Every finding on record at Smithtown Center for Rehabilitation & Nursing Care

Based on observation, Record review, and staff interviews during the Abbreviated Survey (Intake ID: 2682221) initiated on 01/21/2026, the facility did not ensure that each resident's Comprehensive Care Plan was revised by the interdisciplinary team after each assessment to reflect the resident's current status. This was identified for one (1) resident (Resident #2) of three (3) residents reviewed for Siderails. Specifically, Resident #2's Comprehensive Care Plan was not revised to reflect the discontinuation of the residents siderails.Based on observation, Record review, and staff interviews during the Abbreviated Survey (Intake ID: 2682221) initiated on 01/21/2026, the facility did not ensure that each resident's Comprehensive Care Plan was revised by the interdisciplinary team after each assessment to reflect the resident's current status. This was identified for one (1) resident (Resident #2) of three (3) residents reviewed for Siderails. Specifically, Resident #2's Comprehensive Care Plan was not revised to reflect the discontinuation of the residents siderails.The findings are:The facility's Policy and Procedure titled, Bed Rails with a revision date of November 2025 documented the facility would strive to provide a safe sleeping environment for residents with or without the use of bed rails. When the Interdisciplinary Care Plan Teams believed a bed rail reduction was warranted for a resident, the Director of Rehabilitations or designee, would initiate a Bed Rail Assessment. If therapy deemed the resident may benefit with a bed rail reduction, the facility would utilize the care planning process to facilitate the removal of the bed rails.The facility's Policy and Procedure titled, Comprehensive Care Plans with a revision date of January 2025 documented the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan will be developed within seven (7) days after the completion of the comprehensive assessment. Care plans are updated on any as needed based on any occurrences and changes that are relevant to the residents' care.Resident #2 had diagnoses that included primary generalized osteoarthritis (when the cartilage that lines your joints are worn down or damaged and your bones rub together when you use that joint), idiopathic peripheral automimic neuropathy (nerve damage where the cause is unknown), and type 2 diabetes.Resident #2's minimum data set assessment dated [DATE] documented Resident #2 had a Brief Interview of mental status score of 13 indicating intact cognition, did not utilize a bed rail, and required partial/moderate assistance with bed mobility and chair/bed-to-chair transfer.Resident #2's Comprehensive Care Plan Titled Falls initiated on 10/08/2024 and revised on 12/29/2025 documented Resident #2 was at risk for falls due to bilateral (both sides) above the knee amputations. Interventions included but were not limited to therapy evaluation and treat as ordered and to encourage the residents to utilize the side rails to promote bed mobility.A Physician's Order dated 09/24/2025 documented Resident #1 to use two (2) 1/2 side rails for enablers.Resident #1's Physician's Order for two (2) 1/2 side rails for enablers was discontinued on 10/20/2025.An Occupational Therapy Progress Note dated 10/20/2025 documented Resident #2 was screened by rehabilitation for the removal of bed siderails to maintain asafe environment and promote overall quality of life. The information was reviewed on a collaborative basis with the interdisciplinary team regarding the assessment for removal of bilateral bed siderails. An Occupational Therapy Progress Note documented upon assessment, the resident demonstrated the ability to perform functional bed mobility tasks without the need or use of bed siderails and requiring extensive assistance of one person. The determination has been made for bilateral bed siderails to be removed with the interdisciplinary team in agreement to proceed with the removal process.During two observations on 01/21/2026 at 11:57 AM and 01/22/2026 at 9:26 AM Resident #2 did not have side rails on their bed.During an interview on 01/21/2026 at 11:57 AM, Resident #2 stated they were evaluated by the facility for their need for side rails and the facility then removed them. Resident #2 stated they could not recall the exact date they were removed but it was over one month ago.During an interview on 01/22/2026 at 2:57 PM, the Director of Nursing Services stated if a resident is assessed to no longer need the side rails, then the Comprehensive Care Plan should be updated to reflect the change.10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review and interviews during an abbreviated survey (Intake ID: 2682221) initiated on 01/21/2026, the facility did not ensure that the designated representative was notified when the need to discontinue a treatment was identified. This was identified for one (1) resident (Resident #3) of three (3) residents reviewed for Notification of Change. Specifically, Resident #3's two half siderails were removed without notification to designated representative as required. Based on observation, record review and interviews during an abbreviated survey (Intake ID: 2682221) initiated on 01/21/2026, the facility did not ensure that the designated representative was notified when the need to discontinue a treatment was identified. This was identified for one (1) resident (Resident #3) of three (3) residents reviewed for Notification of Change. Specifically, Resident #3's two half siderails were removed without notification to designated representative as required. The finding is: The facility's Policy and Procedure titled, Physician Orders with a revision date of January 2025 documented the resident and/or designated representative will be updated of any medication/treatment changes. Resident #3 had diagnoses that included Dementia, Alzheimer's disease, and lack of coordination. Resident #3's minimum data set assessment dated [DATE] documented Resident #3 had a Brief Interview of mental status score of four (4) indicating a severe cognitive impairment, did not utilize a bed rails, required supervision or touching assistance for bed mobility, and set up assistance for chair/bed-to-chair transfer. A Physician's Order dated 09/06/2025 documented Resident #3 was to utilize two (2) 1/2 side rails for bed mobility. Resident #3's Comprehensive Care Plan titled Activities of Daily Living initiated on 10/06/2025 documented Resident #3 utilized two (2) 1/2 side rails to enable bed mobility. An Occupational Therapy Progress Note dated 10/16/2025 documented Resident #3 was screened by rehabilitation for the removal of bed siderails to maintain a safe environment and promote overall quality of life. Resident #3's Physician's Order dated 10/16/2025 documented to discontinue the two (2) 1/2 side rails for bed mobility. There was no documented evidence that Resident #3's designated representative/power of attorney was notified of the decision to remove Resident #3's side rails. During an observation on 01/22/2026 at 11:58 AM Resident #3 was observed in bed without side rails on their bed. During an interview on 01/22/2026 at 11:58 AM, Resident #3's designated representative/power of attorney stated they were not informed of the removal of the side rails until they arrived to visit Resident #3, and a staff person was in the process of removing the side rails. The designated representative/power of attorney stated they should have been informed as they would have liked to have been part of the decision-making process. During an interview on 01/22/2026 at 2:06 PM, the Director of Rehabilitation stated they assessed Resident #3 for the removal of side rails. The Director of Rehabilitation stated they did not inform Resident #3's designated representative/power of attorney because the nurses on the unit were responsible for notifications. During an interview on 01/22/2026 at 2:57 PM, the Director of Nursing Services stated if there was a change in a resident's treatments or nursing interventions the designated representative should have been informed. 10 NYCRR 415.3(f)(2)(ii)(d)

Based on record review and interviews during the Abbreviated Survey initiated on 01/21/2026, the facility did not ensure the Minimum Data Set assessment was completed accurately and reflected each resident's status. This was identified for one (1) resident (Resident #2) of three (3) residents reviewed for Activities of Daily Living. Specifically, Resident #2's Annual Minimum Data Set assessment dated [DATE] documented Resident #2's functional ability as needing substantial/maximal assistance with putting on and taking off footwear. Resident #2 had bilateral (both sides) above the knee amputations and did not utilize footwear. Based on record review and interviews during the Abbreviated Survey initiated on 01/21/2026, the facility did not ensure the Minimum Data Set assessment was completed accurately and reflected each resident's status. This was identified for one (1) resident (Resident #2) of three (3) residents reviewed for Activities of Daily Living. Specifically, Resident #2's Annual Minimum Data Set assessment dated [DATE] documented Resident #2's functional ability as needing substantial/maximal assistance with putting on and taking off footwear. Resident #2 had bilateral (both sides) above the knee amputations and did not utilize footwear. The findings were: The facility's policy titled Minimum Data Set Assessments dated March 2025 documented all residents will have a comprehensive assessment. The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Resident #2 had diagnoses that included Orthopedic aftercare following bilateral above the knee surgical amputation, Type 2 diabetes mellitus, and primary generalized osteoarthritis. Resident #2's Comprehensive Care Plan for Activities of Daily Living dated 11/08/2025 documented Resident #2 had a selfcare deficit related to physical limitations due to two (2) above the knee amputations and Primary generalized osteoarthritis. Resident #2's Annual Minimum Data Set assessment dated [DATE] documented Resident #2 had a Brief Interview of Mental Status score of 13 indicating an intact cognition. Resident #2 had lower extremity impairments on both sides, used a wheelchair for mobility and did not use limb prosthesis. Resident #2's functional abilities assessment documented the ability to sit to stand and walk 10 feet was not applicable/not attempted. The Minimum Data Set assessment documented Resident #2 required substantial/maximal assistance to put on and take off footwear. During an observation and interview on 01/21/2026 at 11:57 AM, Resident #2 was observed in bed with their legs covered by a blanket. Resident #2 stated they did not have legs. Resident #2 pulled back the blanket covering their lower body and they were observed to be missing the portions of their left and right legs below their mid-thighs. Resident #2 stated they did not utilize prosthetic devices for their legs. During an interview on 01/23/2026 at 3:11 PM, Occupational Therapist #1 stated they completed the Annual Minimum Data Set assessment for Resident #2. Occupational Therapist #1 stated Resident #2 had bilateral above the knee amputations and did not utilize prosthetics. Occupational Therapist #1 stated Resident #2 did not use footwear and they incorrectly documented that Resident #2 needed substantial/maximal assistance with footwear, and they (Occupational Therapist #1) should have documented not applicable instead. During an interview on 01/23/2026 at 3:15 PM, the Director of Rehabilitation stated Resident #2's Minimum Data Set was not completed accurately. The Director of Rehabilitation stated Resident #2 did not use footwear due to bilateral above the knee amputations. The Director of Rehabilitatin stated the Minimum Data Set documentation should be an accurate assessment of the resident. During an interview on 01/23/2026 at 3:42 PM, the Director of Nursing Services stated if a resident does not utilize footwear due to bilateral above the knee amputations, then it should be accurately documented during the Minimum Data Set assessment. 10 NYCRR 415.11(b)

Based on observations, record reviews, and staff interviews, during the Recertification Survey and Abbreviated Survey (NY 00375290) initiated on 4/23/2025 and completed on 4/29/2025, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. This was identified for one (Resident #203) of five residents reviewed for Respiratory Care. Specifically, Resident # 203 was admitted on [DATE] and did not receive all their inhaler medications as ordered until 3/9/2025. The finding is: The facility policy and procedure titled Pharmacy Vendor Services, updated in January 2025, documented that medication/treatments will be supplied by the pharmacy. Medications/treatments will be obtained from the [contracted] Pharmacy in accordance with the policies and procedures outlined in this manual. Should any problems arise with the pharmaceutical services provided, the contact person will be the Supervising Pharmacist at the [contracted] Pharmacy. Medication/treatments may be obtained from an alternate Pharmacy provided that the Pharmacy can provide medication/treatments in accordance with all facility policies and procedures and State and Federal codes, rules, and regulations. Resident #203 was admitted with diagnoses that include Bronchiectasis ( a chronic lung condition where the airways become permanently damaged and widened, leading to a buildup of mucus and increased risk of infection), Respiratory Failure, and Chronic Obstructive Pulmonary Disease. The Minimum Data Set assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) was 15, which indicated intact cognition. The resident was on Oxygen therapy and had shortness of breath. The admission physician's orders dated 3/6/2025 included to administer the following medications: - Symbicort 160 microgram-4.5 microgram/actuation Hydrofluoroalkane (HFA) aerosol inhaler, 2 puffs by inhalation route, 2 times per day for Chronic Obstructive Pulmonary Disease - Ventolin Hydrofluoroalkane (HFA) 90 micrograms/actuation aerosol inhaler, 1 puff by inhalation route, every 6 hours as needed for shortness of breath - Tudorza Pressair 400 micrograms/actuation breath activated, 1 puff (400 micrograms) by inhalation route, every 12 hours for Chronic Obstructive Pulmonary Disease. The Comprehensive Care Plan dated 3/7/2025 for Respiratory care documented the Resident had an alteration in respiratory status related to Asthma, Bronchiectasis, Chronic Obstructive Pulmonary Disease, Pneumonia, and Respiratory Failure. Interventions included to administer medications as per the physician's orders. The physician's history and physical dated 3/9/2025 documented that Resident #203's primary concern was difficulty breathing, and the resident requested their inhalers. The Physician documented the resident had a complex Pulmonary history, including Chronic Obstructive Pulmonary Disease and Pneumonitis secondary to Keytruda therapy (discontinued more than four months ago) for lung cancer, which is now in remission. Resident #203 required 3 liters of Oxygen therapy at baseline but reported worsening breathing difficulties yesterday (3/8/2025). The Physician documented that the resident had diminished breath sounds in bilateral lungs, and mild wheezing (caused by narrowed or blocked airways in the lungs) was noted bilaterally. A review of the Medication Administration Record dated March 2025 documented that Symbicort, Ventolin, and Tudorza were not administered to the resident on 3/6/2025. The initial administration of Ventolin was provided to the resident on 3/7/2025. The initial administration of Symbicort and Tudorza Pressair was on 3/9/2025. The Medication Administration Record documented that Symbicort and Tudorza Pressair were not administered on 3/6/2025 because the facility was awaiting pharmacy. A review of the medical record revealed the resident was discharged on 4/11/2025. During an interview on 4/28/2025 at 11:00 AM, Licensed Practical Nurse #7 stated they were assigned to Resident #203 on 3/7/2025, and the resident's Symbicort and Tudorza Pressair inhalers were not available in the facility. Licensed Practical Nurse #7 stated they notified the Pharmacy and the Physician that the medications were not received. Licensed Practical Nurse #7 stated they administered the Ventolin inhaler, which was delivered by the Pharmacy, because the resident had difficulty breathing. Licensed Practical Nurse #7 stated they did not document the administration of the Ventolin inhaler. Licensed Practical Nurse #7 stated it took a few days for the facility to receive the Symbicort and the Tudorza Pressair inhalers. Licensed Practical Nurse #7 stated the resident was alert and oriented and was okay with receiving the Ventolin inhaler instead of the Symbicort and Tudorza Pressair inhalers due to unavailability of the two inhalers. During an interview on 4/28/2025 at 12:55 PM, Pharmacist # 1 stated Resident #203's physicians' orders were received by the Pharmacy on 3/6/2025 at 8:06 PM, including Tudorza Pressair, Symbicort, and Ventolin. Pharmacist # 1 stated the facility was contacted on 3/6/2025 at 11:28 PM, and Registered Nurse #5 was notified that Tudorza and Symbicort required authorization and clearance because of the high cost of the medications. Pharmacist # 1 stated on 3/7/2025, the Pharmacy received authorization from the facility to deliver Tudorza Pressair, and the medication was delivered to the facility at 5:21 PM on 3/7/2025. Pharmacist # 1 stated on 3/8/2025 at 2:22 PM, the authorization to deliver Symbicort was received by the Pharmacy, and the medication was delivered to the facility on 3/8/2025 at 10:14 PM. During an interview on 4/29/2025 at 2:15 PM, Registered Nurse #5 stated the facility did not have Resident #203's inhaler medications on 3/6/2025. Registered Nurse #5 stated the Pharmacy called, requesting authorization from the facility to dispense the medications. The Physician was made aware of the Pharmacy request that same evening. Registered Nurse #5 stated Symbicort and Tudorza Pressair inhalers are not kept at the facility for emergency use. During an interview on 4/29/2025 at 12:06 PM, Physician #1 stated they did not recall any authorization requests for Resident #203's inhalers from the Pharmacy. Physician #1 stated the resident should have received the inhaler medications timely otherwise, the resident could experience an exacerbation of the Chronic Obstructive Pulmonary Disease. During an interview on 4/29/2025 at 2:15 PM, the Director of Nursing Services was interviewed and stated the facility could have obtained the medications from a local pharmacy if the inhaler medications were not in stock. The Director of Nursing Services stated the Pharmacy makes deliveries twice daily, after midnight and around 4:00 PM. The resident was admitted around 5:45 PM on 3/6/2025 and should have received their medications that same day by 12:00 AM. The Director of Nursing Services stated the Physician should be notified when an authorization is required for the Pharmacy to deliver certain medications. The Director of Nursing Services stated it is the Registered Nurse Supervisor's responsibility to ensure the resident receives their medications as ordered. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/23/2025 and completed on 4/29/2025, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #61) of two residents reviewed for Pressure Ulcers. Specifically, Resident #61 was at high risk for pressure ulcer development and had a physician's order to use an air mattress to prevent skin breakdown. During observations on 4/23/2025, the resident was in bed, and the air mattress weight setting was not consistent with the resident's weight. The finding is: The facility's policy titled Support Surface Guidelines, effective 1/2025, documented that air mattresses will be checked every shift for function, placement, and setting for the resident's comfort level per physician order. The undated Operation Manual for the air mattress documented determine the resident's weight and set the control knob to that weight setting on the control unit. Resident #61 was admitted with diagnoses including Hemiparesis affecting the right dominant side, Encephalopathy, and Aphasia. The Minimum Data Set assessment dated [DATE] documented that the resident had short and long term memory problems and severely impaired cognitive skills for daily decision making. The resident was at risk for developing pressure ulcers and was dependent on staff members for bed mobility and positioning. The resident did not have any pressure ulcers. A Braden Scale (a scale for determining pressure ulcer risk), dated 5/20/2024, documented a score of 11, indicating the resident was at high risk for pressure ulcer development. A physician's order dated 2/21/2025 documented an order to use an Air Mattress. A physician's order dated 4/23/2025 documented Air Loss Mattress, check function and settings on (alternating and weight correct), weight 150-200. A review of the resident's medical record revealed that as of 4/2/2025, the resident's weight was 169.6 pounds. During an observation on 4/23/2025 at 9:54 AM, Resident #61 was observed in bed. The weight setting on the air mattress control unit was set at 320 pounds. During a second observation on 4/23/2025 at 3:20 PM, Resident #61 was not in bed, and the weight setting on the air mattress was maintained at 320. A review of the Treatment Administration record for April 2025 revealed Licensed Practical Nurse #2 signed at 10:30 AM that the air mattress was set to the correct setting (150- 200 pounds). During an interview on 4/23/2025 at 3:20 PM, Licensed Practical Nurse Coordinator #1 stated that the air mattress weight setting was not in accordance with the physician's orders and the setting should be changed to the proper setting of 150-200 pounds. During an interview on 4/28/2025 at 11:20 AM, Licensed Practical Nurse # 2 stated they observed the resident at approximately 11:00 AM on 4/23/2025, and the air mattress weight setting was between 150 to 200 pounds. Licensed Practical Nurse # 2 stated that the physician's order indicates that the air mattress weight setting should be 150 to 200 pounds. Licensed Practical Nurse # 2 stated they could not explain why the air mattress was set to 320 pounds at 9:54 AM and 3:20 PM on 4/23/2025. During an interview on 4/24/2025 at 9:43 AM, Wound Care Registered Nurse #1 stated they are responsible for checking air mattress settings weekly, but the nurses on the day shift are also responsible for ensuring the air mattress weight setting is correct. Wound Care Registered Nurse #1 stated that the proper weight setting helps prevent skin breakdown. Wound Care During an interview on 4/29/2025 at 2:25 PM, Wound Care Nurse Practitioner #1 stated that the weight setting of the air mattress should correspond with the resident's weight to prevent wound development and to assist in wound healing. Wound Care Nurse Practitioner #1 stated that if the air mattress is too firm, the resident would be at risk for wound development. During an interview on 4/24/2025 at 9:49 AM, the Director of Nursing Services stated the nurses should ensure the air mattress weight setting is correct and corresponds to the resident's weight. 10 NYCRR 415.12(c)(1)

Based on observations, record reviews, and staff interviews, during the Recertification Survey and Abbreviated Survey (NY 00375290) initiated on 4/23/2025 and completed on 4/29/2025, the facility did not ensure pharmaceutical services were provided to meet the needs of each resident and that medications were administered to residents in a timely manner as ordered by the physician. This was identified for one (Resident #203) of five residents reviewed for Respiratory Care. Specifically, Resident # 203, with diagnoses of Chronic Obstructive Pulmonary Disease and Lung Cancer remission, did not have all prescribed inhaler medications available in the facility until three days after the resident was admitted to the facility. Cross Reference: F695 Respiratory/Tracheostomy Care and Suctioning. The finding is: The facility policy and procedure titled Pharmacy Vendor Services, updated in January 2025, documented that medication/treatments will be supplied by the pharmacy. Medications/treatments will be obtained from the [contracted] Pharmacy in accordance with the policies and procedures outlined in this manual. Should any problems arise with the pharmaceutical services provided, the contact person will be the Supervising Pharmacist at the [contracted] Pharmacy. Medication/treatments may be obtained from an alternate Pharmacy provided that the Pharmacy can provide medication/treatments in accordance with all facility policies and procedures and State and Federal codes, rules, and regulations. Resident #203 was admitted with diagnoses that include Bronchiectasis ( a chronic lung condition where the airways become permanently damaged and widened, leading to a buildup of mucus and increased risk of infection), Respiratory Failure, and Chronic Obstructive Pulmonary Disease. The Minimum Data Set assessment dated [DATE] documented that the resident's Brief Interview for Mental Status (BIMS) was 15, which indicated intact cognition. The resident was on Oxygen therapy and had shortness of breath. The admission physician's orders dated 3/6/2025 included to administer the following medications: - Symbicort 160 microgram-4.5 microgram/actuation Hydrofluoroalkane (HFA) aerosol inhaler, 2 puffs by inhalation route, 2 times per day for Chronic Obstructive Pulmonary Disease - Ventolin Hydrofluoroalkane (HFA) 90 micrograms/actuation aerosol inhaler, 1 puff by inhalation route, every 6 hours as needed for shortness of breath - Tudorza Pressair 400 micrograms/actuation breath activated, 1 puff (400 micrograms) by inhalation route, every 12 hours for Chronic Obstructive Pulmonary Disease. The Comprehensive Care Plan dated 3/7/2025 for Respiratory care documented the Resident had an alteration in respiratory status related to Asthma, Bronchiectasis, Chronic Obstructive Pulmonary Disease, Pneumonia, and Respiratory Failure. Interventions included to administer medications as per the physician's orders. The physician's history and physical dated 3/9/2025 documented that Resident #203's primary concern was difficulty breathing, and the resident requested their inhalers. The Physician documented the resident had a complex Pulmonary history, including Chronic Obstructive Pulmonary Disease and Pneumonitis secondary to Keytruda therapy (discontinued more than four months ago) for lung cancer, which is now in remission. Resident #203 required 3 liters of Oxygen therapy at baseline but reported worsening breathing difficulties yesterday (3/8/2025). The Physician documented that the resident had diminished breath sounds in bilateral lungs, and mild wheezing (caused by narrowed or blocked airways in the lungs) was noted bilaterally. A review of the Medication Administration Record dated March 2025 documented that Symbicort, Ventolin, and Tudorza were not administered to the resident on 3/6/2025. The initial administration of Ventolin was provided to the resident on 3/7/2025. The initial administration of Symbicort and Tudorza Pressair was on 3/9/2025. The Medication Administration Record documented that Symbicort and Tudorza Pressair were not administered on 3/6/2025 because the facility was awaiting pharmacy. A review of the medical record revealed the resident was discharged on 4/11/2025. During an interview on 4/28/2025 at 11:00 AM, Licensed Practical Nurse #7 stated they were assigned to Resident #203 on 3/7/2025, and the resident's Symbicort and Tudorza Pressair inhalers were not available in the facility. Licensed Practical Nurse #7 stated they notified the Pharmacy and the Physician that the medications were not received. Licensed Practical Nurse #7 stated they administered the Ventolin inhaler, which was delivered by the Pharmacy, because the resident had difficulty breathing. Licensed Practical Nurse #7 stated they did not document the administration of the Ventolin inhaler. Licensed Practical Nurse #7 stated it took a few days for the facility to receive the Symbicort and the Tudorza Pressair inhalers. Licensed Practical Nurse #7 stated the resident was alert and oriented and was okay with receiving the Ventolin inhaler instead of the Symbicort and Tudorza Pressair inhalers due to unavailability of the two inhalers. During an interview on 4/28/2025 at 12:55 PM, Pharmacist # 1 stated Resident #203's physicians' orders were received by the Pharmacy on 3/6/2025 at 8:06 PM, including Tudorza Pressair, Symbicort, and Ventolin. Pharmacist # 1 stated the facility was contacted on 3/6/2025 at 11:28 PM, and Registered Nurse #5 was notified that Tudorza and Symbicort required authorization and clearance because of the high cost of the medications. Pharmacist # 1 stated on 3/7/2025, the Pharmacy received authorization from the facility to deliver Tudorza Pressair, and the medication was delivered to the facility at 5:21 PM on 3/7/2025. Pharmacist # 1 stated on 3/8/2025 at 2:22 PM, the authorization to deliver Symbicort was received by the Pharmacy, and the medication was delivered to the facility on 3/8/2025 at 10:14 PM. During an interview on 4/29/2025 at 2:15 PM, Registered Nurse #5 stated the facility did not have Resident #203's inhaler medications on 3/6/2025. Registered Nurse #5 stated the Pharmacy called, requesting authorization from the facility to dispense the medications. The Physician was made aware of the Pharmacy request that same evening. Registered Nurse #5 stated Symbicort and Tudorza Pressair inhalers are not kept at the facility for emergency use. During an interview on 4/29/2025 at 12:06 PM, Physician #1 stated they did not recall any authorization requests for Resident #203's inhalers from the Pharmacy. Physician #1 stated the resident should have received the inhaler medications timely otherwise, the resident could experience an exacerbation of the Chronic Obstructive Pulmonary Disease. During an interview on 4/29/2025 at 2:15 PM, the Director of Nursing Services was interviewed and stated the facility could have obtained the medications from a local pharmacy if the inhaler medications were not in stock. The Director of Nursing Services stated the Pharmacy makes deliveries twice daily, after midnight and around 4:00 PM. The resident was admitted around 5:45 PM on 3/6/2025 and should have received their medications that same day by 12:00 AM. The Director of Nursing Services stated the Physician should be notified when an authorization is required for the Pharmacy to deliver certain medications. The Director of Nursing Services stated it is the Registered Nurse Supervisor's responsibility to ensure the resident receives their medications as ordered. 10 NYCRR 415.18(a)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/23/2025 and completed on 4/29/2025, the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. This was identified for one (Unit B Medication Cart) of three medication carts reviewed during the Medication Storage Task, and one (Resident #30) of five residents reviewed during the Medication Administration Task. Specifically, 1) the Unit B Medication Cart was observed containing five (5) unlabeled medication souffle cups with various unidentified medications in the top drawer of the cart. 2) Resident #30 was observed with three (3) eyedrop medications and a bottle of eye lubricant at their bedside during the Medication Administration Task. The findings are: 1) The facility policy titled Medication/Treatment Labeling and Storage, revised in January 2025, documented the purpose of this policy to enable the nursing staff to easily identify the medications/treatments for the residents and instructions for proper storage. Residents' medications/treatments are properly labeled by the pharmacy and are to be placed in the proper storage area, such medication room, supplies, and a clean utility room, treatment carts, or medication cart. All medications/treatments are to be stored in their original containers. The facility's Refused Medication policy, revised January 2025, documented that in the event a resident refuses to take a medication, the medication nurse will make every possible attempt to gain cooperation. The medication nurse will notify the unit coordinator or the supervising nurse of any such refusal of medication. The nurse will discard the medications, document the notification and the refusal in the progress note, and notify the doctor. During a medication storage task observation of the Unit B medication cart with Licensed Practical Nurse #5 on 4/25/2025 at 6:27 AM, the medication cart was observed containing five (5) unlabeled medication souffle cups with various unidentified medications in the top drawer of the cart. During an interview on 4/25/2025 at 6:35 AM, Licensed Practical Nurse #5, the medication nurse, stated they had worked on the Unit B for a long time, and they recognized each resident's medications by the medication's appearance. Licensed Practical Nurse #5 stated they stored the pre-dispensed medication cups in the medication cart because the five residents refused to take their morning medications. Licensed Practical Nurse #5 stated they intended to go back to the residents' rooms to administer the medications. Licensed Practical Nurse #5 further stated they did not write the resident's name or room number on the medication cups because they knew which medications went to which residents. During an interview on 4/25/2025 at 7:23 AM, Registered Nurse Supervisor #5 stated Licensed Practical Nurse #5 did not report the medication refusals to them. Registered Nurse Supervisor #5 stated that the nurses are not allowed to pre-pour the medications and store them in the medication carts because it could cause confusion or lead to a medication administration error. During an interview on 4/29/2025 at 10:16 AM, the Director of Nursing Services stated Licensed Practical Nurse #5 should have discarded the refused medications and notified the Nurse Supervisor. The Director of Nursing Services stated that nurses are not allowed to store the refused medications in the medication carts because doing so can lead to a medication administration error. During an interview on 4/29/2025 at 11:12 AM, the Administrator stated that Licensed Practical Nurse #5 should have followed the facility's medication refusal policy and medication storage policy. The Administrator stated Licensed Practical Nurse #5 should not have stored the refused medications in the medication cart. 44963 2) Resident #30 was admitted with diagnoses including Moderate Stage Glaucoma, Macular Degeneration, and Hypertension. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, indicating the resident had intact cognition. The Minimum Data Set assessment documented that the resident had adequate vision with corrective lenses. A physician's order dated 4/3/2025 documented to give Brimonidine 0.2% eye drop (medication to reduce eye pressure), instill one drop by ophthalmic route (through the eye) in the left eye every 12 hours for Open-Angle Glaucoma; to give Vyzulta 0.024% eye drop (medication to reduce eye pressure), instill one drop by ophthalmic route (through the eye) in each eye once daily at bedtime for Open-Angle Glaucoma; Difluprednate 0.05% eye drop (to treat eye pain, redness, and swelling), instill one drop by ophthalmic route (through the eye) in the right eye two times per day for Acute Atopic Conjunctivitis. The order for Difluprednate 0.05% eye drops was discontinued on 4/25/2025. During the Medication Administration observation on 4/25/2025 at 8:19 AM, Resident #30's medication administration was conducted with Registered Nurse #1. When Registered Nurse #1 attempted to administer Brimonidine eye drops medication ( that was stored in the medication cart), Resident #30 refused the eyedrops and stated they (Resident #30) had already self-administered the eyedrops earlier and did not want to receive a double dose of the medication. Resident #30 stated they store their eye drop medications in their room by the bedside. Resident #30 took out a labeled Ziploc bag from an unsecured top drawer of the bedside dresser. The Ziploc bag, labeled with Resident #30's name, room number, and a note Give to patient when discharged , contained four eyedrop bottles: Brimonidine Tartrate Ophthalmic 0.2% Solution, Vyzulta (Latanoprostene Bunod) Ophthalmic 0.024% Solution, Difluprednate Ophthalmic Emulsion 0.05% and Refresh Tears Lubricant Eye Drops. Registered Nurse #1 was immediately interviewed and stated they were not familiar with Resident #30 and did not know about the eyedrops. During an interview on 4/28/2025 at 1:36 PM, Registered Nurse #3, Unit Manager, stated they were not aware Resident #30 had kept eyedrops at the bedside. Registered Nurse #3 stated that the residents cannot keep and administer any medications unless evaluated for self-medication administration and a Physician's order is in place. Registered Nurse #3 stated the resident's medications should have been stored in the Medication Cart, and if the resident wanted and was approved for self-administration of the medications, then the resident should have been provided with a locked box to store the medications. During an interview on 4/29/2025 at 10:42 AM, Attending Physician #1 stated the resident should not keep and administer medications on their own unless they were evaluated. During an interview on 4/29/2025 at 12:25 PM, the Director of Nursing Services stated that residents should be evaluated for self-medication administration before they can store and administer medications on their own. The Director of Nursing Services stated that residents' medications should be stored in the Medication Cart. The Director of Nursing Services stated that once approved, medications at bedside must be stored in a locked box and out of other residents. The Director of Nursing Services stated that Resident #30 should not store medication at bedside without being assessed by the Interdisciplinary Care Team. 10 NYCRR 415.18(d)(e)(1-4)

Based on record review and staff interviews during the Recertification Survey initiated on 4/23/2025 and completed on 4/29/2025, the facility did not ensure that accurate Preadmission Screening for individuals with a mental disorder was accurately completed. This was identified for two (Resident #32 and #74) of 30 residents reviewed for the Pre-Admission Screen review. Specifically, Resident #32 and Resident #74 did not have a completed Level I Screen, Additionally, the screen did not accurately indicate the diagnosis of Dementia for both residents. The findings are: The facility's policy and procedure titled Pre-Admission Screen Annual Resident Review (PASARR), updated on 1/20/2025, documented the Pre-Admission process includes established criteria to determine admission eligibility. The Pre-Admission Screen Annual Resident Review form is reviewed prior to or at the time of admission, and an initial resident review of the Pre-Admission Screen Annual Resident Review must be completed once for every resident. 1) Resident #32 was admitted with diagnoses that included Vascular Dementia and Depression. The Admission Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview for Mental Status score was 11, which indicated moderate cognitive impairment. The resident was not considered by the State Level II Pre-Admission Screen Annual Resident Review process to have a serious mental illness, intellectual disability, or a related condition. A Review of Resident #32's Pre-Admission Screen dated 10/4/2024 revealed that the response to question #21 to determine the type of services the resident required was left blank. The response to question #22, which asks, Does this person have a dementia diagnosis (including Alzheimer's disease) documented in the medical record? indicated that the resident did not have a diagnosis of Dementia. 2) Resident #74 was admitted with diagnoses that included Vascular Dementia, Major Depressive Disorder, and Generalized Anxiety. The Minimum Data Set assessment dated [DATE] documented the resident's Brief Interview of Mental Status score as 3, which indicated the resident's cognition was severely impaired. The resident was not considered by the State Level II Pre-Admission Screen Annual Resident Review process to have a serious mental illness, intellectual disability, or a related condition. A Review of Resident #74's Pre-Admission Screen dated 5/7/2024 revealed that the response to Section #21 to determine the type of services the resident required was left blank. The response to question #22, which asks Does this person have a dementia diagnosis (including Alzheimer's disease) documented in the medical record? indicated that the resident did not have a diagnosis of Dementia. During an interview on 4/25/2025 at 3:10 PM, the Director of Admissions stated they were responsible for reviewing the Pre-Admission Screen for completion. The Director of Admissions stated they were not the Director of Admissions at the time of Resident #32's and Resident #74's admission to the facility. The Director of Admissions stated the screens should have been reviewed for completeness and accuracy. During an interview on 4/28/2025 at 2:52 PM, the Administrator stated that they would expect all residents to be admitted with a completed Pre-Admission Screen. The Administrator further stated that the Director of Admissions should contact the facility that provided the document to obtain a complete and accurate Pre-Admission screen form. 10 NYCRR 415.11(e)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 4/23/2025 and completed on 4/29/2025, the facility did not ensure that an infection prevention and control program designed to prevent the development and transmission of infection was maintained. This was identified for two (Resident #253 and Resident #254) of the three residents reviewed for Transmission Based Precautions. Specifically, Resident #253 had wounds with multi-drug drug-resistant organisms, and Resident #254 had a surgical wound. Both residents had physician orders for Enhanced Barrier Precautions for a wound. Certified Nursing Assistant #1 did not wash their hands after providing care to Resident #253 and then entered Resident #254's room. The findings are: The facility's policy and procedure for Enhanced Precautions revised 2/2025 documented that staff will utilize gloves and gowns for high-contact resident care activities that included bathing, showering, hygiene, grooming, dressing, transferring resident in room or shower or bathing area, changing linens, changing briefs or assisting with toileting, device care or use, wound care. The facility's hand washing policy and procedure, revised on 1/2025, documented that proper hand washing technique is used for the prevention of transmission of infectious diseases. The policy documented all personnel working in the long-term care facility are required to wash their hands before and after resident contact, before and after performing any procedure, after sneezing or blowing nose, after using the toilet, before handling food, after removing gloves, and when hands become soiled, i.e., contact with face, surfaces, resident and equipment. 1) Resident #253 was admitted with diagnoses that included Cellulitis (infection) of Left Lower Limb, Multidrug Resistance (MDR) Pseudomonas Aeruginosa, and Extended-Spectrum Beta-Lactamase (ESBL-enzymes produced by some bacteria that can make them resistant to certain antibiotics) of Left Lower Extremity Ulcer. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated intact cognition. The resident was at risk for developing pressure ulcers and had one venous and arterial ulcer present. A Physician's order dated 3/21/2025 documented Enhanced Barrier Precaution secondary to the wounds. A Comprehensive Care Plan dated 4/11/2025 documented the resident was placed on Enhanced Barrier Precautions related to the wounds. Interventions included to initiate Enhanced Barrier Precautions as ordered, monitor for signs and symptoms of infection, and laboratory workup as per the Physician's orders. 2) Resident #254 was admitted with diagnoses that included Right Total Hip replacement and Infected Right Hip Wound. A Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated intact cognition. The resident was at risk for developing pressure ulcers, had a surgical wound, and received surgical wound care. A Physician's order dated 4/24/2025 documented Enhanced Barrier Precautions for diagnoses of Right Hip Surgical Wound. A Comprehensive Care Plan dated 4/24/2025 documented the resident was placed on Enhanced Barrier Precautions related to wound and Peripherally Inserted Central Catheter. Interventions included to initiate Enhanced Barrier Precautions as ordered, monitor for signs and symptoms of infection, and laboratory workup as per the Physician's orders. During an observation on 4/28/2025 at 10:30 AM, Resident #253's room was observed with Enhanced Barrier Precautions signage outside the room. Certified Nursing Assistant #1 was observed in Resident #253's room doffing (removing) gloves and then discarding them in a red bin (bin used for biohazard waste) that was kept in the resident's room. After discarding the gloves, Certified Nursing Assistant #1 exited Resident #253's room without washing their hands. Certified Nursing Assistant #1 transported the hamper that contained soiled linen down the hall and placed the hamper outside Resident #254's room. There was an Enhanced Barrier Precaution signage outside Resident #254's room. Certified Nursing Assistant #1 was observed donning (putting on) a gown and a face shield without washing their hands, and then entered Resident #254's room. During an interview on 4/28/2025 at 10:30 AM, immediately after the observation, Certified Nursing Assistant #1 stated they were aware that both residents were on Enhanced Barrier Precautions and they should have performed hand hygiene after they had removed their gloves and before they exited Resident #253's room. Certified Nursing Assistant #1 further stated that before they enter another resident's room, they should have performed hand hygiene. During an interview on 4/28/2025 at 11:19 AM, the Infection Control Preventionist stated that staff should put on Personal Protective Equipment when performing high-contact tasks. The Infection Control Preventionist stated that after care for Resident #253, Certified Nursing Assistant #1 should have removed their gloves and performed hand hygiene. The Infection Control Preventionist stated that hand sanitizer is readily available, and the staff should have utilized the hand sanitizer before entering another resident's room. During an interview on 4/28/25 at 2:57 PM, the Director of Nursing Services stated Certified Nursing Assistant #1 should have washed their hands after taking off their gloves and before exiting Resident #253's room. The Director of Nursing Services stated that the Certified Nursing Assistant #1 should not have put on Personal Protective Equipment and entered another resident's room before washing their hands. 10 NYCRR 415.19(b)(4)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/23/2025 and completed on 4/29/2025, the facility did not ensure that services provided or arranged by the facility met the current professional standards of quality. This was identified for one (Unit B Medication Cart) of three Medication carts observed during the Medication Storage Task. Specifically, Licensed Practical Nurse #5 stored the unlabeled and unidentifiable pre-poured medications that were refused by five residents in the top drawer of the medication cart. Licensed Practical Nurse #5 stated they knew the medications by their appearance and intended to administer the medications to the residents at a later time. The finding is: The facility policy titled Medication/Treatment Labeling and Storage, revised in January 2025, documented the purpose of this policy to enable the nursing staff to easily identify the medications/treatments for the residents and instructions for proper storage. Residents' medications/treatments are properly labeled by the pharmacy and are to be placed in the proper storage area, such medication room, supplies, and a clean utility room, treatment carts, or medication cart. All medications/treatments are to be stored in their original containers. The facility's Refused Medication policy, revised January 2025, documented that in the event a resident refuses to take a medication, the medication nurse will make every possible attempt to gain cooperation. The medication nurse will notify the unit coordinator or the supervising nurse of any such refusal of medication. The nurse will discard the medications, document the notification and the refusal in the progress note, and notify the doctor. During a medication storage task observation of the Unit B medication cart with Licensed Practical Nurse #5 on 4/25/2025 at 6:27 AM, the medication cart was observed containing five (5) unlabeled medication souffle cups with various unidentified medications in the top drawer of the cart. During an observation on 4/25/2025 at 6:30 AM, Licensed Practical Nurse #5 took one of the unlabeled medication cups and proceeded to reapproach a resident (not in the sample) to administer the medications. Licensed Practical Nurse #5 was immediately interviewed and stated that they had worked on the same unit for a long time, and they recognized each resident's medications by appearance. Licensed Practical Nurse #5 stated they did not write the resident's name or room number on the medication cups because they knew which medications went to which residents. Licensed Practical Nurse #5 stated they stored the pre-dispensed medication cups in the medication cart because the five residents refused to take their morning medications. Licensed Practical Nurse #5 stated they intended to go back to the residents' rooms to administer the medications. During an interview on 4/25/2025 at 7:23 AM, Registered Nurse Supervisor #5 stated Licensed Practical Nurse #5 did not report the medication refusals to Registered Nurse Supervisor #5. Registered Nurse Supervisor #5 stated that the nurses are not allowed to pre-pour the medications and store them in the medication carts because it could cause confusion or lead to a medication administration error. During an interview on 4/29/2025 at 10:16 AM, the Director of Nursing Services stated that nurses are not allowed to pre-pour the medications or store the medications refused by the residents in the medication cart because doing so can lead to a medication administration error. During an interview on 4/29/2025 at 11:12 AM, the Administrator stated that Licensed Practical Nurse #5 should have followed the facility's policy for medication refusal and medication storage. The Administrator stated Licensed Practical Nurse #5 should not have stored the refused medications in the medication cart. 10 NYCRR 415.11(c)(3)(i)

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/23/2025 and completed on 4/29/2025, the facility did not ensure the right to self-administer medications. This was identified for one (Resident #30) of two residents reviewed for Skin Condition. Specifically, Resident #30 was self-administering their eyedrop medications by themselves. The resident was not assessed by the Interdisciplinary team and did not have a physician's order to self-administer their medications. The finding is: The facility's Self Administration of Medications policy and procedure, revised in January 2025, documented to permit bedside medications for residents when ordered by the Attending Physician. The Interdisciplinary Care Team shall review the resident's request to self-administer medication. There shall be a written order from the Attending Physician for the specific medication that can be self-administered by the resident. All medications shall be packaged in prescription containers and may be labeled with the term May keep at bedside. The medication shall be stored in a locked drawer or locked compartment under proper temperature conditions. The self-administration of medication shall be monitored by the day shift medication nurse. Resident #30 was admitted with diagnoses including Moderate Stage Glaucoma, Macular Degeneration, and Hypertension. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, indicating the resident had intact cognition. The Minimum Data Set assessment documented that the resident was able to understand and be understood, and had adequate vision with corrective lenses. A physician's order dated 4/3/2025 documented to give Brimonidine 0.2% eye drop (medication to reduce eye pressure), instill one drop by ophthalmic route (through the eye) in the left eye every 12 hours for Open-Angle Glaucoma; to give Vyzulta 0.024% eye drop (medication to reduce eye pressure), instill one drop by ophthalmic route (through the eye) in each eye once daily at bedtime for Open-Angle Glaucoma; Difluprednate 0.05% eye drop (to treat eye pain, redness, and swelling), instill one drop by ophthalmic route (through the eye) in the right eye two times per day for Acute Atopic Conjunctivitis. The order for Difluprednate 0.05% eye drops was discontinued on 4/25/2025. A nursing progress note written by Licensed Practical Nurse #4 dated 4/6/2025 documented that the resident refused eyedrops at bedtime (HS), stating they had already instilled their eye drops that they had with them. Resident was reminded that they cannot self-administer medications without approval from a Physician or supervision from nursing staff. The resident became agitated and did not want to give the eye drops they brought from home to the nurse (Licensed Practical Nurse #4). A nursing progress note written by Licensed Practical Nurse #4 dated 4/11/2025, 4/12/2025, 4/16/2025, and 4/21/2025 documented that Resident #30 continued to request to self-administer their eye drops; however, allowed the nurse to supervise and assist. During an interview and observation on 4/23/2025 at 11:42 AM, Resident #30 was observed with a red discoloration in the right eye. Resident #30 stated they were taking two different eye medications and a refresher for lubrication. Resident #30 stated they had Glaucoma diagnosis for a long time, and they had been self-administering the eye drops. The nursing staff was aware because the nurses were present when the resident administered the eyedrops. Resident #30 stated they were capable of administering their eyedrops as they have done in the community themselves for a long time. There was no documentation in the resident's medical record of an assessment, a comprehensive care plan, or a physician's order to self-administer medications. During the Medication Administration observation on 4/25/2025 at 8:19 AM, Resident #30's medication administration was conducted with Registered Nurse #1. When Registered Nurse #1 attempted to administer Brimonidine eye drops medication ( that was stored in the medication cart), Resident #30 refused the eyedrops and stated they (Resident #30) had already self-administered the eyedrops earlier and did not want to receive a double dose of the medication. Resident #30 stated they store their eye drop medications in their room by the bedside. Resident #30 took out a labeled Ziploc bag from an unsecured top drawer of the bedside dresser. The Ziploc bag, labeled with Resident #30's name, room number, and a note Give to patient when discharged , contained four eyedrop bottles: Brimonidine Tartrate Ophthalmic 0.2% Solution, Vyzulta (Latanoprostene Bunod) Ophthalmic 0.024% Solution, Difluprednate Ophthalmic Emulsion 0.05% and Refresh Tears Lubricant Eye Drops. Registered Nurse #1 was immediately interviewed and stated they were not familiar with Resident #30 and did not know about the eyedrops. A review of the physician's orders revealed there was no physician's order for the use of Refresh Tear Lubricant Eye Drop, and there was no physician's order to self-administer any medications. The Actual Vision Impairment care plan dated 4/4/2025 documented that Resident #30 exhibited vision impairment related to glaucoma and macular degeneration. The interventions included, but were not limited to: medicate as per Physician's orders and monitor for visual changes. A revised intervention dated 4/25/2025 documented resident may self-administer eye drops and keep the eye drops at the bedside. During an interview on 4/28/2025 at 1:36 PM, Registered Nurse #3, Unit Manager, stated they were not aware Resident #30 had kept eyedrops at the bedside. Registered Nurse #3 stated that the residents cannot keep and administer any medications unless evaluated for self-medication administration and a Physician's order is in place. Registered Nurse #3 stated the resident's medications should have been stored in the Medication Cart, and if the resident wanted and was approved for self-administration of the medications, then the resident should have been provided with a locked box to store the medications. Registered Nurse #3 stated that nurses should notify their supervisor if a resident requests to self-administer their medications. During a phone interview on 4/28/2025 at 7:21 PM, Licensed Practical Nurse #4, who wrote the nursing progress notes on 4/11/2025, 4/12/2025, 4/16/2025, and 4/21/2025, stated that on 4/6/2025, they became aware that Resident #30 was administering their own eyedrops. Licensed Practical Nurse #4 stated they educated Resident #30 that a nurse would apply the eyedrops while the resident was in the facility. Licensed Practical Nurse #4 stated the resident should not self-medicate without being evaluated. Licensed Practical Nurse #4 stated that while Resident #30 continued to assist during administrations of the eyedrops, Licensed Practical Nurse #4 did not inform their supervisor to evaluate the resident to self-administer the medications. During an interview on 4/29/2025 at 10:42 AM, Attending Physician #1 stated the resident must be evaluated by a nursing or medical provider before they can administer their own medications. Attending Physician #1 stated that they should be notified and a Physician order should be in place before the resident can store and apply their own eyedrop medications. During an interview on 4/29/2025 at 12:25 PM, the Director of Nursing Services stated that the resident must be evaluated for self-medication administration. The Director of Nursing Services stated that a Physician's order must be obtained, and a care plan should be developed for self-medication administration. The Director of Nursing Services stated that the resident must be educated and monitored to ensure the resident can safely self-administer the medications. 10 NYCRR 415.3(f)(1)(vi)

Based on record review and interviews during the Recertification Survey initiated on 2/21/2024 and completed on 2/27/2024, the facility did not ensure that the resident's Primary Care Physician comprehensively reviewed the resident's total program of care, including medications and treatments, and a decision about the continued appropriateness of the resident's current medical regimen. This was identified for one (Resident #52) of two residents reviewed for antibiotic use. Specifically, Resident #52 had a Physician's order to administer Xifaxan (an antibiotic that fights bacterial infection only in the intestines) for a prolonged period from 1/10/2024 until 2/27/2024. The physician's progress notes lacked documentation related to the prolonged use of and the reason for the antibiotic use. The finding is: A review of the policy and procedure titled, Physician Services dated 1/2024 documented that the medical care of each resident is under the supervision of a Licensed Physician. Residents are seen by their attending physician as indicated by their clinical condition. The resident's Attending Physician participates in the resident's assessment and care planning, monitoring changes in the resident's medical status and providing consultation or treatment when called by the facility. Physician orders and progress notes shall be maintained in accordance with current regulations and facility policy. The resident's attending physician reviews the resident's program of care, including but not limited to medications, treatments, laboratory reports, and consultation recommendations. Resident #52 has diagnoses that included Irritable Bowel Syndrome. The Minimum Data Set assessment dated [DATE] documented Resident #52 had a Brief Interview for Mental Status score of 13 which indicated intact cognition. The Comprehensive Care Plan dated 1/10/2024 for alteration in Gastrointestinal Status, was developed for Irritable Bowel Disease. The use of antibiotics was not reflected in the Comprehensive Care Plan. The Order Listing Report, date range:1/10/2024-2/27/2024, documented an active order to give Xifaxin 550 milligrams by mouth three times daily, without a stop date, for Irritable Bowel Syndrome. The Medication Administration Record dated January 10, 2024, through February 27, 2024, documented Resident #52 received Xifaxin 550 milligrams three times a day as per the Physician's orders. The facility was unable to produce an antibiotic tracking form from 1/10/2024 through 2/27/2024 for Resident #52's use of the antibiotic, Xifaxin. The Physician/Provider Progress Notes reviewed from 1/10/2024 through 2/27/2024 documented a diagnosis of Irritable Bowel Syndrome. The progress notes did not include an assessment of the use of the antibiotic Xifaxin. During an interview on 2/27/2024 at 2:33 PM with attending Physician #1, they stated the physician progress notes should have clearly documented the use of the resident's medication Xifaxin and this was an oversight. During an interview on 2/27/2024 at 2:36 PM, the Medical Director stated that the attending physician should have assessed the use of the medication Xifaxin and documented the rationale and the use of the medication in their progress notes. 10 NYCRR 415.15(b)(2)(iii)

Based on record review and interviews conducted during the Recertification Survey initiated on 2/21/2024 and completed on 2/27/2024, the facility did not implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for all residents receiving antibiotic therapy. This was identified for one (Resident #52) of two residents reviewed for antibiotic use. Specifically, Resident #52 was receiving Xifixan (an antibiotic) since 1/10/2024 for Irritable Bowel Syndrome prophylactically (prevention) without documented evidence to support its continued use, or appropriate indications for its continued use. Additionally, there was a lack of monitoring and tracking of Xifixan's use. The finding is: A review of the policy and procedure titled Antibiotic Stewardship Program dated 1/2024, documented that the Antibiotic Stewardship refers to a set of commitments and activities designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The policy included developing and maintaining a system to monitor antibiotic use, which includes reviewing antibiotic prescriptions for inclusion of dose, duration, and indication quarterly; and at least annually, reviewing antibiotic use data by the facility and by individual providers to determine if there is excessive use of specific antimicrobial agents. Resident #52 has diagnoses that included Irritable Bowel Syndrome. The Minimum Data Set assessment dated [DATE] documented Resident #52 had a Brief Interview for Mental Status score of 13 which indicated intact cognition. The Comprehensive Care Plan dated 1/10/2024 for alteration in Gastrointestinal Status, was developed for Irritable Bowel Disease. The use of antibiotics was not reflected in the Comprehensive Care Plan. The Order Listing Report, date range:1/10/2024-2/27/2024, documented an active order to give Xifaxin 550 milligrams by mouth three times daily, without a stop date, for Irritable Bowel Syndrome. The Medication Administration Record dated January 10, 2024, through February 27, 2024, documented Resident #52 received Xifaxin 550 milligrams three times a day as per the Physician's orders. The facility was unable to produce an antibiotic tracking form from 1/10/2024 through 2/27/2024 for Resident #52's use of the antibiotic, Xifaxin. The Physician/Provider Progress Notes reviewed from 1/10/2024 through 2/27/2024 documented a diagnosis of Irritable Bowel Syndrome. The progress notes did not include an assessment of the use of the antibiotic Xifaxin. During an interview on 2/27/2024 at 2:48 PM, the Infection Preventionist (IP)/Registered Nurse (RN) #2 stated they were responsible for tracking antibiotic use in the facility. Registered Nurse #2 stated they were not aware of any reports to monitor the resident's use of Xifaxin. Resident #52's antibiotic use was not monitored because it is a chronic medical condition to treat Irritable Bowel Syndrome. Antibiotics used in the absence of an infection are not monitored because there is no short-term acute infection. During an interview on 2/27/2024 at 2:33 PM with attending Physician #1, they stated the physician progress notes should have clearly documented the use of the resident's medication Xifaxin and this was an oversight. During an interview on 2/27/2024 at 2:36 PM, the Medical Director stated they would expect the Infection Preventionist to track antibiotic use. The Medical Director stated they review the facility tracking form for antibiotic use monthly at the Quality Assurance and Performance Improvement meeting for appropriateness of the antibiotic use. The Medical Director stated they try to limit the use of antibiotics to prevent Antibiotic resistance. Additionally, the Medical Director stated that although Xifaxin was an antibiotic, Xifaxin was being used to treat a medical condition and therefore was not being monitored under the antibiotic stewardship program. The attending physician should have assessed the use of the medication Xifaxin and documented the rationale and the use of the medication in their progress notes. During an interview on 2/27/2024 at 2:54 PM, the Director of Nursing Services (DNS) stated that antibiotics are to be reviewed monthly by the provider and the Infection Preventionist (IP). The Director of Nursing Services further stated that the Medical Director had not considered Xifaxin as an antibiotic, and the medication was not reviewed under the antibiotic stewardship program. During an interview on 2/27/2024 at 3:20 PM, the Pharmacy Consultant stated prophylactic antibiotic use should not be reviewed, or checked for appropriate dosing, or effectiveness because of it being used for a chronic condition. The Pharmacy Consultant stated the Infection Preventionist (IP) should be tracking and monitoring the use of residents on antibiotics. Additionally, the Pharmacy Consultant stated they would expect the facility to be tracking their antibiotics use monthly. 10 NYCRR 415.19(a)(1-3)

Based on observation, interviews, and record review, during an abbreviated survey (Complaint # NY00313651), the facility did not ensure that an allegation of abuse were reported immediately, but not less than 2 hours after the allegation is made if the events that caused the allegations involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the abuse do not involve abuse or do not result in serious bodily injury, to the New York State Department of Health (NYS DOH). This was evident in 1 (Resident #1) out of 3 residents reviewed for abuse. Specifically, Resident #1 reported that they were rough handled by a staff. The facility did not report the alleged allegation of abuse to the NYS DOH. The finding is: The facility's policy titled Abuse, Mistreatment, Neglect Investigation revised 11/2011 documented the facility will thoroughly investigate all incidents of alleged resident abuse, mistreatment or neglect in accordance to 2803D of the public health law. Reports of alleged resident's abuse, mistreatment or neglect with suspected validity will be reported to the NYS Department of Health. Should the investigation reveal that abuse/neglect occurred, the administrator would report such findings to the state-licensing agency within 24 hours of the determination that abuse/neglect or mistreatment has occurred. The facility's policy titled Abuse Mistreatment, Neglect, Misappropriation and Exploitation Prevention revised 11/2016 documented that report all alleged violations where there is reasonable cause to believe the abuse, neglect, mistreatment or misappropriation that has occurred in accordance with NYS DOH Nursing Home Incident Reporting manual. Resident #1 was admitted with diagnoses including Dementia, Parkinson's Disease and Malnutrition. The Minimum Data Set (MDS assessment tool) dated 2/14/2023 documented the resident with Brief Interview for Mental Status score of 12 indicating moderately impaired cognition. The Facility's Grievance Recommendation Referral Form dated 3/28/2023 documented that the resident reported aide is rough while they were providing care in the shower. The Social Worker (SW) #2 statement from the Grievance/Recommendation Referral Form dated 3/28/2023 documented that Resident #1 reported that staff are rough with them during showers. The Psychiatrist note dated 3/30/2023 documented that as per staff, they made several allegations of abuse. During an interview with the Director of Nursing (DON) on 3/30/2023 at 4:01 PM, they stated that on 3/28/2023, Resident #1 stated that an aide was throwing them around in the shower. Resident #1's complaint is an allegation of abuse. The facility will report such allegation (s) to the NYS DOH within 24 hours if the investigation reveal abuse. During an interview with the Administrator on 4/4/2023 at 1:19 PM, they stated that on 3/28/2023, Resident #1 reported that they were rough handled during a shower. Rough handling would be considered an allegation of abuse. It was not a reportable event. The facility would have reported the allegation on 3/28/2023 if the allegation was substantiated. 10 NYCRR 415.4 b (2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/18/2022 and completed on 4/22/2022, the facility did not ensure that each resident's right to personal privacy including medical treatment was maintained. This was identified for one (Resident #310) of one resident reviewed for privacy. Specifically, the Dentist was observed performing an oral examination for Resident #310 in the resident's room with the room door opened. The resident and the Dentist were both visible from the hallway while the Dentist was examining the resident's mouth. The finding is: The facility Policy and Procedure for Privacy dated 7/2005 documented the resident is to be treated with consideration, respect, and full recognition of his/her dignity and individuality, including privacy in treatment and care. Privacy is to be provided for residents while being examined and treated. Curtains are drawn while the resident is being examined or treated. Resident #310 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. During initial rounds on Unit C on 4/18/2022 at 11:25 AM while walking in the hallway towards Resident #310's room, the resident was observed sitting in a wheelchair at their bedside. The resident's room door was opened and the curtains were not drawn. The resident's mouth was observed opened and a Dentist was observed shining a light in the resident's mouth examining the resident's teeth and calling out concerns to their assistant who was also present in the resident's room and was taking notes. The resident and the Dentist were both visible from the hallway. Resident #310 was interviewed on 4/22/2022 at 12:45 PM and stated that staff providing privacy during care was very important to them (Resident #310). The resident stated that during the dental examination they (Resident #310) did not realize that the privacy curtains were not drawn. Resident #310 stated that they (Resident #310) would have wanted privacy had they realized the curtains were opened. A Comprehensive Care Plan (CCP) for Dental Care dated 5/16/2019 documented interventions including but not limited to referral to dental services yearly and as needed. The Dentist was interviewed on 4/18/2022 at 11:45 AM and stated they (Dentist) normally completed the resident's oral examinations with the room door open and did not think that not closing the room door would be a privacy issue. The Registered Nurse (RN) Manager was interviewed on 4/22/2022 at 12:06 PM and stated the Dentist usually conducted examinations in the resident's room. The RN stated that the Dentist should have ensured the resident had privacy before conducting the dental examination for Resident #310. The Director of Nursing Services (DNS) and the Administrator were interviewed concurrently on 4/22/2022 at 12:30 PM. The Administrator and the DNS both stated that the facility has a designated examination room where the Dentist could conduct their consultation, however, examinations were also conducted in the resident rooms. Both the Administrator and the DNS stated that the Dentist was expected to always provide privacy to residents during treatment and care by drawing the curtains. 415.3(d)(1)(ii)

Based on observation, record review and interview during the Recertification Survey initiated on 4/18/2022 and completed on 4/22/2022, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for 1 of 3 medication carts reviewed during the Medication Storage and Labeling Task. Specifically, 1) Resident #75's Ademelog insulin pen, 2) Resident #360's [MEDICATION(S)] insulin pen, and 3) Resident #119's Ademelog and [MEDICATION(S)] insulin pens were observed opened with no date indicating when the insulin pens were first opened. The finding is: The facility Medication/Treatment Labeling and Storage policy and procedure, last revised on 4/2016, documented that the facility shall maintain proper labels for medications. Insulin vials and pens must be dated when the first dose is administered. The expiration date is 28 days after the first administration. 1) Resident #75 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #75 did not receive insulin injections during the 7-day MDS lookback period. Resident #75's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Resident #360 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #360 was a new admission and the Admission Minimum Data Set (MDS) assessment was not completed during the recertification survey. Resident #360 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3) Resident #119 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #119 received insulin injections 7 of 7 days in the MDS lookback period. Resident #119's physicians' order dated 3/21/2022 and renewed 4/18/2022 documented [MEDICATION(S)] [MEDICATION(S)] U-100 Insulin [MEDICATION(S)] 100 unit/ml subcutaneous pen. Resident #119's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Unit D medication storage cart was reviewed with RN #2 on 4/22/2022 at 11:12 AM. In the top drawer, Resident #75's Ademelog insulin pen, Resident #360's [MEDICATION(S)], and Resident #119's Ademelog and [MEDICATION(S)] insulin pens were observed opened with no open date. RN #2 stated that they (RN #2) were unsure of how many days the insulin pens may be used after they are opened. RN #2 stated that Resident #75's, Resident #360's and Resident #119's insulin pens should all be dated because the insulin pens have to be discarded at some point. RN #2 stated that they (RN #2) did not open the pens during today's shift or any shift this week that they (RN #2) worked. RN #2 further stated that they do not know when the insulin pens were opened. The Facility Pharmacist was interviewed on 4/22/2022 at 11:37 AM. The Pharmacist stated that the Ademelog, [MEDICATION(S)], and [MEDICATION(S)] insulin pens are usable for 28 days once opened and stored at room temperature. The Pharmacist stated that it is the facility's responsibility to determine how the clinical staff will store and label insulin pens. The Director of Nursing Services (DNS) was interviewed on 4/22/2022 at 12:41 PM. The DNS stated that opened insulin pens can be stored on the cart and should be labeled with the date the pen was opened. The DNS stated that the insulin pens are usable for 28 days after opening and stored at room temperature. 415.18(d)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 4/18/2022 and completed on 4/22/2022 the facility did not ensure that a resident who enters the facility with an indwelling catheter was assessed for the need of the indwelling catheter and had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was identified for 1 (Resident #70) of 3 residents reviewed for Urinary Catheter. Specifically, Resident #70 was admitted to the facility with an indwelling Foley catheter on 4/6/22 without physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The finding is: The policy and Procedure for Catheter- Urinary and Suprapubic dated 7/1/2005 documented physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The orders should include catheter and balloon size. Inserted catheters are maintained by a licensed nurse following physician orders. Resident # 70 is a female that was readmitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severe cognitive impairment. The MDS assessment also documented the resident had an indwelling catheter. On 4/18/2022 at 2 PM and 4/20/2022 at 12:45 PM the resident was observed wearing a leg bag containing urine from an indwelling catheter. A review of the Nursing admission assessment dated [DATE] documented the resident had a 16 French 10 cubic centimeter (cc) catheter in place. A review of the readmission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The History and Physical (H&P) completed by the physician dated 4/6/2022 had not documented the resident utilized a catheter. The physician documented that the resident was continent and had urgency. A Comprehensive Care Plan (CCP) dated 4/06/2022 for Indwelling Catheter documented the resident has a potential for alteration in [CONDITION(S)] status related to [CONDITION(S)] ([CONDITION(S)]) and [CONDITION(S)]. Interventions included but were not limited to: assess for signs/symptoms (s/sx) of infection i.e.: Increased temperature, pain, drainage, educate resident/family on disease process and provide support, and treatments as per MD order. There were no interventions related to care of the urinary indwelling catheter or the urinary leg bag. A review of the April 2022 Treatment Administration Record (TAR) documented no treatments were provided for the catheter. A review of the April 2022 Resident Nursing instructions for the Certified Nursing Assistants (CNA), documented under the toileting section, that the resident had a Foley catheter. Licensed Practical Nurse (LPN) #1, who was the charge nurse, was interviewed on 4/20/2022 at 12:12 PM and stated that they (LPN #1) were not aware that the resident had a catheter. CNA #1 was interviewed on 4/20/2022 at 12:23 PM and stated the resident has a catheter. CNA #1 stated they (CNA#1) have been draining the resident's catheter every shift. The Physician was interviewed on 4/21/2022 at 12:20 PM and stated they (physician) depend on the admission nurse's assessment. The physician further stated if the resident was admitted with a catheter, there should be orders for the catheter. The physician stated they (physician) could not recall the H & P assessment they (physician) completed on 4/6/22. The physician further stated the resident has an obstruction and not [CONDITION(S)], as [CONDITION(S)] is a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Registered Nurse (RN) #1, who completed the Resident # 70's admission, was interviewed on 4/21/2022 at 12:52 PM and stated the wrong diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #1 stated an order should have been obtained for the foley catheter from the physician. 415.12(d)(1)

Based on record review, and interviews during the Recertification Survey initiated on 4/18/2022 and completed on 4/22/2022, the facility did not ensure that each resident had a person-centered care plan developed and implemented that includes measurable objectives and times frames to meet the resident's medical and nursing needs. This was identified for one (Resident #108) of two residents reviewed for vision and hearing. Specifically, Resident #108 was admitted to the facility with a hearing impairment. There was no documented evidence that a Comprehensive Care Plan (CCP) was developed to address the resident's hearing impairment. The finding is: Resident #108 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident had severely impaired cognition and the resident's hearing was highly impaired. The resident did not utilize any hearing appliance. An interview with Resident #108 was attempted on 4/19/2022 at 12:14 PM. Resident #108 was unable to hear the verbal greetings. The resident motioned the surveyor with a hand signal to enter the room and stated that they (Resident #108) could not hear. The resident was then interviewed by writing the questions on a note pad that was available on the residents overbed table. The resident further stated that they (Resident #108) were waiting for an audiology appointment. A 48 Hour Care Plan (baseline care plan) dated 3/4/2022 documented the resident was hearing impaired and had no devices. The intervention was to obtain an Audiology consult. A Comprehensive Care Plan (CCP) titled Communication dated 3/21/2022 was reviewed. The CCP did not include goals and or interventions to address the resident's hearing impairment. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Registered Nurse (RN) #3 who was the Unit Nurse Manager, was interviewed on 4/22/2022 at 11:47 AM and stated that the RN that completed the admission should have initiated the CCP. RN #3 stated if the admission RN was unable to complete the CCP the RN Manager should have initiated the required CCP. RN #3 acknowledged that the CCP for communication was incomplete and did not address the resident's hearing impairment including the goals and interventions. RN #3 stated that not completing the CCP was an oversight. RN #3 stated that there should have been a CCP developed to address the resident hearing status. The Director of Nursing Services (DNS) was interviewed on 4/22/2022 at 12:46 PM and stated that the admission RN was responsible for completing the admission assessment and that the assessment should have been completed within 24 hours. The DNS stated that an offsite RN initiates a 24-hour CCP for the new admissions and that by the following day the Comprehensive CCP was initiated by the RN Manager or any available RN. The DNS stated that a CCP for the resident's hearing impairment should have been initiated. 415.11(c)(1)

Based on observation and interviews during the abbreviated survey (NY 079), the facility did not ensure professional standards of quality was provided for 1 of 3 residents reviewed. Specifically, for Resident #1, the facility did not ensure the resident's hydration needs, including, labs and fluid intake were assessed and calculated by the dietician. This is evidenced by: The Policy and procedure dated July 1 2005 documented Labs- nutritional implications- it is the responsibility of the dieticians to monitor resident labs and respond to those that have a nutritional implication .The procedure included the dietary department Reviews admission labs if indicated as a part of dietary assessment. The dietitian reviews the labs as indicated and respond to those with a nutritional implication. Responses to labs are handled on an individual basis. Labs and responses are noted in the medical record on the progress notes and the dietary section as indicated. Resident # 1 admitted [DATE] has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set, dated dated dated [DATE] documented the resident's cognitive status as severely impaired Brief Interview For Mental Status(BIMS- 5), totally dependent on staff with two person assist for transfers and toilet use , on locomotion on unit, extensive assist of staff for bed mobility and dressing,. The resident required only setup help for eating meals and had no impairment to functional Limitation in Range of Motion. The resident is non- ambulatory and was always incontinent of bowel and bladder. The Comprehensive Care Plan (CCP) dated 01/13/2021 documented Resident is at risk for altered nutrition status and malnutrition related to treatment in the hospital for [CONDITION(S)] of left foot, difficulty walking. Resident is morbidly obese. Goals included, to have no signs/symptoms (s/s) of dehydration. Interventions Consistency: Ground, Diet Dietitian consult as needed, Feed status: set-up, Liquid consistency: Thin liquids, monitor fluid consumption, Monitor food consumption, Monitor tolerance to diet consistency, Monitor weights as per MD order. A Dietary note dated 1/13/21 documented: Resident is 78year old admitted to this facility after treatment in the hospital for left foot [CONDITION(S)], difficulty walking .Current diet: salt/fat restricted, ground, thin liquids. Food allergies: nuts, shellfish. Weight not obtained on admission. Noted weight in hospital was 216 pounds (lbs). Monitor weights and food and fluid intake. The Weight record on 1/19 documented a weight of 213 pounds(lbs) and a weight on 1/26 documented a weight of 213.6 pounds. The History and Physical (H and P) completed by the physician on 1/13/21 documented inadequate nutrition and recommended vitamins. The resident labs for the resident was : 1/15- Blood Urea Nitrogen (BUN)-22mg/dl, Creatinine -1.20; Na-(sodium)- 136, K(potassium)- 5; 1/20- BUN- 17mg/dl, Cr-1.34; 1/27- BUN 24 mg/dl, Creatinine 1.23, NA- 139, K- 5; 2/1- BUN 32 mg/dl, Creatinine- 1.25, NA- 146, K- 4.5; 2/5- BUN 46 mg/dl, Creatinine1.63, NA- 167, K- 4.8 . Normal Values of BUN is 8-20mg/dl, Creatinine MG/DL 0.44-1.03, NA- MMOL/L 136-144, K- MMOL/L 3.6-5.1. The Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nursing Note (NN) dated 2/5/21 at 1:55 pm documented resident noted with increased lethargy this shift, noted with poor po intake given lethargy, 1/2 NS @ 60cc/hr infusing in Right FA. Reviewed worsening labs with physician and residents decline, BUN 46/Creatnine 1.63, Sodium 167 While Blood Count (WBC) 11.2. A NN dated 2/06/2021 at 8:06 pm documented as per ER patient was admitted on [DATE] at 22:58, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Certified Nurse Assistant (CNA) Documentation Record for January 2021- documented some days the resident consumed less than 1000 cc per day, notably, on January 16th, 18th, 22nd, 23rd, 25th, 28th, 29th . The Resident CNA Documentation Record for February 2021, notably, from [DATE]st - 5th documented the resident intake of fluids less than 500 cc /day. The Dietician was interviewed on 3/22/21 at 3:05 PM and stated she was not aware of the resident's labs. She further stated she have not reviewed the resident's labs nor was she made aware of any abnormal BUN/Creatinine/Sodium/Potassium levels. The resident was receiving 1020 cc/day from her tray plus a water jug is left at bedside. She stated the daily fluid intake was not calculated because she didn't have an admission weight. On 3/23/21 at 2:41 PM, the dietitian further stated that she was not aware the CNA's documented fluid intake per shift for the resident. The Director of Nursing Services (DNS) was interviewed on 3/22/20 at 4:00 PM and stated Nursing is not responsible to notify dietary regarding labs. This is the responsibility of the physician. If there is a concern, the physician should have notified dietary. Interdisciplinary daily meetings report and discuss issues that come up in the facility. The Medical Director was interviewed on 3/23/21 at 1:43 AM and stated the dietary consult is important to understand the dietary needs of the resident. The medical director reviewed the labs and stated the resident came in with azotemia and her Labs were acceptable until February 2021. He stated it is important for the dietician to calculate the fluid needs of the resident. 415.12(g)(2)]

Based on observations, record review, and interviews during a COVID-19 Focused Infection Control Survey, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections. Specifically, 1) A staff member was not using Personal Protective Equipment (PPE) correctly. 2) The facility did not follow cohorting requirements on 1 of 4 units. The findings are: The CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 12/14/20, documented: HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection. The Facility's Policy and Procedure on Prevention and Control of COVID -19 dated 4/2020 documented under Procedure # 5- Healthcare Personnel (HCP) must use gloves, gowns, masks, N-95 masks if available, eye protection on entry to a room of patients with suspected or positive COVID- 19. The New York State Department of Health (NYSDOH) Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities, dated 3/13/2020 and revised 7/10/2020, documented that if there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. 1) Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #5 had a Brief Interview for Mental (BIMS) Score of 3, indicating severely impaired cognition. Resident #5 received Physical Therapy starting on 1/28/2021. Resident #5 was presumed positive for COVID-19 on 2/5/2021. The physician's orders [REDACTED].#5 was on droplet precautions. The physician's orders [REDACTED]. The Diagnostic Laboratory Result dated 2/5/2021 documented Resident #5 was presumptive positive for COVID-19. On 2/11/2021 at 3:00 PM, 1 of 2 staff, (Staff # 1) who is a Physical Therapist Assistant (PTA), was observed coming out of Resident # 5's room without wearing an N-95 mask. Staff #1 was only wearing a surgical mask. The PTA (Staff #1) was immediately interviewed on 2/11/2021 at 3:05 PM and stated that Staff #1 was not fit tested and that was why Staff #1 was not wearing an N95 mask. Staff #1 further stated that he was aware Resident# 5 has a COVID-19 [DIAGNOSES REDACTED]. On 2/12/2021 at 2:35 PM, Staff #1 further stated he was providing Physical Therapy ( PT) exercises to Resident # 5 on 2/11/2021, the resident was wearing a surgical mask and there was no coughing observed. The Infection Control Nurse was interviewed on 2/12/2021 at 2:45 PM and stated that all staff working with COVID-19 residents should be wearing an N95 mask with a surgical mask. The Nurse Educator was interviewed on 2/12/2021 and stated Staff #1 should have been wearing an N95 mask because he was fit tested on [DATE] and passed the fit testing. The Nurse Educator further stated all staff on the COVID-19 unit should be wearing an N95 mask whether or not they were fit tested . The Director of Nursing Services (DNS) was interviewed on 2/12/21 at 3:30 PM and stated that all staff caring for COVID-19 residents should wear an N95 mask. 2) The New York State Department of Health DAL dated April 29, 2020 documented, As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-19 positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful separate out patients in individual facilities. An observation of Unit A was made on 2/11/2021 at 3:50 PM. On Unit A, 3 COVID-19 positive residents (Residents # 1, #2 and #3) were observed in their wheelchairs near the blue tape line on the corridor floor of Unit A, separating the COVID-19 unit from the non-COVID-19 unit. Resident #1 and # 2 were properly wearing their masks. Resident #3 was wearing the mask around the chin, not covering the mouth and nose. Resident # 3 was observed getting up from the wheelchair and walking off the designated COVID-19 section of Unit A that is on the same floor as non COVID-19 residents. Resident #3 was redirected by Certified Nursing Assistant (CNA) #6 back into the chair and onto the COVID-19 section of the unit. After CNA #6 walked away, Resident # 3 wheeled past the blue taped line (on the floor), and around to the nurse's station. The resident passed two non COVID-19 residents and came within 6 feet of 1 non COVID-19 resident. CNA #6 then again came around the corner, redirected Resident #3 then wheeled Resident #3 onto the COVID-19 unit and into Resident #3's room. CNA # 6 was interviewed on 2/12/2021 at 3:24 PM and stated Residents #1, #2 and #3 were in the hallway near the blue tape line on the COVID-19 positive side of Unit A. Residents # 1, # 2 and #3 have to be redirected into their rooms because they have COVID-19. Resident # 3 keeps getting up and goes onto the non COVID-19 side. CNA #7 was interviewed on 2/12/2021 at 3:50 PM. CNA #7 stated that staff are constantly redirecting the confused residents. CNA #7 further stated that Resident # 3 crosses the line to go to the non COVID-19 unit, is very combative, confused and always has to be re-directed back onto the COVID-19 positive side of Unit A. Registered Nurse (RN) Supervisor #8 was interviewed on 2/12/2021 at 3 PM and stated that from about 3:15 PM to about 3:45 PM on 2/11/2021, he was on Unit A and all residents were in their rooms. RN Supervisor #8 stated he had to leave the unit to provide care on another unit and that he came back to the unit at 4:30 PM. At that time (4:30 PM), there was a situation with residents coming out of their rooms. RN Supervisor #8 stated he assigned staff to sit outside the resident's rooms on the COVID-19 side of Unit A. During the end of 7 AM-3 PM shift, he was made aware by one of the CNAs that there was an issue with residents coming out of their rooms. It was hard to contain confused residents. RN Supervisor #8 stated he did not have prior knowledge that Residents #1, #2 and #3 were coming out of their rooms. The 3 PM-11 PM staff had informed him that they had seen the DOH Surveyors and observed residents coming out of their rooms. RN Supervisor # 8 further stated that he took it upon himself to implement 30 minute checks for staff to sit and monitor the residents. RN Supervisor # 9 was interviewed on 2/12/2021 at 2:25 PM and stated that she worked from 7 AM and floated to Unit A at 3 PM and then went on break for 20 minutes at 3 PM from Unit A. There was no other nurse on the unit. She stated that the unit should have been staffed with two nurses and when she went on break there was no issues with wandering residents. The Infection Control Preventionist was interviewed on 2/12/2021 at 4:52 PM and she stated that the facility now knows that there is an issue with Unit A because there is no physical barrier and confused residents try to get on the non COVID-19 side of the unit. These were not new behaviors exhibited by Residents #1, #2 or #3 per staff that work on that unit. The Infection Preventionist states she was not aware of the wandering behaviors of the residents on those units and that she was not aware that the residents were mobile. 415.19(a)(1),(b)(1)