024-8/12/2024. There was no documentation for the contact precaution order for methicillin resistant staphylococcus aureus. During a medication administration observation on 8/14/2024 at 9:49 AM Licensed Practical Nurse #23 took Resident #54's ordered medications to the resident's room. There was a contact precautions sign outside the room that documented contact precautions everyone must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on a gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. Licensed Practical Nurse #23 did not perform hand hygiene, put on gloves, did not put on a gown, and entered the resident's room for medication administration. In addition to the oral medications, an inhaler and a vial of eye drops were also brought into the room by Licensed Practical Nurse #23. After the medication administration was completed, Licensed Practical Nurse #23 removed their gloves, picked up the inhaler and the vial of eye drops with their ungloved hands, exited the room, and placed the inhaler and vial of eye drops on top of the medication cart. Licensed Practical Nurse #23 did not perform hand hygiene, put on a new set of gloves obtained from another resident's room and wiped the outside of the inhaler and the eye drops with a disinfectant wipe. They discarded the gloves, did not perform hand hygiene, and placed the medications back into the medication cart. During an interview on 8/14/2024 at 9:54 AM Licensed Practical Nurse #23 stated Resident #54 was on contact precautions for methicillin resistant staphylococcus aureus in a wound and they also had an indwelling urinary catheter. They stated they should have worn a gown into the room but there were none available outside the door and because they had already prepared the medications in the medication cup, they just went in the room. A gown should be worn anytime they entered the resident's room. They should have utilized hand sanitizer before the room was entered and after each time gloves were removed. Not doing so they could carry the germs with them out of the room. They should have taken a wipe into the room with them and wiped the medications down before exiting the room as they also had germs on them that exited the room. Those germs were then placed on the medication cart. Gloves did not replace the need for hand hygiene, and they should have performed hand hygiene before and after glove use to prevent the spread of infection. During an interview on 8/15/2024 at 3:56 PM Registered Nurse Unit Manager #18 stated if a resident was on contact precautions, personal protective equipment should be worn per the directions on the signage outside the door. Contact isolation required the use of gown and gloves and prevented the spread of infection of whatever organism the resident had. Gloves were not a replacement for hand hygiene. Hand hygiene was performed anytime hands were visibly soiled, in between tasks, and any time before gloves were put on or after they were taken off. It was not acceptable the nurse did not wear a gown because there were none available outside the room. They expected the nurse to go back to their medication cart, lock up the medications, obtain gowns, and start the process over again. Hand washing and cleaning items brought into the room before they exited was important to prevent the spread of the organisms. During an interview on 8/16/2024 at 1:30 PM, the Infection Preventionist #16 stated when a contact precaution room was entered gloves and gowns had to be worn every time, regardless of the reason the room was being entered, including a medication pass. Hands should be washed before entering and exiting the room and in between glove changes. This prevented the spread of organisms and kept residents safe. Personal protective equipment was in a storage device outside the precaution rooms. If those supplies were depleted, they expected staff restock it before they went into the room. There were extra gowns and gloves in the clean utility room on each unit so depleted supplies outside the room was not a viable excuse for entering the room without applying the necessary equipment. Any items being brought out of a precaution room should be wiped down with the proper wipe and allowed to completely dry before removing from the room. Items such as inhalers and medication vials were included so the items did not cross contaminate in the medication cart. Housekeeping placed personal protective equipment storage devices outside the rooms when precautions were initiated and removed them when precautions were discontinued. They, or the Director of Nursing, communicated those needs to housekeeping and double checked it was done. Resident #54 was on contact precautions for COVID-19, but as of 8/11/2024 precautions were discontinued. If there was precaution signage outside a resident's door, even if the resident's precautions had been discontinued, staff were educated the signage was followed or it was clarified whether the precautions were still active. 10NYCRR 415.19(a)(b) 50561

Based on observation, interview, and record review during the abbreviated survey (NY00313265), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #3) reviewed. Specifically, Resident #3 did not receive their medically ordered Povidone Iodine solution (treatment to decrease the risk of infection) treatment to their toes as ordered and when the treatment was not done, there was no documented evidence the medical provider was notified so the treatment order could be re-evaluated. Findings include: Resident #3 had diagnoses including peripheral vascular disease (PVD, decreased circulation disorder) and heart failure. The 12/30/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition, did not reject care, required extensive assistance with most activities of daily living (ADL), and did not have any pressure ulcers. The 11/17/21 comprehensive care plan (CCP) documented the resident had impaired circulation. Interventions included to assess the resident's fingers and toes for warmth and color, elevate legs when resting, ensure proper fitting footwear, inspect feet for areas of rubbing or injury, inspect foot, ankle, and calf, skin each shift for changes of maceration (occurs when skin is in contact with moisture for too long), redness, purple tinge, blue, rust color, weeping, edema, puffiness, tenderness, and areas with no sensation. On 2/28/23, nurse practitioner (NP) #7's progress note documented they saw the resident for a nonproductive cough. The resident had 1 + edema (swelling) in both their left and right ankles and feet. The plan was to continue with 40 milligrams (mg) of a diuretic once daily and monitor the edema. The 2/28/23 physician orders documented to paint the resident's right great toe with skin prep (treatment)every shift for irritation. On 3/1/23 and 3/2/23, NP #7's progress notes documented the resident had peripheral edema, 1 + in their left ankle and foot and 1 + in the right ankle and 2 + in the right foot. The 3/2/23 physician's orders documented to discontinue skin prep to right great toe and start Povidone-Iodine Solution 10% apply to right great toe topically for toe pain and left third toe every shift. The 3/23 Medication Administration Record (MAR) documented Povidone-Iodine Solution 10% apply to right great toe topically for toe pain and left third toe was not applied on the night shift: - on 3/5/23 and licensed practical nurse (LPN) #13 documented the resident was sleeping. - On 3/17/23 and 3/18/23 and LPN #10 documented the resident was sleeping. The 3/24/23 Braden Scale For Predicting Pressure Ulcer Risk Evaluation documented the resident's skin was constantly moist, had very limited mobility, required moderate to [NAME] assistance with moving. The corresponding 3/24/23 nursing progress noted documented the resident had a Braden Score of 13 (moderate risk of developing pressure ulcers). The 3/23 MAR documented Povidone-Iodine Solution 10% apply to right great toe topically for toe pain and left third toe was not applied on the night shift: - on 3/24/23 and 3/25/23 and LPN #10 documented the resident was sleeping. - On 3/27/23 and LPN #10 documented the resident was sleeping. - On 3/31/23 and LPN #11 documented other/ see progress notes. On 3/31/23, LPN #11's linked MAR progress note documented days. On 4/4/23 at 11:26 AM, the resident stated in an interview, they were feeling better than they felt earlier and gave permission for the feet to be observed by the surveyor. The resident's right great toe and left 3 third toe had a dark red substance present. The resident stated in an interview at that time, the nurse had put their treatment on their feet today and they had some pain in their toes that was not too bad. During an interview with LPN Unit Manager #3 on 4/5/23 at 10:45 AM, they stated the resident received an Iodine treatment to their toes every shift. The treatment should be completed anytime during the shift and if the resident was sleeping the nurse should try again to complete the treatment when the resident was awake. The night shift nurse worked 11 PM to 7 AM and the resident was scheduled to get up by the night shift so the night LPN could complete the treatment when the resident got up. They were unaware the night LPNs were documenting the resident was sleeping and the treatment was not being completed as ordered. They stated they expected the nurse to try to complete the treatments as ordered and if they could not, the night nurses should have told the nursing Supervisor so the provider could be made aware and possibly change the treatment schedule. They stated it was important for the resident to receive the treatment to keep the toes dry and prevent infection. During an interview with NP #7 on 4/5/23 at 12:36 PM, they stated the resident was receiving a treatment to their toes as they had PVD. The treatment aided with keeping the area dry and was used to prevent infection. The resident did not have any open areas at this time and the condition of their toes remained the same. They stated the nurse should complete treatments as ordered and if they were unable to the provider should be made aware. They stated if they were made aware they would have evaluated the resident. During an interview on 4/5/23 at 1:25 PM, the Director of Nursing (DON) stated treatments should be completed as ordered. If treatments could not be completed as ordered the nurse should have told the nursing Supervisor so it could be passed along to the physician to see if the order could be changed. During a telephone interview on 4/6/23 at 9:59 AM with LPN #10, they stated If a resident had a treatment ordered to be completed on their shift, it should be completed as it was physician order. They usually started the treatments scheduled on the night shift between 12 AM and 1 AM. They did not like to wake residents up if they were sleeping, as they felt sleep was important. If a resident was sleeping when they went to complete the scheduled treatment, they documented the resident was sleeping on the MAR. They would give a verbal report to the oncoming day shift nurse but did not always state they were unable to complete Resident #3's treatment. They were aware the resident was scheduled to receive a treatment to their toes for circulation reasons but did not think it was detrimental if the resident did not receive the treatment. They did not think missing the treatment a couple of times was going to make a difference. They did not notify the nursing Supervisor, Unit Manager, or medical provider the treatment was no completed due to the resident being asleep. 10NYCRR 415.12

Based on interview and record review during the abbreviated survey (NY 856) the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents. Specifically, Resident #1 was newly admitted with a known wander history and was identified at risk for elopement. The resident refused to wear a Wanderguard (wander alert device), was not continually supervised, left the building undetected and was found on the steps of another building down the hill from the facility (approximately 0.21 miles). When located, the resident had a bruise to their head, was transported to the hospital where a CT (computed tomography, medical imaging) scan revealed a frontal lobe hemorrhage. The resident passed away 5 days later. This resulted in harm to Resident #1 that was not Immediate Jeopardy. The facility policy Elopement Prevention reviewed/revised 10/22 documented: - All residents would have an elopement evaluation completed upon admission, readmission, quarterly, significant change, and annually, and as needed. - If a resident was identified as at risk for elopement, the licensed nurse would initiate individualized care plans. - If the elopement evaluations indicated the resident was a risk for elopement the nursing Supervisor/Nurse Manager would obtain a Wanderguard bracelet, apply the bracelet, and document. The bracelet could be placed on the resident's wheelchair if appropriate in the event it would/could cause physical or emotional distress with placement on the wrist or ankle, and implement diversional activities as needed such as television, crossword puzzle, or snacks. - The assigned licensed nurse would check the resident every shift to ensure the Wanderguard was in place and that the band was in good repair. Resident #1 had diagnoses including dementia with behaviors. There was no Minimum Data Set (MDS) completed prior to the resident's discharge. The 10/13/22 hospital inpatient mental health progress report sent to the facility upon admission documented the resident was seen in the emergency department after the county Sheriff's office called emergency medical services (EMS). The resident was wandering the streets and was believed to be confused thinking people were in their home and they needed to go home and take care of the kids. The resident was positive for paranoid delusions and believed hospital staff wanted to keep them locked up and felt as they were in prison. The resident was diagnosed with neurocognitive disorder dementia. The resident had memory problems, was unaware of their medical condition or did not know the medications they were taking. The resident was angry, agitated and repeated they wanted to go home. The resident was deemed to lack capacity to make decisions about their health and would not be safe living alone. The 10/14/22 hospital discharge summary sent to the facility upon admission documented the resident was brought to the hospital after being found wandering out in the street. The resident was found to have cognitive decline and unable to care for themselves and discharged to the nursing facility for ongoing care and monitoring. The 10/14/22 at 2:42 PM nursing progress note entered by registered nurse (RN) Manager #1 documented an elopement evaluation. The resident had a history of elopement at home; verbally expressed the desire to go home or packed belongings to go home or stayed near a door; exhibited a wandering behavior pattern or goal directed wandering; was recently admitted (last 30 days) and had not accepted the situation. Staff were notified of the resident's elopement risk, the resident's location was to be frequently monitored (did not include what the frequency was), exit alarms utilized, and the medication list was reviewed with the provider. On 10/14/22 at 3:40 PM, RN/MDS Coordinator #13 documented the resident was sitting in a chair in their room. RN/MDS Coordinator #13 attempted to complete the PHQ-9 (patient health questionnaire, mood assessment). The resident was uncooperative and avoided answering any questions. The resident asked when dinner was, and the RN/MDS Coordinator responded dinner was from 4:30-5:00 PM. The assessment was not able to be completed at that time. The 10/14/22 at 3:45 PM admission summary nursing progress note entered by RN Manager #1 documented the resident was admitted to the facility following a hospital stay. The resident was alert and oriented to person with confusion. Their BIMS (brief interview for mental status) was 8/15, which was consistent with moderate cognitive impairment. The resident presented with a broken left lens in their glasses and stated they fell a couple of weeks ago. The resident was independent with transfers and ambulation and required limited assistance with ADLs (activities of daily living). The elopement assessment was completed and put the resident at risk for elopement. A Wanderguard was attempted to be placed numerous times, but the resident became physically aggressive with staff each time. The Wanderguard was placed in the resident's personal belongings bag which was on the resident's lap at the time of the assessment. The (medical) provider was notified of the Wanderguard being refused and they stated to continue to attempt when the resident was more willing. The RN Manager planned to reapproach the resident in approximately 30 minutes to re-attempt Wanderguard placement to their person. Staff on the unit were notified of the resident's elopement risk and refusal of the Wanderguard, the resident was in their room resting comfortably in the recliner and appeared to have a calm demeanor. The Resident Care Record (RCR, care instructions) dated 10/14/22 completed by RN Manager #1 documented the resident was alert and confused, was independent for transfers and was to have supervision with ambulation. The resident's behavior included elopement risk with the intervention of a Wanderguard placed in the resident's personal belongings. There was no documentation related to monitoring the resident or time intervals. The 10/14/22 at 5:08 PM physician assistant (PA) #11 progress note documented the resident was seen for the new admission assessment. They had neurocognitive disorder/dementia and was seen by the psychiatrist at the hospital the day prior. The resident was frustrated and displeased being at the facility, requested to go home, was calm, and sitting in their chair. The resident used occasional profanity, stated they could take care of themselves, and missed their cat. The PA attempted multiple non-pharmacologic measures such as tea, stuffed animal, a live dog visit, and television to calm the resident. The resident was calm and resting peacefully in the chair and nursing staff was to place a Wanderguard. The PA recommended if the resident attempted to leave to seek a transfer to the emergency department for placement in a locked unit. [MEDICATION(S)] (antipsychotic) was ordered to help calm the resident's paranoia. The PA was accompanied by physical therapist (PT) #12 during the visit in a collaborative effort with the resident. Thirty minutes later the PA was notified the resident was missing and found by the Administrator. The 10/15/22 Facility Investigation documented: - The resident was admitted to the facility at approximately 2:15 PM on 10/14/22. Initial admission evaluations were attempted by nursing, therapy, MDS, and social work. - Diversional activities were in place to reduce stimulation and allow the resident to adjust to their new environment. The resident was offered a drink, snack, dog visit, and a robotic cat and all were declined. - RN Manager #1 initially evaluated the resident at approximately 2:20 PM and identified the resident to be an elopement risk. The RN Manager attempted to place the Wanderguard multiple times and the resident became combative. The resident was noted to be keeping their personal belongings close to them and placed the Wanderguard in the bag while still attempting to place (another) Wanderguard. - At approximately 3:45 PM, RN Manager #1 re-approached the resident to attempt to place the Wanderguard and the resident again became combative and agitated. The RN conversed with the resident until they were calm, and the resident was noted to be resting comfortably in their recliner. - RN Manager #1 met with PA #11 to review the new admission and discuss the difficulty placing the Wanderguard. The plan was to re-approach in 30 minutes to again attempt to place the Wanderguard. - Therapy staff attempted assessments at 2:30 PM, and from 3:15 PM to 3:30 PM. RN/MDS Coordinator #13 attempted an assessment at 3:45 PM. The resident declined to participate in the assessments. - On 10/14/22 at approximately 4 PM, activity aide #7 was notified by Resident #1's family, the resident was not in their room. The activity aide immediately notified RN Manager #1 and a search was initiated. - At approximately 4:14 PM, RN Manager #1 notified the Administrator, who immediately checked the cameras at the front door. Resident #1 was observed exiting the building at 4:09 PM. The Administrator immediately exited the building and proceeded down the driveway. - The Administrator observed the resident standing, then sitting on the steps (at an office building) adjacent to the end of the facility driveway and approached the resident at approximately 4:18 PM. - The resident refused to accompany the Administrator back to the building and stated go away leave me alone multiple times. - The Administrator called the facility to request assistance and activity aide #7, the Director of Social Work, ADON #8, as well as the resident's family member responded to the scene. - ADON #8 noted a left forehead hematoma as well as increased lethargy. - The resident was brought back to the facility by vehicle and brought to their room for evaluation. Emergency medical services (EMS) were notified, and the resident was transferred to the hospital. During an interview with licensed practical nurse (LPN) #3 on 10/19/22 at 4:30 PM, they stated when Resident #1 was admitted , the LPN and RN Manager #1 took the resident to their room and did the skin assessment. The resident said they did not want to be there and was non-compliant with much of the assessment. The LPN told the CNAs the resident wanted to go home. The LPN left shortly before 3 PM and was not present when RN Manager #1 attempted to place the Wanderguard. During an interview with certified nursing assistant (CNA) #2 on 10/19/22 at 4:37 PM, they stated on 10/14/22 upon starting their shift at 3:00 PM, they were told by LPN #3 the resident was a wander risk and was saying they did not want to be at the facility. CNA #4 was covering the unit with CNA #2. They were the only 2 CNAs and RN Manager #1 was on the medication cart. At the beginning of the shift, they stopped in Resident #1's room and saw them with PA #11. The CNA did not observe the resident to be walking about the unit or in their room and saw the resident seated in their recliner. The CNAs were working together doing rounds for approximately 45 to 60 minutes. CNA #2 heard from the nurse the resident's family was visiting and could not locate the resident. The CNA searched the floor. The CNA stated they could not recall if they were told the resident refused to have the Wanderguard placed. The CNA stated they were not instructed to supervise the resident or ensure their location as they began rounds but they were made aware the resident was an elopement risk. During a telephone interview with the resident's family member on 10/20/22 at 10:23 AM, they stated they arrived at the facility on 10/14/22 to visit the resident at approximately 4:00 PM, spoke to RN Manager #1 about the resident's resistance to wear the Wanderguard and was going to talk to the resident about it. The family member did not see the resident in their room and asked a staff member and they began to look for the resident. The relative was alerted the resident was found outside and met the Administrator down the hill from the facility where the resident was found. The resident was on the steps of a building and the relative noticed a large bump on the side of the resident's head. The resident could not state what happened and the relative initially thought the resident was angry and refusing to talk to them. The relative then noticed the resident's eyes shifted to the left and they were barely comprehending as to what was being said. The resident passed away in the hospital on 10/19/22 from a subdural hematoma (brain bleed). During a telephone interview with CNA #4 on 10/20/22 at 10:41 AM, they stated they worked with CNA #2 at the beginning of the evening shift (3 PM-11 PM) on 10/14/22 and began rounds. They arrived at Resident #1's room and PA #11 was with the resident. The CNA was told the resident was a new admission and was a wander risk prior to starting rounds. They provided care to another resident, upon completion the CNA then saw PA #11 and RN Manager #1 talking and heard them discuss the issue with not being able to place the Wanderguard on the resident. The resident was sitting in their recliner watching television and the CNA continued to do rounds. They were not made aware of any specific instructions and saw multiple staff in and out of the resident's room, as they were all working on the admission assessment. They heard around 4:00 PM, the resident was not in their room. They had not seen the resident wandering or getting up and did not hear them say anything about wanting to leave. The CNA assisted in the unit search. During an interview with RN Manager #1 on 10/20/22 at 11:55 AM, they stated they knew the resident was at risk for elopement upon admission, based on chart review and the hospital record. The resident arrived at approximately 2:15 PM and the RN Manager did their admission assessment. The resident became combative when the RN Manager attempted to place the Wanderguard and the RN Manager attempted to reapproach multiple times, spent time building rapport with the resident and offered a variety of diversional activities. The RN Manager did not try to get other staff to place the Wanderguard because they knew the resident had not participated in the evaluations with physical and occupational therapy, the RN/MDS Coordinator, the social worker and thought the resident would not allow them to place the device either. The RN Manager discussed the issue with PA #11, and they decided to let the resident adjust to the surroundings and try again in 15 to 30 minutes. The resident was sitting calmly in their recliner watching television. Since admission, the resident held onto a shopping bag containing personal items like books and personal care items, so the RN Manager placed a Wanderguard in the bag as an option until they could reapproach. When the resident's family arrived at 4:00 PM, the RN Manager spoke to them about the resident's refusal to wear the Wanderguard and asked for assistance. The family stated they would talk to the resident and see the RN Manager before they left. It was then they noted the resident was no longer in their room and the search began. The RN Manager told CNAs #2 and 4 the resident was at risk for elopement and did not have a Wanderguard on, and it was placed in their bag. The RN Manager also added that to the RCR which was in the resident's room. The RCR included care instructions and would be updated as different disciplines completed evaluations and the resident was observed. There was no time for any other updates prior to the resident leaving. The RN Manager did not provide any specific directives to the CNAs related to ongoing supervision or frequency of checking on the resident. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and interview during the recertification survey conducted [DATE]-[DATE], the facility failed to store food in accordance with professional standards for food service safety for 3 of 5 kitchenettes (1B, 3B, and 4B kitchenettes) reviewed. Specifically, there were undated and outdated foods stored in the 1B, 3B, and 4B kitchenettes. Findings include: The facility policy Foods Brought in for Residents revised ,d+[DATE] documented upon receipt of food brought in for residents by family, food items were labeled with resident name and date received. Food refrigerated in the facility kitchenettes must be labeled with resident's name and date received. Food could be held in the facility refrigerator up to 3 days (i.e., received on [DATE] must be consumed by the end of [DATE]) for cold and hot foods, after which foods will be discarded. The ,d+[DATE] Kitchen/Floor Sanitation Inspection form included a section for kitchenettes which documented Resident snack fridge: no outdated items. From [DATE] to [DATE], this section was initialed as being completed for the 1B, 3B, and the 4B kitchenette. The following observations were made in the kitchenettes: - on [DATE] at 10:48 AM, the 4B kitchenette refrigerator had an undated bowl of beans and an undated bowl of potatoes. - on [DATE] at 11:15 AM, the 3B kitchenette refrigerator had an undated chunk of fudge wrapped in tinfoil, butter wrapped in plastic dated [DATE], and sour cream inside a small plastic container that had a use by date of [DATE]. - on [DATE] at 1:38 PM, the 1B kitchenette refrigerator had an opened package of cheese with a use by date of [DATE]. - on [DATE] at 12:57 PM, the 3B kitchenette refrigerator had a block of unopened cheese with no use by date. The bottom of the cheese package had a sticky debris and was stuck to the bottom of the shelf. During an interview on [DATE] at 4:11 PM, the Food Service Director stated that the dietary staff should check the kitchenette refrigerators each day during their shifts, and the Food Service Director would try to check the refrigerators on resident units 2 to 3 days a week. The kitchenette refrigerators were last checked two weeks ago, and this had not been documented. The Food Service Director stated that staff had been trained to check, rotate, or discard outdated food. They stated that that it was not acceptable for undated or outdated food to be kept in kitchenette refrigerators. Resident food items in the refrigerators expired after 3 days, and most food items would have a use by date. They stated that kitchenette refrigerators should be cleaned daily and deep cleaned weekly, and the sticky debris in the 3B kitchenette refrigerator was not acceptable. During an interview in [DATE] at 10:56 AM, food service worker #22 stated that the food service workers and hospitality staff would check the expiration of the food in the kitchenettes each morning before their shift was over. They stated they floated and had worked all four floors of the facility. Each day they were responsible for both sides of one resident floor. Food service worker #22 stated that the expiration dates would be determined by checking the date on the packet of food or the date written on food, which would be the 3 day expiration date after the food had been opened. They stated that resident foods were also labeled with a 3 day open date and should be dated by food service workers or by the staff that was given the food to put away. When the food expired it should be thrown out, this was not documented, and the residents were made aware if their food was discarded. They stated resident food was checked for expiration dates so residents would not get sick. During an interview on [DATE] at 11:06 AM, hospitality aide #23 stated they always put expiration stickers on food items that had a 3 days open date. When dietary staff brought the juices and milks to the kitchenettes, they should be putting the dates on those items. Hospitality aide #23 stated they would check the food in the kitchenettes daily and was responsible for working both sides of the 3rd floor. They stated that the facility food sticker dates were 3 days from the date a food item was opened. They would also look at the food product's expiration date. If a food item in the kitchenette was found to be expired but not opened it would be sent back to the kitchen. If the food was opened the food would be thrown out. They stated the same stickers were used for resident personal foods, which had the same 3 day limitation. Resident families were made aware of the 3 day expiration policy when the food was brought in. They stated they would make the nurse aware of outdated resident food, toss the food into a garbage container, and then let the kitchen staff know about any of the expired food products from the kitchen. They stated that residents would be notified about the expiration day of their food and made aware the food would be discarded if not eaten that day. They stated they checked for expired foods because they would not want a resident to eat something that was spoiled, and possibly get sick. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification survey conducted 6/21/22-6/24/22, the facility failed to ensure a resident's right to personal privacy of accommodations and personal care for 1 of 1 resident reviewed (Resident #13). Specifically, Resident #13 had a video monitor in their room which transmitted live video of the resident to the nursing station and the facility did not obtain the resident's or the resident representative's consent for video monitoring. Findings include: The facility policy Photography, Video, and Audio Recording reviewed 12/16/21, documented the facility prohibited the use of any type of recording or photography during procedures or when staff was providing care to residents. Resident #13 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/18/22 Minimum Data Set (MDS) documented the resident had moderately impaired cognition, and required extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident's Admission Agreement packet dated 6/13/18 and electronically signed by the resident documented all patients, staff, providers, volunteers, and visitors were entitled to their privacy. Taking photos, voice recordings, or videos that included others without their consent was prohibited. The comprehensive care plan (CCP) initiated 10/22/21 documented the resident was at risk for falls. The CPP did not include the use of a video for resident monitoring. A nursing progress note dated 6/6/22 at 7:37 AM documented the resident was found face down in their room on the floor. Two certified nurse aides (CNAs) had just provided care minutes earlier. The provider and family member were notified. The resident was assessed and transferred back to bed with a mechanical lift and the bed was moved for resident safety. There was no documentation a plan for video monitoring of the resident was in place or was planned. The resident care instructions dated 6/17/22 documented the resident was a fall risk, had enabler bars, and was to be encouraged to sit in common areas when out of bed. The instructions did not include video monitoring. There was no documented evidence the resident or the resident's representative consented to and agreed upon the placement of video monitoring in the resident's room. During an observation on 6/23/22 at 10:11 AM, Resident #13 was in their bed, fully clothed, and was being prepared for a wound treatment to their sacrum (lower back near the buttocks). A video camera was observed on the resident's dresser pointed directly at the bed. CNA #14 stated it was there because the resident had attempted to climb out of bed 3 times in the past month. CNA #14 stated that the nurse was able to observe the resident from the nursing station. CNA #14 unplugged the monitor and continued to prepare the resident for the wound treatment. During an observation on 6/23/22 at 1:36 PM, a video monitor at the Unit 2 nursing station showed the resident lying in bed with their eyes closed. The monitor was in plain sight on the desk in the nursing station. There were no staff present in the nursing station. The nursing station's door was open and the room had windows with vision lines into the dining room. The monitor was visible from the hall when passing by the nursing station. During an interview on 6/23/22 at 1:18 PM, the resident's representative stated the facility notified them promptly of any incidents or falls. They were aware of falls in the past few weeks. The last time they visited they noticed the bed up against the wall and a mat on the floor next to the bed. They did not notice a video monitor and had not been asked to consent for use of a video monitor. On 6/23/22 at 1:38 PM the resident did not respond when asked about the camera in their room. During an interview on 6/23/22 at 1:23 PM, CNA #16 stated the resident was at risk for falls. Fall interventions included the bed rails were up, a low bed, a fall mat, and a video camera to monitor the resident if they tried to get out of bed. They stated the camera was relatively new, and they were not aware of any special instructions about its use. They explained that it was technically a baby monitor. The CNA stated they had not been instructed to unplug or move the camera during care. During an interview on 6/23/22 at 1:23 PM, CNA #15 stated the resident was a fall risk and interventions included siderails up, a fall mat on floor, and a video camera that was placed in the room after the last fall. The resident moved their legs out of bed frequently, and the camera was used to keep an eye on the resident. The video camera was monitored at the nursing station, and they were not given special directions for use of the camera during care. They stated the resident did not speak much and was unsure if they could understand camera use. They were not sure how long the camera had been in use. During an interview on 6/23/22 at 1:28 PM, CNA #14 stated the resident was a fall risk. Interventions included a low bed with fall mats, and a baby monitor to watch the resident if they tried to get out of bed. The screen was at the nursing station, and had been in use for about 2 weeks. Staff were supposed to make sure it was off or facing away from the resident during care. It was important to protect the privacy of residents. CNA #14 stated they were not aware of other residents using cameras at this time. During an interview on 6/23/22 at 1:42 PM, LPN (licensed practical nurse) #13 stated the resident was at risk for falls. They had a couple of falls in the past month, and interventions included a fall mat, and a baby monitor to keep an eye on the resident. Staff were to make sure the resident was positioned in the center of the bed, provide frequent checks, and make sure the baby monitor was on and focused on the bed. LPN was not sure if it was on the care plan, or who put the intervention in place. The resident's level of understanding varied. There were no instructions given to make sure the camera was not on during care to provide resident privacy. The video monitor could be watched by the nurse when at the nursing station. During an interview on 6/23/22 at 1:52 PM, registered nurse (RN) #4 Unit Manager stated they were not aware of the video monitor in resident's room. The regular Unit Manager for Unit 2 was out on leave, and RN #4 was helping as able. They stated they were not sure who put the video monitor in the room. Any video should have a consent and the care plan should be updated. During an interview on 6/23/22 at 1:57 PM, the Director of Nursing (DON) stated the 2nd floor RN Unit Manager had been out since May 31st. They stated they were new to the facility and thought the video monitors had been used in the past. They thought they were used when the COVID unit was open. The video camera was there to keep an eye on the resident for fall prevention. Care plans should be updated with current interventions in use. The DON was not sure who had placed the video monitor, or when it had been initiated. During a telephone interview on 6/23/22 at 3:31 PM, the Unit 2 RN Unit Manager stated the resident was considered a fall risk, they could turn themself over and roll. Interventions included frequent checks and changes, low bed, and the call bell in reach. Prior to 5/31/22 there were no recent falls and no video monitor in use. Video baby monitors had been used on the COVID unit to help keep an eye on residents at risk for falls. They did not think families were notified, or consents were obtained. They had educated staff verbally about maintaining privacy by turning the video off or away from the resident during care. There was no CCP, written consent or staff education regarding use of video monitors. 10 NYCRR 415.3(d)(1)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY 453, NY 650, NY 645, NY 873, NY 209, NY 251) conducted 6/21/22-6/24/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 6 residents (Resident # 120) reviewed. Specifically, Resident #120 was not provided incontinence care in a timely manner as care planned. Findings include: The facility policy Standards of Care- Activities of Daily Living (ADLs) reviewed 12/14/21, documented each resident shall receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care. Residents would be assisted to keep clean, neat, and well groomed. Resident #120 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/7/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was totally dependent for all activities of daily living (ADLs) and was always incontinent of bowel and bladder. The comprehensive care plan (CCP) initiated 12/9/21 documented the resident required total assistance with transfers and mobility related to motor vehicle accident, [CONDITION(S)], and contractures of upper extremities. Interventions included keep the bed against the wall, check resident every 2 hours and change incontinence brief as needed, total assistance with bed mobility, and turn and position every 2 hours. The resident care record (RCR) dated 6/1/22 documented bowel and bladder incontinence and to check and change every 2 hours and as needed. The resident required total assistance for transfers, bed mobility, and dressing. The following observations of Resident #120 were made: -on 6/24/22 at 8:46 AM the resident was in bed with their eyes closed and was not dressed from the waist up. -on 6/24/22 at 9:43 AM certified nurse aides (CNAs) #20 and #21 entered the resident's room to provide morning care. They stated they were unsure when the resident had last been provided incontinence care. The incontinence brief was saturated with urine, the 2 bed protectors and the bed sheet were wet. The bed protectors were wet up to the resident's shoulders. The CNAs stated the resident should have been checked and changed every 2 hours. During care the resident was washed and dried, a clean brief was applied, the resident was dressed, and transferred to their chair via a mechanical lift. CNA documentation of care for 6/24/22 documented the resident had been incontinent of bladder on the night shift with care occurring between 10 PM and 6 AM. There was no documented incontinence care on the day shift on 6/24/22. During an interview on 6/24/22 at 9:43 AM, CNA #20 stated they came in that morning at 5 AM. Resident #120 was on their assignment, and this was the first care they had provided for the resident. The CNA stated care instructions were in the closet on the RCR. The resident was supposed to receive incontinence care every 2 hours, or more frequently as needed. This was the first opportunity they had to provide care to resident since the beginning of their shift. They stated if the resident remained in a wet brief, it was probably uncomfortable for the resident, and not good for their skin. During an interview on 6/24/22 at 9:43 AM, CNA #21 stated they had come in at 6 AM. This was the first care they had provided to Resident #120 that morning. The resident was supposed to be checked and changed every 2 hours. The care instructions could be found in the closet. During an interview on 6/24/22 at 10:11 AM, licensed practical nurse (LPN) #7 stated they were familiar with the resident, and they helped with care as needed. Incontinent residents should be checked and changed every 2 hours and more frequently if needed. Resident #120 was totally incontinent and required total assistance with all care. They stated the resident should not be left wet or soiled due to possible skin issues, or discomfort. During an interview on 6/24/22 at 10:24 AM, registered nurse (RN) Unit Manager #4 stated staffing usually consisted of 4 CNAs on days, 3-4 CNAs on evenings, and 2 CNAs on nights. Nurses and hospitality aides helped, and resident needs were met. Incontinent residents should be checked and changed every 2 hours. Care instructions were found on RCR in closets and were kept updated by LPNs and signed off by the RN Unit Manager. The resident should not be left in wet briefs due to risk for altered skin integrity. 10NYCRR 415.12(a)(3)

Based on observation, record review and interview conducted during the recertification and abbreviated surveys (NY 839), it was determined for 2 of 6 residents (Resident #12 and 14) reviewed for falls, the facility did not provide adequate supervision to prevent accidents for Resident #14 and did not ensure Resident #12's environment was free of accident hazards. Specifically, when Resident #14, identified to be at risk for falls, was left unattended in the bathroom, she fell and fractured her neck; the physician was not notified and the resident expired as a result of the fall. This resulted in actual harm that is not immediate jeopardy to Resident #14. When Resident #12 had several falls associated with his recliner chair, the facility did not ensure the recliner chair was assessed for the resident's safe use to prevent recurrent falls. Findings include: 1) Resident #14 had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The Minimum Data Set (MDS) assessment signed as complete on [DATE], documented the resident's cognition was severely impaired, she required extensive assistance with most activities of daily living (ADLs) including ambulating and toileting, and had an impairment to one side of her upper extremity. The MDS documented the resident required hearing aids and oxygen therapy, and did not record the resident used any mobility devices. The comprehensive care plan (CCP), dated [DATE], documented the resident was at risk for falls, as she transfers herself on occasion and due to generalized weakness. Interventions included to ambulate the resident to the bathroom every 2 hours and as needed, with rolling walker and gait belt per PT (physical therapy) recommendations; try to anticipate her needs; and keep her call light within reach at all times. The resident care record (care instructions), dated [DATE], documented the resident was alert with confusion. She was a fall risk, utilized a bed and chair alarm, had a ,[DATE] side rail, and a low bed. The care record specified the resident was to be ambulated with the assistance of one person three times a day. The care record did not document that the resident was independent in her ambulation (left blank). It did specify the resident was to be toileted every 2 hours, used a rolling walker and gait belt for transfers, with 1 person assistance. The box indicating the resident could be left alone in the bathroom was blank. RN progress notes, dated [DATE] at 7:36 PM, recorded the resident was yelling out and found on the floor in the bathroom. The RN assessed the resident at that time. The resident denied hitting her head. The RN found no lumps or redness on the resident's head, and noted the resident was able to move her head freely to the left and did not move it well to her right. No redness was noted to her back or buttocks and the resident freely moved her left arm and both legs. LPN notes, dated [DATE] at 8:08 PM, 8:28 PM, and 9:09 PM recorded the resident's neurological checks, with her pupils equal and reactive and motor reactions appropriate. On [DATE] at 9:56 PM, LPN notes recorded the resident was resting at that time with no complaints voiced when she was awakened. A very small abrasion was observed on her upper thigh. At 10:47 PM on [DATE], neurological checks revealed pupils and and motor reaction were appropriate. At 1:20 AM on [DATE], LPN notes specified the resident had a 5 out of 10 pain level. (Tylenol was given at that time.) No neurological checks were documented in these nursing notes at that time. On [DATE] at 4:28 AM, the RN documented staff heard the resident yell out. When they went into her room, they found her lips cyanotic on 2 liters of oxygen via nasal cannula, and she was mouth breathing. The resident's oxygen saturation rate was decreased lying down, oxygen saturation rate was 70%. Staff assisted the resident upright in bed and were instructed to start oxygen at 12 liters via mask. Vital signs included: Temperature was 99.2 degrees F.; blood pressure was ,[DATE]; pulse was 115; respirations were 42; and blood glucose level was 327. The resident was noted to be diaphoretic. The RN called the MD and was told to send the resident to the emergency room . When the ambulance arrived at 4:25 AM, the resident had stopped breathing and was pronounced at 4:33 AM. A Summary of Investigation, dated [DATE], regarding the resident's fall of [DATE] at 7:05 PM, was signed as completed by the Director of Nursing (DON). This Summary included the Incident Details Report, witness statements, and the DON conclusion, including: - An undated witness statement, signed by the unit's charge licensed practical nurse (LPN) #14, specified she found the resident on the bathroom floor, with her wheel chair tipped over on top of her legs at approximately 7:05 PM. She noted she removed the wheel chair from the resident, and called for staff assistance and the nursing supervisor. Certified nurse aides (CNAs) were obtaining the resident's vital signs and a pillow was placed under the resident's head, as the RN supervisor arrived. - The RN supervisor's Incident Report Statement, dated [DATE] at 3:11 AM, and sent via email, described the incident after her arrival to assess the resident on the bathroom floor. The RN supervisor documented the residnet may have been using the wheel chair to ambulate with or pull herself up. The resident was then assisted off the floor via Hoyer lift with the assistance of 3 staff. The RN noted CNA #16 was instructed to support the resident's head. The resident was positioned in bed without difficulty. The RN documented that CNA #16 reported to charge LPN #17 that the resident was in the bathroom alone at the time of her fall, as she had to leave the unit to respond to a fire alarm sounding in the assisted living facility. - When the Director of Maintenance was interviewed on [DATE] at 11:22 AM, he stated there was fire alarm activity in the assisted living building adjacent to the skilled nursing facility on [DATE] at 6:25 PM. From these timelines, it appears the resident was left alone in the bathroom from 6:25 PM until she was found on the floor at approximately 7:05 PM. - The RN supervisor's Incident Report Statement, dated [DATE] at 3:11 AM, also documented the Care card checked - resident alone in bathroom. Care plan was followed. There was no documented rationale how the RN supervisor made the determination that the resident's care plan was followed. The most recent care record dated [DATE] (see above) did not specify that the resident was to be alone in the bathroom. That section was left blank. - The DON's Summary of Investigation specified after the RN assessment, the resident was assisted off the floor per mechanical lift and 2 person assistance. The Summary recorded the resident had a history of [REDACTED]. The DON documented the resident did not require constant supervision while in the bathroom, per her care plan. This DON's summary did not address the RN supervisor's email statement that was 9 days after the resident's fall; did not address the 40 minutes (approximately) the resident was left alone in the bathroom by CNA #16, as she reported to LPN #17; and did not address the lack of interviews of CNA #16 or LPN #17 to determine whether the resident could be left alone in the bathroom for that extended period of time. The undated physician discharge summary documented the resident had been doing well up until the night she fell . The resident's cause of death on [DATE] was determined to be a cervical fracture, secondary to blunt force trauma from a fall that was sustained when the resident tried to get up and go to the bathroom. A death certificate dated [DATE] documented the resident's time of death was 4:33 AM on [DATE] and the immediate cause of death was a cervical vertebra two fracture, as a consequence of blunt force trauma from a fall. During an interview with certified nurse aide (CNA) #15 on [DATE] at 8:15 AM, she stated if a resident was a fall risk and required a bed and chair alarm, she would know that by reviewing the resident's care record. She stated residents who were a fall risk would not be left alone in the bathroom. She stated she was familiar with the resident and on [DATE] when she arrived at work, she was notified the resident fell and there were some questions regarding the CNA actually reporting to the LPN the resident was in the bathroom by herself. She stated the resident was not supposed to be left alone in the bathroom, as she was very unsteady on her feet, and was known to frequently try to transfer herself to the bathroom. During an interview with the RN Manager #8 on [DATE] at 9 AM, she stated residents at risk to fall were identified on the resident care record. She stated she could not recall if the resident was a risk to fall, or if she was safe to be left alone in the bathroom; it would be documented on her care record. RN Manager #8 stated if a resident fell , and there was no injury, the physician did not need to be notified. During an interview with RN #10 Supervisor on [DATE] at 10:15 AM, she stated she completed an assessment on the resident after the fall. There were no obvious injuries and the resident did not complain of any pain. She stated the resident had been care planned to be left alone in the bathroom. She stated she reviewed the resident care record and determined the resident was allowed to be in the bathroom by herself. She stated she could not recall if the resident was a fall risk, or if she utilized a bed or chair alarm. During an interview with LPN #14 on [DATE] at 11:45 AM she stated while she was passing medications on the evening [DATE], she heard a very loud bang and she found the resident on the floor of her bathroom with the wheel chair on top of her. She stated she could not recall if the resident was at risk to fall and when the resident was toileted staff usually waited outside the bathroom door for her as she had a history of [REDACTED]. 2) Resident #12 had [DIAGNOSES REDACTED]. The [DATE] fall risk assessment documented the resident was a high risk for falling. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was moderately impaired, he had no falls and he required one-person physical assistance with transfers and mobility. The [DATE] resident care record (direct care instructions) documented the resident was independent with transfers and ambulation; was a fall risk; and had a low bed for safety. The comprehensive care plan (CCP), updated on [DATE], documented the resident was at risk for falls related to losing his balance often. Interventions included non-skid footwear, call light within reach, following the care record as recommended, and instructing resident to call for assistance before attempting to transfer. The [DATE] at 3:30 PM Incident Report documented the resident was found on the floor in his room, with his back leaning against his recliner. The resident had no injuries; he was independent with ambulation and transfers; and the care plan was followed. The resident stated he slid out of the recliner. The [DATE] at 3:35 PM physical therapy (PT) note documented a quarterly screen was completed for the resident. The note documented that per nursing, the resident no longer ambulated, he only transferred from his recliner to the wheel chair, and a PT evaluation would be requested to upgrade his transfer status and for positioning in the recliner. The [DATE] at 5:09 AM Incident Report documented the resident was found seated on the floor in front of his recliner. The resident had no injuries; was assisted back into his recliner; and when he leaned forward to adjust his blanket, the recliner began to tilt. There was no documented evidence of immediate interventions to prevent recurrence. The [DATE] at 2:28 PM PT note documented the resident was seen for a transfer evaluation. His plan changed to: non-ambulatory, stand pivot transfer from wheel chair to recliner; and one assist from bed to wheel chair. There was no documented evidence the resident's recliner was assessed to determine if it was safe for his continued use. The [DATE] at 10:50 PM Incident Report documented the resident was found on the floor in front of his recliner and there were no injuries. Interventions included a PAC alarm (alarming device clipped to clothing) and the resident would be monitored every 15 minutes through the night. The [DATE] at 6:07 AM nursing progress note documented the resident slept in his recliner; it tipped forward with every small movement; and he had to be pulled up from the bottom few inches of the chair multiple times. The note documented the situation was reported to the supervisor as unsafe, and the nurse manager and assistant nurse manager were emailed regarding the issue. The updated [DATE] resident care record documented the resident had a PAC alarm; was non ambulatory; and required one assist to stand pivot to the wheel chair or side chair. On [DATE] at 4:40 PM, the resident was observed in his room seated in the recliner. The recliner was fully reclined and he was adjusting the blankets on his legs. On [DATE] at 10:10 AM, registered nurse (RN) #10 Supervisor stated in an interview that when she assessed the resident on [DATE] she: - found the recliner tipped forward; the foot rest was extended and touching the floor; the resident slid out; and was seated on the footrest; - checked the function of the recliner and the foot rest retracted without issue; - when the resident scootched down in the chair, and the foot rest was extended, the chair was like a slide; and - she discussed the issue with the Unit Manager. She did not know if the resident's use of the chair had been assessed for safety. On [DATE] at 10:25 AM, RN #3 Manager stated in an interview she did not recall RN #10 speaking with her on [DATE]. She stated PT evaluated the resident on [DATE] and recommended elevating his legs in the recliner. She stated the resident refused to sleep in the bed and when the resident fell from his recliner on [DATE], a PAC alarm was initiated. She stated she did not feel any other changes needed to be made to the plan of care, as multiple interventions were implemented prior. She stated the resident's recliner was never switched out for a different model. On [DATE] at 11 AM, PT #9 Supervisor stated in an interview that on [DATE], she assessed the resident's transfer status and the wounds on his feet, and recommended his feet be elevated in his recliner. She stated she was only aware the resident fell from the recliner on [DATE], and if she had she been aware of the other falls, she would had assessed the chair for safety. 10NYCRR 415.12(h)(1)