Every finding on record at St James Rehabilitation & Healthcare Center

Based on observation, record review, and interviews during a recertification survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that a comprehensive person-centered care plan was developed for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for one (1) (Resident #24) of two (2) residents reviewed for Respiratory care. Specifically, Resident #24 has a physician's order for 2 liters of continuous oxygen therapy via nasal cannula. There was no documented evidence that a comprehensive person-centered care plan was developed related to the use of oxygen therapy. The finding is:The facility's policy titled Care Plans Comprehensive Person-Centered dated 12/01/2022 documented the comprehensive person-centered care plan includes measurable objectives and time frames. Describes the services to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being.The facility's policy titled Oxygen Administration dated 08/2025 documented to verify the physician's order and review the resident's care plan.Resident #24 was admitted with diagnoses that included pneumonia, dementia, and major depressive disorder. The Minimum Data Set assessment dated [DATE] documented Resident #24 had a Brief Interview for Mental status score of 00, indicating the resident had severe cognitive impairment. The Minimum Data Set assessment documented the resident received oxygen therapy.A physician's order dated 11/18/2025 documented oxygen therapy 2 liters per minute via nasal cannula, continuously.A review of Resident #24's comprehensive care plans revealed there were no care plans developed to address the resident's use and need for the oxygen therapy. During an observation on 12/03/2025 at 10:43 AM, Resident #24 was sitting in a wheelchair in their room with a nasal cannula applied to their nose and connected to an oxygen concentrator (a medical device that provides supplemental concentrated oxygen). Resident #24 was not interviewable. During an observation on 12/08/2025 at 10:12 AM, Resident #24 was observed sitting in a wheelchair with a nasal cannula applied to their nose and connected to an oxygen concentrator.During an interview on 12/08/2025 at 10:13 AM, the Registered Nurse Manager #1 stated there should be a care plan in place for the resident's use of oxygen therapy. Registered Nurse Manager #1 stated the resident's care plan should have been created when the physician's order for oxygen therapy was entered in the electronic medical record. Registered Nurse Manager #1 stated they were responsible for updating care plans and should have updated Resident #24's care plan to address the use of oxygen therapy.During an interview on 12/09/2025 10:17 AM, the Director of Nursing Services stated the resident's care plan should have been developed when the physician's order for oxygen therapy was entered into the electronic medical record. The Director of Nursing Services stated the nurse manager, or the nurse supervisor can update the care plans. 10 NYCRR 415.11(c)(1)

Based on observations, record review and staff interviews during a recertification survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (1) of seven (7) residents reviewed for Pressure Ulcers. Specifically, Certified Nursing Assistant #1, who was not qualified to provide wound care treatment, was observed providing a wound care treatment to Resident #98's stage 3 pressure ulcer during morning care on 12/03/2025. Cross reference F880 Infection Control The finding is: Resident #98 was admitted with diagnoses including non-pressure chronic ulcer of the left calf (back of the lower leg), peripheral vascular disease, and atrial fibrillation. The admission Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The resident was at risk for developing pressure ulcers and had one (1) Stage 2 pressure ulcer that was present upon admission. The resident was always continent of urine and was occasionally incontinent of bowel.The physician's orders dated 12/02/2025 documented to topically apply medihoney wound dressing external gel (wound dressings) to bilateral buttocks and sacral area every day and during the evening, after a normal saline cleanse followed by a silicone dressing shift for the wound healing. During an observation and interview on 12/03/2025 at 10:30 AM, Resident #98 was lying in their bed. The bed side table was observed with a four (4) inch by four (4) inch border gauze dated 12/03/2025 with a nurse's initials. The gauze was noted with a white substance on it. The resident stated the nurse left the gauze on the table for Certified Nursing Assistant #1 to apply on their (resident's) buttocks after the bed bath.During a morning care observation on 12/03/2025 from 10:48 AM to 11:10 AM, Certified Nursing Assistant #1 provided a bed bath to Resident #98. The resident's pressure ulcers to the sacrum and the buttocks did not have a cover dressing on. Certified Nurse Assistant #1 cleansed the resident's uncovered pressure ulcers with a soiled towel that was used to clean the resident's genital area.During an interview on 12/03/2025 at 11:13 AM, Certified Nursing Assistant #1 stated some nurses leave the wound care treatment on the resident's bedside table for the Certified Nursing Assistant to apply after they provide the resident with a bed bath. Certified Nursing Assistant #1 stated they were not trained to do the wound care; they were just helping the nurses.During an interview on 12/03/2025 at 11:25 AM, Licensed Practical Nurse #6 stated they completed Resident #98's wound care treatments in the morning. Licensed Practical Nurse #6 stated they do not allow Certified Nursing Assistants to apply wound treatments because Certified Nursing Assistants are not qualified to do the wound care.During an interview on 12/09/2025 at 02:00 PM, the Director of Nursing Services stated only nurses are allowed to complete the wound care treatments. The Director of Nursing Services stated nurses should handle the wound care since they are skilled in infection control and can accurately follow the physician's orders.10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure each resident with pressure ulcers received necessary services consistent with standards of practices to promote healing and prevent infection. This was identified for one (1) (Resident #98) of seven (7) reviewed for pressure ulcers. Specifically, Resident #98 was admitted with a stage two pressure ulcer to right buttocks on 11/26/2025 and there was no documented evidence that wound treatment was ordered and provided to the resident's pressure ulcer until 12/02/2025.The finding is: The Facility Policy for admission assessment dated [DATE] documented to contact the attending physician to communicate and review the findings of the initial assessment and other pertinent information and obtain admission orders that are based on these findings. Notify the supervisor and the attending physician of any immediate needs that the resident may have. The Facility's Pressure Injury Overview Policy dated 03/06/2025 documented it is the responsibility of the nursing staff to monitor, provide care, manage, report, and document all wounds including the development of new wounds and/or pressure injuries. Resident #98 was admitted with diagnoses including non-pressure chronic ulcer of the left calf (back of the lower leg), peripheral vascular disease, and atrial fibrillation. The admission Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The resident was at risk for developing pressure ulcers and had one (1) Stage 2 pressure ulcer that was present upon admission. The resident was always continent of urine and was occasionally incontinent of bowel. The Admission/readmission Evaluation dated 11/26/2025 documented Resident #98 had a pressure ulcer to their right buttock. The resident's right buttock had loss of dermis (top layer of skin) and presented as a shallow open ulcer with a red/pink wound bed. The Care Plan dated 11/26/2025 for at risk for pressure injury development documented intervention to administer treatments and medications as ordered and monitor for effectiveness. There was no baseline care plan developed specific to the Stage 2 pressure ulcer to the right buttock. The admission physician's orders dated 11/26/2025 documented weekly skin checks.A review of the physician's orders from 11/26/2025 to 12/02/2025 revealed there were no wound care treatment orders to address the pressure ulcer identified on admission.The physician visit note dated 11/29/2025 at 13:13 documented the resident had a right buttock ulcer. The note did not indicate any treatment recommendations for the right buttock ulcer.A review of the physician's orders from 11/26/2025 to 12/02/2025 revealed there were no wound care treatment orders to address the pressure ulcer identified on admission. A review of the Treatment Administration Record from 11/26/2025 to 12/02/2025 indicated no treatments were provided to the resident's right buttock pressure ulcer. The wound care evaluation dated 12/02/2025 documented Resident #98 had a stage 3 pressure ulcer to the right buttock pressure ulcer that measured 2.3 centimeters in length 2.9 centimeters in width and 0.1 centimeters depth. The wound had 100 percent granulation with light exudate. The physician's orders dated 12/02/2025 documented to topically apply medihoney wound dressing external gel (wound dressings) to the buttocks every day and during the evening after a normal saline cleanse followed by a silicone dressing shift for wound healing. During an interview on 12/03/2025 at 11:25 AM, Licensed Practical Nurse #6 stated they did not know that Resident #98 had a pressure ulcer to the right buttocks and were not able to provide a treatment for Resident #98's pressure ulcers because there were no physician's orders. During an interview on 12/05/2025 at 11:14 AM, Wound Care Nurse #1 stated the admission nurse identified that Resident #98 had a Stage 2 pressure ulcer on the right buttock on 11/26/2025 and there was no physician's order for a treatment until they (Wound Care Nurse #1) assessed Resident #98 on 12/02/2025. Wound Care Nurse #1 stated they did not work in the facility until 12/01/2025 due to the holiday. Wound Care Nurse #1 stated the admission nurse should have notified the Physician on 11/26/2025 and obtained a treatment order for the identified pressure ulcer. During a wound care observation for Resident #98 on 12/08/2025 at 10:00 AM with the Wound Care Nurse #, the right buttock wound appeared to be dime size. The wound bed was noted to be pink in color with no drainage or signs of infection. The peri wound area was normal to the resident's skin tone. During an interview on 12/08/2025 at 10:54 AM, Registered Nurse Supervisor #2 stated they admitted Resident #98 on 11/26/2025; however, they were not responsible for obtaining the physician's orders. Registered Nurse Supervisor #2 stated Resident #98's had a Stage 2 pressure ulcer on the right buttock on the admission. Registered Nurse Supervisor#2 stated after they assessed the resident's buttocks, they cleansed the pressure ulcer with normal saline and covered the area with a dry protective dressing. Registered Nurse Supervisor #2 stated another nurse (name not recalled) called the Physician to obtain orders that were recommended by the hospital. Registered Nurse Supervisor #2 stated the hospital did not recommend a pressure ulcer treatment. Registered Nurse Supervisor #2 stated they did not communicate with the nurse who entered the hospital recommended physician's orders in the medical record. Registered Nurse Supervisor #2 stated the Wound Care Nurse typically evaluates the resident the next day and obtains physician orders for the appropriate treatments. Registered Nurse Supervisor #2 stated they assumed the Wound Care Nurse was going to assess the resident the following morning and would enter the treatment orders for the pressure ulcer.During an interview on 12/09/2025 at 11:07AM Nursing Supervisor #5 stated they worked on 11/26/2025 until 11:00 PM and called the Physician to obtain the admission orders for Resident #98. The Primary Physician approved all the medications that were listed in the hospital discharge papers. Nursing supervisor#5 stated they usually did not look at the admission skin assessment; however, they verbally communicate with the admission assessment nurse to see if the resident needs additional treatment orders. Nursing supervisor #5 stated on 11/26/2025 they left the facility before the admission nurse (Nursing Supervisor #2) completed the admission assessment for Resident #98 therefore they did not communicate and obtain the treatment orders for the resident's pressure ulcer.During an interview on 12/09/2025 at 12:25 PM, Primary Care Physician#1 stated that on 11/29/2025, they evaluated Resident #98 and obtained information about Resident #98's right buttock stage 2 pressure ulcer. Primary Care Physician #1 stated they do not follow the wound care evaluations and treatment orders. Primary Care Physician #1 stated they assumed there was a physician's order for the resident's wound care treatment. Primary Care Physician#1 stated at the end of the day, they were responsible for all physician orders and should have ensured there was a treatment order in place for the resident's pressure ulcer.During an interview on 12/09/2025 at 2:00PM, The Director of Nursing Services stated Resident #98 should have received wound care treatments from admission. The Director of Nursing Services stated that the resident's Physician and nurses should have ensured a treatment order was in place for the wound treatment. 10 NYCRR 415.12(c)(1)

Based on record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that the medical care of each resident was supervised by a Physician. This was identified for one (1) (Resident #98) of seven (7) residents reviewed for Pressure Ulcers. Specifically, a stage 2 pressure ulcer to Resident #98's right buttocks was identified upon admission on [DATE]. The attending physician did not evaluate the wound and did not ensure that treatment orders were in place until 12/02/2025.The finding is: The facility physician services policy dated 03/06/2025 documented a Physician supervising the medical care of residents includes (but not limited to): prescribing medications and therapy, conducting routine requires visits, monitoring changes in residents' medical status, providing consultation or treatments when called by the facility, and overseeing a relevant plan of care for the residents.Resident #98 was admitted with diagnoses including non-pressure chronic ulcer of the left calf (back of the lower leg), peripheral vascular disease, and atrial fibrillation. The admission Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The resident was at risk for developing pressure ulcers and had one (1) Stage 2 pressure ulcer that was present upon admission. The resident was always continent of urine and was occasionally incontinent of bowel.The Admission/readmission Evaluation dated 11/26/2025 documented Resident #98 had a pressure ulcer to their right buttock. The resident's right buttock had loss of dermis (top layer of skin) and presented as a shallow open ulcer with a red/pink wound bed.The Care Plan dated 11/26/2025 for at risk for pressure injury development documented intervention to administer treatments and medications as ordered and monitor for effectiveness. There was no baseline care plan developed specific to the Stage 2 pressure ulcer to the right buttock.The admission physician's orders dated 11/26/2025 documented weekly skin checks.A review of the physician's orders from 11/26/2025 to 12/02/2025 revealed there were no wound care treatment orders to address the pressure ulcer identified on admission.The physician visit note dated 11/29/2025 at 13:13 documented the resident had a right buttock ulcer. The note did not indicate any treatment recommendations for the right buttock ulcer.A review of the physician's orders from 11/26/2025 to 12/02/2025 revealed there were no wound care treatment orders to address the pressure ulcer identified on admission.A review of the Treatment Administration Record from 11/26/2025 to 12/02/2025 indicated no treatments were provided to the resident's right buttock pressure ulcer. The wound care evaluation dated 12/02/2025 documented Resident #98 had a stage 3 pressure ulcer to the right buttock pressure ulcer that measured 2.3 centimeters in length 2.9 centimeters in width and 0.1 centimeters depth. The wound had 100 percent granulation with light exudate. The physician's orders dated 12/02/2025 documented to topically apply medihoney wound dressing external gel (wound dressings) to the buttocks every day and during the evening after a normal saline cleanse followed by a silicone dressing shift for wound healing. During an interview on 12/05/2025 at 11:14 AM, Wound Care Nurse #1 stated the admission nurse identified that Resident #98 had a stage 2 pressure ulcer on the right buttock on 11/26/2025 and there was no physician's order for a treatment until they (Wound Care Nurse #1) assessed Resident #98 on 12/02/2025.During an interview on 12/09/2025 at 12:25 PM, Primary Care Physician#1 stated that on 11/29/2025, they evaluated Resident #98 and obtained information about Resident #98's right buttock stage 2 pressure ulcer. Primary Care Physician #1 stated they do not follow the wound care evaluations and treatment orders. Primary Care Physician #1 stated they assumed there was a physician's order for the resident's wound care treatment. Primary Care Physician#1 stated at the end of the day, they were responsible for all physician orders and should have ensured there was a treatment order in place for the resident's pressure ulcer.During an interview on 12/09/2025 at 2:00PM, The Director of Nursing Services stated Resident #98 should have received wound care treatments from admission. The Director of Nursing Services stated that the resident's Physician and nurses should have ensured a treatment order was in place for the wound treatment. 10 NYCRR 415.15(b)(1)(i)(ii)

Based on observation, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that Nurse Aides were able to demonstrate competency in skills and techniques necessary to care for the resident's need. This was identified for one (1) (Resident #1) of one (1) resident reviewed for Accidents. Specifically, Resident #1 reported that they sustained an injury to their left great toe to Certified Nursing Assistant #2 on 12/04/2025; however, there was no documented evidence that Certified Nursing Assistant #2 reported the resident's injury to the nurse.The finding is: The facility policy on Accidents/Incidents last revised 04/2013 documented the facility shall provide a safe and secure environment for staff and residents. Staff who witness an accident/incident shall report the incident to the nursing supervisor as soon as practicable to ensure that an appropriate assessment occurs and that medical attention is obtained, as needed.Resident #1 was admitted with diagnoses that included peripheral vascular disease (a circulatory problem where narrowed blood vessels reduce blood flow to your limbs) and diabetes mellitus. A 5-Day Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated the resident had intact cognition. The resident had no behavioral symptoms and was dependent on staff for bed mobility and transfers. The resident was able to wheel themself 50 feet to 150 feet once seated in a wheelchair. During an observation on 12/04/2025 at 11:06 AM, Resident #1 was observed seated on the side of the bed with their feet on the floor. The resident was not wearing socks at the time of the observation. A hematoma (blood pooled under the skin) was observed on the left great toenail. Resident #1 stated that someone rolled over their toe with a wheelchair during a music program. The resident was unable to give the date and time of the incident. Resident #1 stated at the time of the incident their toe did not hurt, and they did not know the toe would become discolored.During an interview on 12/08/2025 at 9:00 AM, Certified Nursing Assistant #2 stated they cared for the resident on Wednesday 12/03/2025 and they did not see the discoloration on the resident's left big toe. Certified Nursing Assistant #2 stated on Thursday 12/04/2025, the resident showed them the discoloration on their left great toe and did not complain of pain. Certified Nursing Assistant #2 stated they did not think it was a big deal. Certified Nursing Assistant #2 stated they did not report the hematoma to anyone because the regular nurse was not on duty that day. Certified Nursing Assistant #2 stated that the resident was not complaining of pain therefore, they did not report it to the nurse. Certified Nursing Assistant #2 further stated that they should have reported the injury to the resident's toe to the nurse. A Review of the Certified Nursing Assistant Task for skin observation dated 11/25/2025-12/07/2025 was completed and there was no documentation of the discoloration to the resident's toe on 12/04/2025.During an interview on 12/08/2025 at 09:20 AM, Licensed Practical Nurse #7 stated they were not made aware of the resident's left great toe discoloration. Licensed Practical Nurse #7 stated that Certified Nursing Assistant #2 should have reported the discoloration to the nurse. During an interview on 12/09/2025 at 10:18 AM, the Director of Nursing Services stated Certified Nursing Assistant #2 should have reported the change in resident's skin condition to the nurse. The Director of Nursing Services stated that it was not the Certified Nursing Assistant's responsibility to decide what was a big deal, and that they must report any changes in the residents' in skin condition to the nurse. 10 NYCRR 415.26(c)(1)(iv)

Based on observation, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that all medications and biologicals were stored in locked compartments. This was identified for one (1) (Unit 2 North, B medication cart) of four (4) units reviewed during the Medication Storage Task. Specifically, the medication cart for Unit 2 North (B cart) was observed with an unlabeled souffle cup containing one tablet of Januvia 25 milligrams (a medication to lower blood sugar in an adult with type 2 Diabetes Mellitus) in the top drawer. Licensed Practical Nurse #3 confirmed that Resident #49 refused their 06:00 AM Januvia 25 milligrams dose, and instead of discarding the medication, the nurse stored the medication in an unlabeled souffle cup in the medication cart.The finding is:The undated facility policy titled Medication Labeling Storage documented medications are stored in an orderly manner to prevent the possibility of mixing medications of several residents. Resident #49 was admitted with diagnoses that included type 2 diabetes mellitus, chronic obstructive pulmonary disease (a lung condition that blocks the airflow making it difficult to breath), and heart failure. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 10, indicating the resident had moderately impaired cognition. A physician's order dated 05/24/2025, documented Januvia 25 milligrams oral tablet give one tablet by mouth, once a day, for Diabetes Mellitus.During an observation on 12/04/2025 at 06:16 AM, the top drawer of the B medication cart on Unit 2 North had a souffle cup containing one orange tablet. A review of the December 2025 Medication Administration Record for Resident #49 documented Resident #49 received their 06:00 AM dose of Januvia on 12/04/2025. During an interview on 12/04/2025 at 06:16 AM, Licensed Practical Nurse #3 stated they attempted to administer the Januvia tablet to Resident #49 and the resident refused the medication because they preferred to continue sleeping. Licensed Practical Nurse #3 stated they should have discarded the tablet and should not have placed the prepared medication back in the medication cart. Licensed Practical Nurse #3 stated they did not discard the tablet because they wanted to reapproach the resident when the resident woke up.During an interview on 12/04/2025 at 06:19 AM, Registered Nurse Supervisor #2 stated the medication nurse should have discarded the refused medication and should not have stored the medication in an unlabeled souffle cup in the medication cart. During an interview on 12/05/2025 at 07:35 AM, the Director of Nursing Services stated the nurses should not store prepared medication in a souffle cup in the medication cart. The Director of Nursing Services further stated the nurse should discard the refused medication and reapproach the resident when the resident is ready to take their medication.10 NYCRR 415.18 (d)(e) (1-4)

Based on observations, interviews, and record review during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with their goals and preferences. This was identified for one (1) (Resident #206) of seven (7) residents reviewed for Nutrition. Specifically, Resident #206 had a physician's order for thin liquids and a therapeutic no added salt diet with a mechanically altered chopped texture, related to the diagnosis of heart failure. During the breakfast and lunch meal service on 12/05/2025, Resident #206 was provided with regular diet meals with a mechanically altered chopped texture with additional salt packets on the meal trays.The finding is:The facility's undated policy titled Therapeutic Diets documented a therapeutic diet must be prescribed by the residents attending physician. Diet order must match the terminology used by the food and nutrition services department. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietician as part of a treatment for a disease or clinical conditions.Resident #206 was admitted with diagnoses that included Heart Failure, Hypertension, and Ulcerative Colitis. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, indicating the resident had moderate cognitive impairment. Resident #206 was on a therapeutic diet that was mechanically altered.The current physician's order documented no added salt diet, mechanically altered chopped texture, thin liquids consistency related to heart failure.A Comprehensive Care Plan dated 10/05/2025 documented Resident #206 was at high nutrition/hydration risk related to mechanically altered diet. Interventions included to provide the resident a no added salt diet as prescribed.A dietary progress note dated 10/07/2025 documented Resident #206 was prescribed a no added salt diet.During an observation and interview on 12/03/2025 at 10:55 AM, Resident #206 was sitting in their wheelchair in their room. Resident #206 stated they are supposed to be on a no added salt diet, but they were getting the incorrect meals. Resident #206 stated sometimes they do not eat because of the salt in their meals. Resident #206 stated they told the nursing staff they were getting wrong food, but it has not changed. During an observation and interview on 12/05/2025 at 8:07 AM, Resident #206 was sitting in a wheelchair in their room eating breakfast. Resident #206 consumed the oatmeal and some of the eggs on the breakfast tray. A salt packet was observed on the meal tray. Resident #206 stated they were not supposed to have salt; they do not use the salt packets and did not know why they receive the salt packets on their meal tray.A meal ticket dated 12/05/2025 for Resident #206 documented breakfast regular-mechanically altered chopped diet, including one salt packet on the tray. During an observation on 12/05/2025 at 12:45 PM, Resident #206 was sitting in their room. The resident's lunch tray was observed on the overbed table which contained salt packets on the tray.A meal ticket dated 12/05/2025 for Resident #206 documented lunch, regular-mechanically altered chopped diet, including one salt packet on the tray. During an interview on 12/08/2025 at7:48 AM, the Registered Nurse Manager #1 stated the dietary staff transcribes the dietary orders on the meal tickets. Registered Nurse Manager #1 stated the Certified Nursing Assistants check the meal tickets for the items on the meal tray and do not check for the type of diet the resident is prescribed. Registered Nurse Manager #1 stated the Certified Nursing Assistants do not know what type of diet each resident is prescribed. During an observation and interview on 12/08/2025 at 7:54 AM, Registered Nurse Manager #1 checked Resident #206's breakfast meal tray. The breakfast meal tray contained salt packets, and the meal ticket documented regular-mechanically altered chopped meal. Registered Nurse Manager #1 stated dietary staff were responsible for entering the diet orders in the meal ticket system. Registered Nurse Manager #1 stated Resident #206 had a physician's order for a no added salt diet due to the resident's diagnosis of heart failure. Registered Nurse Manager #1 stated the breakfast meal provided was not the prescribed diet for Resident #206. During an interview on 12/08/2025 at 8:46 AM, Registered Dietician #1 stated the dieticians check the physician's orders in the meal ticket system on a quarterly basis. Registered Dietician #1 stated they were not sure why Resident #206's meal ticket did not match the physician's order for a no added salt diet. Registered Dietician #1 stated a dietician should have checked the meal ticket system and changed the resident's meal ticket to match the physician's order. Registered Dietician #1 stated nursing staff did not report the discrepancy to them. During an interview on 12/08/2025 at 10:58 AM, Primary Care Physician #1 stated the dietary staff should follow the physician's order for a no added salt diet and should not have provided the resident with a regular diet and salt packets.10 NYCRR 415.14(e)

Based on observations, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not ensure that food was prepared, distributed, and served in accordance with professional standards for food service safety. This was identified for two (2) (Resident #09 and Resident #10) of two (2) residents reviewed for Tube Feeding and during the Kitchen task. Specifically, 1) Resident #09 and Resident #10's tube feeding formula and the water bags were unlabeled and did not indicate the resident's name, the date, and the time the tube feeding was initiated. 2) During the tray line service observation on 12/09/2025, the temperature of the prepared cold food items was observed to be above 41 degrees Fahrenheit. The findings are: 1) The facility's policy titled Enteral Feeding Tubes and Care, last revised on 01/01/2025, documented that resident who is fed by an enteral feeding tube shall receive appropriate treatment and services. Feeding solution is hung for no longer than twenty-four hours. Clinical dietary staff will calculate the amount of free water and caloric value for patients on enteral feedings. The feeding set is changed and labeled with the name of the patient, date, and time every twenty-four hours. Resident #09 was admitted with diagnosis including dysphagia (difficulty swallowing) following cerebral infarction. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #09 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Resident #09 had a feeding tube and received an average fluid intake per day by tube feeding. A Comprehensive Care Plan titled Tube Feeding for Nutritional Support, dated 06/28/2023 and revised on 09/25/2025, documented interventions including providing the resident with tube feeding as ordered, providing water flush as ordered and maintaining the head of the bed at 30-45 degrees during feeding. The current physician's order documented Osmolite (a nutritional formula for tube feeding that provides calories, protein, vitamins and minerals) 1.5/1000 milliliters at 83 milliliters per hour, auto water flush per 1000 milliliters at 83 milliliters per hour. Start time at 05:00 PM until completed. During an observation on 12/03/2025 at 10:47 AM, Resident #09 was lying in bed. An enteral tube feeding bottle and a water bag was hanging on a feeding tube stand without a label that included the resident's name and the time the tube feeding was started. The resident was not receiving the tube feeding at the time of the observation. During an interview on 12/03/2025 at 10:58 AM, Licensed Practical Nurse #04, the Medication Nurse, stated they did not know why the enteral tube feeding bottle and the water bottle were unlabeled. Licensed Practical Nurse #04 stated that the enteral tube feeding bottle, and the water bottle were connected during the 3:00 PM to 11:00 PM shift and was started at 5:00 PM. Licensed Practical Nurse #04 stated when they came in this morning, Resident #09 was disconnected from the feeding. During an interview on 12/03/2025 at 11:00 AM, Registered Nurse #03, the Nurse Supervisor, stated that the nurse who worked during the 3:00 PM to 11:00 PM shift should have labeled the enteral tube feeding bottle and water bottle with the resident's name and the time that the feeding was started. During an interview on 12/04/2025 at 2:25 PM, Licensed Practical Nurse #05 stated that they were the medication nurse who worked during the 3:00 PM to 11:00 PM shift on 12/02/2025. Licensed Practical Nurse #05 stated they remembered putting the label on the feeding and water bottle before starting the feeding. Licensed Practical Nurse #05 stated they did not know what happened to the label after their shift. During an interview on 12/08/2025 at 10:15 AM, the Director of Nursing Services stated the enteral tube feeding bottle and water bottle should be labeled before the start of the feeding. The Director of Nursing Services stated that the label should include the resident's name and the time the feeding started. The Director of Nursing Services stated they expect all nurses to label the feeding and water bottle. -Resident #10 had a diagnosis of dysphagia (difficulty swallowing). Resident #10's Quarterly Minimum Data Set assessment dated [DATE], documented a Brief Interview for Mental Status score of 11, indicating moderate cognitive impairment. The assessment documented the resident's primary source of nutrition and hydration was through a feeding tube. A comprehensive care plan for tube feeding last revised 12/03/2025 documented the resident required tube feeding for nutritional support secondary to swallowing difficulty and inability to consume adequate food and fluids by mouth. Interventions included to provide tube feeding, monitor the resident's tolerance of the tube feeding, and flush as ordered. The physician's orders dated 12/03/2025 documented tube feeding, continuous feed of Pivot (tube feeding formula) 1.5, 1400 milliliters, at 80 milliliters per hour; automatic water flush of 1000 milliliters at 80 milliliters per hour from 4:00 PM until it is completed, every shift. During an observation on 12/03/2025 at 11:10 AM, Resident #10's tube feeding pump was connected to a tube feeding formula bag and a bag of water; both bags were unlabeled and undated. During an interview on 12/03/2025 at 1:00 PM, Registered Nurse Supervisor #4 stated Resident #10's feeding requires two bottles of formula, so they poured the formula into a bag. Registered Nurse Supervisor #4 further stated the formula bag, and the water bag should have been labeled and dated. 2) An undated facility policy and procedure titled Food Temperatures, documented the temperatures of the food items will be taken and properly recorded for each meal. Take temperatures often to monitor for safe holding temperature ranges of at or below 41 degrees Fahrenheit for cold foods. All cold food items must be maintained and served at a temperature of 41 degrees Fahrenheit or below. Foods sent to the units for distribution (such as meals, snacks, nourishments, oral supplements) will be transported and delivered to maintain temperatures at or below 41 degrees Fahrenheit for cold foods. During an observation of the lunch meal tray line service on 12/09/2025 at 12:08 PM, the Food Service Director measured the temperature of a 4-ounce almond milk. The temperature was noted to be 52.9 degrees Fahrenheit and the temperature of a 4-ounce container of yogurt was noted to be 59.6 degrees Fahrenheit. During an interview on 12/09/2025 at 12:30 PM, the Food Service Director stated the temperature of the cold food items were not appropriate. The Food Service Director stated cold food items that are held at temperatures above 41 degrees Fahrenheit increases the risk for foodborne illness when consumed. 10 NYCRR 415.12(g)(2) and 415.14(h)

Based on observations, record review, and interviews during the Recertification Survey initiated on 12/03/2025 and completed on 12/09/2025, the facility did not maintain an infection prevention and control program to help prevent the transmission of communicable diseases and infections. This was identified for one (1) (Resident #98) of seven (7) residents reviewed for Pressure Ulcers. Specifically, Resident #98 had Stage 3 pressure ulcers on their bilateral buttocks and sacrum. During morning care on 12/03/2025, Certified Nurse Assistant #1 cleaned the resident's uncovered pressure ulcers with a soiled towel that was used to clean the resident's genital area.The finding is: The Facility Pressure Injury Overview Policy dated 03/06/2025 documented steps of dressing changes including cleaning of the wounds indicating a no touch technique. The policy did not define no touch technique. Resident #98 was admitted with diagnoses including non-pressure chronic ulcer of the left calf (back of the lower leg) , peripheral vascular disease, and atrial fibrillation. The admission Minimum Data Set assessment dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The resident was at risk for developing pressure ulcers and had one (1) Stage 2 pressure ulcer that was present upon admission. The resident was always continent of urine and was occasionally incontinent of bowel. The physician's orders dated 12/02/2025 documented to topically apply Medihoney wound dressing external gel (wound dressings) to bilateral buttocks and sacral area every day and during the evening, after a normal saline cleanse followed by a silicone dressing shift for the wound healing. The wound care evaluation note dated 12/02/2025 documented Resident #98 had a stage 3 pressure ulcer to the sacrum that measured 4 centimeters in length, 1.6 centimeters in width, and 0.1 centimeter in depth. Resident #98 also had a stage 3 pressure ulcer to the left buttock that measured 1.1 centimeter in length, 1.3 centimeters in width, and 0.1 centimeters in depth. Additionally, Resident #98 had a stage 3 right buttock pressure ulcer that measured 2.3 centimeters in length, 2.9 centimeters in width and 0.1 centimeters in depth. During an observation and interview on 12/03/2025 at 10:30 AM, Resident #98 was lying in their bed. The bed side table was observed with a four (4) inch by four (4) inch border gauze dated 12/03/2025 with a nurse's initials. The gauze was noted with a white substance on it. The resident stated the nurse left the gauze on the table for Certified Nursing Assistant #1 to apply on their (resident's) buttocks after the bed bath. During a morning care observation on 12/03/2025 from 10:48 AM to 11:10 AM, Certified Nursing Assistant #1 provided a bed bath to Resident #98. The resident's pressure ulcers to the sacrum and the buttocks did not have a cover dressing on. Certified Nurse Assistant #1 cleansed the resident's uncovered pressure ulcers with a soiled towel that was used to clean the resident's genital area. During an interview on 12/03/2025 at 11:13 AM, Certified Nursing Assistant #1 stated some nurses leave the wound care treatment on the resident's bedside table for the Certified Nursing Assistant to apply after they provide the resident with a bed bath. During an interview on 12/03/2025 at 11:25 AM, Licensed Practical Nurse #6 stated they completed Resident #98's wound care treatments in the morning. Licensed Practical Nurse #6 stated they do not allow Certified Nursing Assistants to apply wound treatments because Certified Nursing Assistants are not qualified to do the wound care. During an interview on 12/05/2025 at 11:14 AM, Wound Care Nurse#1 stated only licensed nurses are allowed to provide the wound care treatments. Wound Care Nurse #1 stated it was crucial to follow the physician's order and to provide the wound care treatments properly to prevent skin deterioration and infection. Wound Care Nurse #1 stated the wound should be cleansed with normal saline to prevent infection and promote healing. Wound Care Nurse #1 stated the soiled towel used to clean the resident's perineal and genital area should not have contacted the resident's wounds. During an interview on 12/09/2025 at 02:00 PM, the Director of Nursing Services stated only nurses are allowed to complete the wound care treatments. The Director of Nursing Services stated nurses should handle the wound care since they are skilled in infection control and can accurately follow the physician's orders. 10 NYCRR 415.19(a) (1-3)

Based on observation, record review, and interviews during the Recertification survey, initiated on 5/1/2024 and completed on 5/9/2024, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Dining and Kitchen Tasks. Specifically, 1) During the initial tour of the kitchen, opened and undated packages of food were observed in the walk-in freezer and the refrigerator; the walk-in refrigerators and freezer were noted with debris and food spills; and multiple food preparation surfaces in the kitchen were observed with built-up food residue, racks for can storage had a layer of dust; 2) Therapeutic Recreation Aide #1 did not perform hand hygiene after touching the garbage can and proceeded to open food container on a residents' meal trays. The findings are: 1) The facility policy and procedure titled, Cleaning Instructions Food Carts dated 1/1/2024, documented that food carts will be cleaned and sanitized immediately after each use; the refrigerators will be cleaned thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed. Spills and leaks will be cleaned up as they occur; the slicer will be cleaned and sanitized before and after each use, and clean and sanitize the countertop on which the slicer is located; the counter space will be cleaned and sanitized prior to and following food preparation and meal service, and as needed; small appliances (such as mixers and food processors) will be cleaned and sanitized before and after each use. The facility policy titled, Food Storage dated 2021 and last revised 1/2024, documented that food is stored in an area that is clean, dry, and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. All foods that are removed from the original packaging must be labeled and dated with receiving date and expiration dates. Foods will be stored and handled to maintain the integrity of the packaging until ready to use. Refrigerated Storage: all refrigerator units are always kept clean. All foods should be covered, labeled, and dated. An initial tour of the kitchen was completed on 5/1/2024 at 9:59 AM with the Food Service Director and the Assistant Food Service Director. The following was observed: the walk-in combination refrigerator/freezer unit was observed with an open undated package of American cheese slices in the refrigerator; and an open undated package of hash browns in the freezer. The refrigerator floor was noted with black spots, which appeared like meat blood drippings,e, and other food and paper particles. In the dry storage area, the rack for storing canned foods was dusty. Multiple pieces of equipment not currently in use were noted to be dirty including the side of the steamer was splattered with food residue, the pellet system table and machine were left with food residue, the floor mat at the steam table was covered with egg and other food particles, the ice cream chest gaskets had a black residue all around the unit, an open, and the actively in-use garbage can was stored next to a clean stack of soup/salad bowls. A follow-up tour of the kitchen was completed on 5/3/2024 at 11:10 AM with the Food Service Director. The base of the food slicer and its worktable were observed to have brown drips. The lip of the work table had a layer of built-up grease and food. A follow-up tour of the kitchen was completed on 5/9/2024 at 9:52 AM with the Assistant Food Service Director. A rack of uncovered and undated raw burger patties was observed in the walk-in combination refrigerator/freezer. The rack containing three pans of Jello was dirty with residual food. The freezer floor was covered with debris, and the freezer had an open, undated package of hash browns and an open, undated package of perogies, with ice build-up inside of the bag. Cook #1 was interviewed on 5/9/2024 at 9:59 AM and stated that they had panned out the burger patties and put them in the refrigerator. Cook #1 stated they should have covered the patties. The Assistant Food Service Director was interviewed on 5/9/2024 at 10:17 AM and stated they check the walk-in refrigerators twice a day for cleanliness. The Assistant Food Service Director stated that they make a list of what needs to be cleaned. A cleaning person comes in three times per week; however, everyone should be cleaning up after themselves. The Assistant Food Service Director stated that the walk-in refrigerators are swept and mopped every night. The Assistant Food Service Director stated that the cooks are responsible for sealing any open packages, dating, and properly storing the food packages. Each person is responsible for cleaning their workstation, including the top and bottom of the counters. At the time of the interview, the Surveyor and the Assistant Food Service Director toured the kitchen and noted that underneath the cook's table and the coffee urn table, there was food residue and grease buildup present. The Food Service Director was interviewed on 5/9/2024 at 10:38 AM and stated a cleaning person is assigned to perform special cleaning assignments three times a week, such as cleaning the mixer machine and food racks. The Food Service Director stated that daily cleaning is also done; however, there is no cleaning schedule. The food service director stated that the open packages of food in the freezer should have been sealed and dated. The rack of raw beef patties should have been covered and dated and the Jello should not have been placed on a dirty rack. The Food Service Director stated that each person is responsible for cleaning their workstation and acknowledged that the areas underneath the worktables are not being cleaned. 2). The facility policy and procedure titled, Meal Service dated 1/1/2024, documents the facility staff will serve resident trays and will help residents who require assistance with eating. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. A facility policy and procedure titled, Hand Washing/Hand Hygiene created in 4/2024 documents the facility considers hand hygiene the primary means to prevent the spread of health-care-associated infections. Hand hygiene is indicated immediately before touching a resident, after touching a resident, and after touching the resident's environment. A Dining observation was completed on 5/1/2024 at 11:24 AM in the first-floor main dining room. Therapeutic Recreation Aide #1 was observed touching a garbage can and then opening food containers on a resident's tray without performing hand hygiene. Therapeutic Recreation #1 then proceeded to serve another meal tray without performing hand hygiene. During the Dining observation on 5/1/2024 at 11:30 AM in the first-floor main dining room the Registered Nurse Education Coordinator was observed fixing their hair and then setting up a resident meal tray without performing hand hygiene. The Registered Nurse Education Coordinator was immediately interviewed on 5/1/2024 after the observation and stated they should have performed hand hygiene prior to preparing the meal tray. Therapeutic Recreation Aide #1 was interviewed on 5/1/2024 at 11:31 AM and stated that they did receive education on infection control protocols and hand hygiene. Therapeutic Recreation Aide #1 acknowledged that they should have performed hand hygiene before serving meals to the residents. 10 NYCRR 415.14(h)

Based on record review, and interviews conducted during the Recertification Survey initiated on 5/1/2024 and completed on 5/09/2024, the facility did not ensure each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident. This was identified for one (Resident #82) of one resident reviewed for choices. Specifically, the facility did not allow Resident # 82 to have access to outside food brought in by their family member. The finding is: The facility's Policy and Procedure for Food Brought in by Family last revised in July 2019 documented that if a resident is found eating/being assisted to eat foods/liquids brought from visitors that are not of the proper consistency (per diet order), the resident/visitor will be educated regarding proper food/ drink safety. Staff will offer to modify the food/drink consistency to comply with the diet order. Any non-compliance by the visitor/resident will be brought to the attention of the nursing supervisor/administrator immediately. Resident # 82 has diagnoses that include Diabetes Mellitus and Morbid Obesity. The Minimum Data Set assessment dated [DATE] documented Resident #82 had a Brief Interview for Mental Status score of 11 which indicated the resident's cognitive function was moderately impaired. The Minimum Data Set further documented that the Resident had no behaviors. The Comprehensive Care Plan (CCP) for nutrition last revised on 2/14/2024 documented that Resident # 82 had diet restrictions and required fine-chopped texture and thin liquids; the resident was on a planned weight loss diet; and had a behavior problem related to noncompliance with eating with supervision in the dining room despite continuous education and encouragement; noncompliance with diet texture, was on aspiration precautions, and high choking risk; resident preferred ordering takeout from pizzeria and fast food restaurants. Interventions included explaining and reinforcing to the resident the importance of maintaining the diet ordered; encourage the resident to comply; explain the consequences of refusal and obesity/malnutrition risk factors; The resident preferred to eat in their room. The physician orders dated 2/27/2024 included Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 unit per milliliter (Insulin Lispro) with instructions to Inject 20 units subcutaneously before meals for Diabetes. Additionally, the physician's orders included a heart-healthy, Mechanically Altered Chopped texture diet, and Thin Liquids consistency. The physician's evaluation dated 4/18/2024 indicated that Resident #82 was competent to make informed medical decisions. The Progress Note, written by Registered Dietician # 6, dated 4/20/2024 at 12:47 documented Resident #82 was not interested in diet instructions. The resident acquires food and snacks from the family member who would bring [NAME]-Hoo drinks, Hawaiian Punch, family-sized Potato chip bags, and other High-salt snack foods. The current diet may promote slow weight loss, aid in better management of Diabetes Mellitus, and improve ambulation. The Resident has refused any type of diet instructions. The Social Services Note dated 5/1/2024 documented the Social Worker spoke with the family member, via telephone regarding sending healthy food items that are compliant with the resident's dietary restrictions. Educated the family member about the resident's diet. The family member was appreciative of the call and stated they did not want to go against dietary restrictions and would be picking up the items left at the front desk. The Physician's Progress Note dated 5/2/2024 documented Resident # 82 was seen today for noncompliance with their Diabetic diet. Cookies, soda, etc. were found in the resident's room. This has been an ongoing issue and the resident has been counseled numerous times. The resident also has presented as a choking hazard and has required observation. Resident # 82 was interviewed on 5/02/2024 at 1:48 PM and stated they were very upset because they were told by the Social Worker that they were not allowed to have food that was brought in by their family member. The food was confiscated by the facility and sent back to the family member a few days later. Registered Dietician # 6 was interviewed on 5/06/2024 at 2:04 PM and stated Resident # 82 was not allowed to eat certain foods because of Diabetes and Aspiration Precautions. Registered Dietician # 6 stated they sent the food back with the resident's family member. Registered Dietician # 6 further stated despite the education, the resident continues to be non-compliant and the facility has to ensure the resident does not eat food that is prohibited. Social Worker # 7 was interviewed on 5/07/2024 at 12:27 PM and stated they spoke to Resident # 82's family member who agreed the food that was brought in was not healthy for the resident. Social Worker #7 stated that the resident does have capacity based on the Physician evaluation; however, they did not feel the facility violated the resident's rights. The Director of Nursing Services (DNS) was interviewed on 5/06/2024 at 2:05 PM and stated We educated the family and the resident multiple times and the family continues to bring in food that is not allowed to the resident. The food was sent back with the family member last week. The Director of Nursing Services (DNS) further stated that despite the education, the resident continues to be non-compliant and the facility has to ensure the resident does not eat food that is prohibited. 10 NYCRR 415.5(b)(1-3)

Based on observation, record review, and interviews conducted during the Recertification Survey initiated on 5/1/2024 and completed on 5/9/2024, the facility did not ensure that residents were free of any significant medication errors. This was identified for one (Resident #122), of five residents observed during the medication administration task. Specifically, the Physician's order for Resident #122 documented to hold Admelog insulin (a fast-acting insulin that starts to work about 15 minutes after injection, and peaks in about 1 hour) if the resident's blood sugar level was below 300 milligrams per deciliter. Resident #122's blood sugar level was documented as 137 milligrams per deciliter on 5/8/2024 at 6:00 AM. During a medication pass observation for Resident #122, on 5/8/2024 at 7:28 AM, Licensed Practical Nurse #4 intended to administer the physician-ordered Semglee-insulin Glargine (a long-acting insulin injected once daily and provides a steady insulin level throughout the day) 10 units of insulin; however, in error, they administered 10 units of the Admelog insulin. The findings are: The Facility Policy for Insulin Administration last revised on 1/14/2024 documented that for the safe administration of insulin; the type of insulin, strength, and method of administration must be verified with the physician's order before administration. Resident # 122 was admitted with diagnoses that include Type 2 Diabetes Mellitus without complications. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 2, which indicated severely impaired cognition. The Minimum Data Set documented the resident was receiving insulin treatments. The Diabetes Mellitus comprehensive care plan initiated on 8/24/2018 documented the resident will receive Diabetes medications as ordered by the Physician. On 5/8/2024 at 7:24 AM, Licensed Practical Nurse #4 was observed administering 10 units of Admelog SoloStar Solution Pen-injector 100 Units/milliliters Insulin Lispro to the resident's lower left abdomen. Licensed Practical Nurse #4 stated before administering the insulin, they had checked the resident's blood glucose level, which was 147 milligrams per deciliter. Licensed Practical Nurse #4 stated that they were supposed to administer the insulin to Resident #122 at 6:00 AM and they were late because they were providing care to other residents. The Medication Administration Record for 5/8/2024 indicated Resident #122's blood glucose level was 137 milligrams per deciliter at 6:00 AM. A review of the Physician Orders dated 4/12/2024 was conducted after the medication administration observation. The physician's orders indicated the following: -Semglee Solution Pen-injector 100 Units/milliliters Insulin Glargine Inject 10 units subcutaneously one time a day for Diabetes to be given daily at 6:00 AM; and -Administer Admelog SoloStar Solution Pen-injector 100 Unit/milliliters Insulin Lispro (1 Unit Dial), Inject 20 units subcutaneously at 8:00 AM daily for Diabetes. Hold for blood sugar level below 300 milligrams per deciliter or if breakfast is refused Upon reconciliation of physician orders on 5/8/2024 at 11:30 AM, it was determined that Licensed Practical Nurse #4 provided the incorrect type of Insulin and the incorrect dose to Resident #122. Registered Nurse Supervisor #1 was interviewed on 5/8/2024 at 12:51 PM and stated Resident #122 should receive all prescribed medications as ordered. Registered Nurse Supervisor #1 stated they would educate Licensed Practical Nurse #4 regarding insulin administration. Licensed Practical Nurse #4 was re-interviewed on 5/9/2024 at 7:00 AM and stated on 5/8/2024 they administered 10 units of Admelog insulin to Resident #122 instead of the Semglee long-acting insulin, in error. Licensed Practical Nurse #4 stated the resident should not have received the Admelog insulin because the resident's blood glucose was lower than 300 (milligrams per deciliter). The Director of Nursing Services was interviewed on 5/9/2024 at 12:28 PM and stated Resident #122 received the wrong type of insulin on 5/8/2024. The Director of Nursing Services stated that they spoke with Licensed Practical Nurse #4 who acknowledged that Resident #122 accidentally received 10 units of Admelog instead of Semglee, the long-acting insulin. The Director of Nursing Services stated that they expected Licensed Practical Nurse #4 to administer medications as per the Physician's orders. The Medical Doctor was interviewed on 5/9/2024 at 12:52 PM and stated Resident #122 received the short-acting insulin instead of the long-acting insulin. The Medical Doctor stated the Physician's order specifically indicated to not administer Admelog insulin when the resident's blood glucose level was lower than 300 milligrams per deciliter. The Medical Doctor stated when a wrong type or wrong dose of insulin is administered, the resident's blood glucose could drop significantly and could potentially harm the resident. 10 NYCRR 415.12(m)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 5/1/2024 and completed on 5/9/2024 the facility did not provide a sanitary and comfortable environment for residents, staff, and the public. Specifically, four live roaches, one dead roach, and one unidentified crushed insect were observed in the first-floor conference room. Additionally, the kitchen shelf, where the Styrofoam cups were stored, was observed to have a heavy accumulation of dust and debris beneath it. The finding is: The facility policy titled Pest Control dated 10/18/2022 documented the facility has an ongoing pest management program that includes prevention, control of pest activity, and infestation, and ensures that proper handling of all pesticides is in place. On 5/1/2024 at 9:45 AM, two one-gallon beverage urns containing both coffee and hot water were served to the survey team along with a sleeve of Styrofoam coffee cups and individual creamers. Upon preparing one cup with coffee and creamer, 4 small live roaches were observed floating on the coffee surface. The facility Administrator was interviewed on 5/1/2024 immediately after the observations and stated that they believed that the insects may have originated from the cups which were supplied by the facility kitchen. The Pest Management Service Inspection Report Records dated 5/3/2023 through 4/28/2024 were reviewed. Roach activity was reported on 5/31/2023, 7/18/2023 and 8/1/2023. Reports documented observations of crawling bugs on 8/22/2023 at the 1st-floor nursing station on 2/12/2024. Multiple recommendations were made in the reports to the facility for better sanitation practices in the kitchen to prevent insect intrusion. On 5/1/2024 at 11:30 AM, the facility's coffee / hot water urns which supply resident coffee and hot water were inspected in the kitchen while accompanied by the Food Service Director. The coffee/hot water urns showed no evidence of insects; however, appeared to have an accumulation of dust on the surface of the machine. The Food Service Director stated that the coffee / hot water urns should have been cleaned every morning by the incoming shift but did not appear to have been cleaned at that time. Dietary Aide #1 was interviewed and stated that they were responsible for cleaning the coffee and hot water urns but did not conduct a thorough job of cleaning them that morning. The dry storage area where the Styrofoam cups originated from was inspected. The area beneath the shelf where the cups were stored was observed to have a heavy accumulation of dust and debris beneath it. On 5/1/2024 at 12:42 PM, the cabinet immediately below the coffee urns in the facility's conference room was inspected; one unidentified crushed insect within the cabinet and one dead roach in a glue trap behind the cabinet were found. This was immediately reported to the Administrator. The Administrator stated that the glue trap behind the cabinet was placed by the pest control company and denied any previous observations of roaches. 10 NYCRR 415.29

Based on observation, record review and staff interviews during the Recertification Survey initiated on 6/15/2022 and completed on 6/27/2022, the facility did not ensure that each resident had a comprehensive person-centered care plan developed and implemented, that included measurable objectives and timeframes to meet the resident's medical and nursing needs. This was identified for one (Resident #33) of one resident reviewed for abuse. Specifically, Resident #33 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence that a care plan with measurable goals and interventions was developed for the use of the PIV line or antibiotic. The finding is: Resident #33 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 12 which indicated the resident had moderately impaired cognition. The MDS documented the resident had Pleural Effusion. During an observation conducted on 6/15/2022 at 11:30 AM Resident #33 was observed lying in bed. Resident # 33 was awake, alert and responded appropriately to greetings. The resident was observed with a PIV line to the left hand. A Physicians order dated 6/11/22 documented to place a peripheral intravenous (PIV) line, flush PIV line every shift for one day, and Sodium Chloride Solution 0.9% at 60 milliliters (ml) an hour intravenously one time only for Hypotensive episode. A Nursing note dated 6/12/2022 documented that a Peripheral 22 gauge [needle] IV was placed in the resident's left forearm. Normal saline fluid was to be administered at 60 ml/hour for 24 hours as ordered. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] ??). The resident's Electronic Medical Record (EMR) was reviewed on 6/27/22. The EMR lacked documented evidence of that a Comprehensive Care Plan (CCP) was developed for the initiation of IV fluids due to an Hypotensive episode and for the use of [MEDICATION(S)] due to Pneumonia. Registered Nurse (RN #2) Manager was interviewed on 6/27/22 at 3:24 PM and stated that they (RN #2) were responsible for updating the CCP to include that the resident had a peripheral IV line and was receiving IV Hydration and oral Antibiotic therapy. RN #2 stated that it was an oversight and that they (RN #2) usually initiates a CCP for infection and incorporates the antibiotic and IV in the CCP. RN #2 stated that a CCP should have been developed that included appropriate goals and interventions to reflect that the resident had a PIV line for Hydration and was receiving antibiotic therapy. The Director of Nursing Services (DNS) was interviewed on 6/27/22 at 3:40 PM and stated that the RN Managers, RN Supervisors or the RN in charge on the day the PIV was placed and when the antibiotic was ordered was responsible for initiating the CCPs. The DNS further stated a CCP should have been initiated for the PIV and for the antibiotic therapy. 415.11(c)(1)

Based on observation, record review and interviews and during the Recertification Survey initiated on 6/15/2022 and completed on 6/27/2022, the facility did not ensure that residents who use [CONDITION(S)] drugs received Behavioral Interventions in an effort to discontinue these drugs prior to the administration of the as-needed (PRN) [CONDITION(S)] medication. This was identified for one (Resident #99) of six residents reviewed for Unnecessary Medications. Specifically, Resident #99 received [MEDICATION(S)] ([MEDICATION(S)]-an antianxiety medication) PRN with no documented evidence that non-pharmacological interventions were attempted prior to the administration of the antianxiety medication. The finding is: The [CONDITION(S)] medication policy dated 6/24/2019 documented that orders for [CONDITION(S)] medications are only for the treatment of specific medical and /or psychiatric conditions or when the medication meet the needs of the patient to alleviate significant distress that are not met by the use of non-pharmacologic approaches/interventions. Non-Pharmacological interventions will be attempted and documented prior to the use of [CONDITION(S)] medications. Resident #99 was admitted with diagnoses including Dementia, Major Depressive Disorder, and Anxiety Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severely impaired cognition. The MDS indicated the resident did not exhibit behavioral symptoms in the MDS look-back period. The Physician's order dated 2/18/2022 and last renewed on 6/19/2022 documented [MEDICATION(S)]([MEDICATION(S)]), 0.5 milligrams (mg) one tablet by mouth every 12 hours as needed for Anxiety. The Comprehensive Care Plan (CCP) dated 2/23/2022 titled the resident uses anti-anxiety medications ([MEDICATION(S)]) included interventions to offer non-pharmacologic interventions such as conversation, hand massage, diversional activities, music therapy, redirection, reassurance, education on deep breathing and relaxation techniques, or to provide a quieter environment. The Medication Administration Record (MAR) revealed that Resident #99 received [MEDICATION(S)] 0.5 mg one tablet as follows: 10 occasions in February 2022; 42 occasions in March 2022; 35 occasions in April 2022, 21 occasions in May 2022, and 11 occasions in June 2022. The Psychiatry Physician Assistant (PA) progress note dated 6/15/2022 documented to continue the current psych medication regimen as prescribed. The progress note further documented that Resident #99 will not benefit from a Gradually Dose Reduction (GDR) at this time as it may affect their ability to function and could lead to cognitive decline. The progress note further documented that the Psychiatry follow-up would be in 3 months, and then as needed. Certified Nursing Assistant (CNA) #11 was observed on 6/27/2022 at 10:56 AM sitting next to Resident #99 in their (Resident #99's) room, drawing with Resident #99. Resident #99 was observed trying to throw the art supplies from the table. CNA #11 was interviewed on 6/27/2022 at 10:58 AM and stated they (CNA #11) were assigned to Resident #99's room which has a total of four residents. Resident #99's room has a CNA assigned daily 24 hours a day. CNA #11 stated that their job was to make sure the residents in this room were being occupied with drawing, listening to music, and reading books. CNA#11 stated Resident #99 gets very anxious at times. CNA #11 stated they (CNA #11 ) call the nurse when Resident #99 gets anxious, is crying aloud, and tries to swing their arms. CNA #11 stated that nurses administer medications to Resident #99 for Anxiety. CNA #11 stated they (CNA #11) do not document the interventions they attempt anywhere, they just call the nurse. The License Practical Nurse(LPN)#1 was interviewed on 6/27/2022 at 11:10 AM and stated that they (LPN #1) administer [MEDICATION(S)] 0.5 mg one tablet every 12 hours as needed to Resident #99. LPN #1 stated they documented in the MAR that the antianxiety medication was administered however, they (LPN #1) did not document what non-Pharmacological interventions were attempted. LPN #1 stated there is one CNA dedicated to Resident #99's room twenty-four hours, every day to monitor and help the residents with their Anxiety and to make sure they (residents) were safe. LPN #1 stated Resident #99 could verbalize that they are anxious. LPN #1 stated that Resident #99 gets agitated, yells, screams, and throws things. LPN #1 stated they (LPN #1) did not attempt any non-pharmacological interventions for Resident #99 because there is a CNA assigned to the resident's room all day. The Registered Nurse (RN) #2 was interviewed on 06/27/2022 at 11:05 AM and stated they (RN#2 ) were the unit manager. RN #2 stated Resident #99 was impulsive and very anxious at times. RN #2 stated there was one CNA dedicated to Resident #99's room around the clock twenty-four hours, every day to help Resident #99 with their anxiety and to make sure they (Resident #99) were safe. RN #2 stated that the nurses are supposed to document the non-pharmacological interventions attempted before each use of the PRN antianxiety medications. The Primary Medical Doctor (MD) #1 was interviewed on 06/27/22 at 12:47 PM and stated that Resident #99 was receiving [MEDICATION(S)] 0.5 mg while they were in the hospital. MD #1 stated that [MEDICATION(S)] 0.5 mg was on the hospital discharge medication list for Resident #99's anxiety disorder. MD #1 stated that Resident #99's family member was in the facility every day to visit Resident#99. They further stated that Resident #99's family member was in agreement to use [MEDICATION(S)] for anxiety. MD #1 stated that they (MD #1) attempted a Gradual Dose Reduction (GDR) on 6/1/2022 from 0.5 mg every 8 hours to every 12 hours PRN. MD #1 stated that they knew the facility was implementing the non-pharmacological interventions, but they did not know the staff was not documenting those interventions. The Director of Nursing Services (DNS) was interviewed on 6/27/22 at 3:04 PM and stated that there was one CNA dedicated to Resident #99's room for implementing the non-pharmacological interventions and to make sure the residents were safe in that room. The DNS stated that there was a form entitled Behavior Monthly Flow Sheet'' for the nurses to use each time before administering PRN antipsychotic medications, however, the Behavior Monthly Flow Sheet was not initiated and completed for Resident #99. The DNS stated they (DNS) do not know why the nurses were not using this form for Resident #99. The DNS further stated that they (DNS) will educate the nurses to use this form to document the non-pharmacological interventions. 415.12(I)(2)(ii)

St. [NAME] Rehabilitation and Healthcare NY 638 9/13/2021 F689 D Based on observation, record review and staff interviews during an abbreviated survey (Complaint # NY 638) conducted on 9/13/2021, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for two (Resident #1 and Resident2) of three residents reviewed. Specifically, Resident #1 was observed without floor mats in place. Resident #2 was observed without a perimeter mattress in place. The findings are: The facility's policy titled Falls Prevention protocol dated 6/25/2019 documented the Registered Nurse (RN) assessment and any new actions will be implemented as ordered. The Unit Manager and Director of Nursing Services (DNS) will be notified of the fall and interventions taken. The plan of care will be reviewed and revised to include the fall and new interventions placed to prevent further falls. The policy also documented If there is a change in the plan of care or a change in the approach to the patient safety, staff will be trained/in-serviced as needed to ensure understanding and compliance with safety measures. 1) Resident #1 was admitted on [DATE] with diagnoses including [CONDITION(S)], Below the Knee [CONDITION(S)] and [CONDITION(S)]. The Admission Minimum Data Set (MDS-an assessment tool) dated 7/2/2021 documented the resident's Brief Interview for Mental Status (BIMS) score was 7 indicating severely impaired cognition. Resident #1 required total assistance of two persons for transfers, extensive assistance of two persons for bed mobility and toilet use. Resident #1 had impaired range of motion on bilateral lower extremities. Resident #1 had 2 falls documented since admission with no injury. The Fall Risk Review dated 6/25/2021 documented resident with score of 18 indicating high risk for falls. The Comprehensive Care Plan (CCP) dated 6/25/21 documented the resident is at risk for falls related to gait/balance problems. The Interventions included anticipate and meet the resident's needs, be sure the residents call light is within reach and encourage to use it for assistance as needed, bed in the lowest position, provide safe, secure and clutter free environment. The Accident/Incident (A/I) report dated 6/26/21 at 11:00 AM and Nursing Progress Notes (NPN) dated 6/26/21 at 11:20 AM documented the resident was observed lying on the floor next to the bed. The Resident has diagnosis of Dementia and Absence of left leg below knee. The vital signs were stable and no change in baseline mental status. There was no new skin or musculoskeletal injury. An intervention documented floor mats ordered. The CCP dated 6/26/2021 documented the resident had an actual fall with no injury related to Dementia/ absence of left leg. The floor mats were added as an intervention on 6/28/2021. The Certified Nurse's Aide Kardex/Tasks as of 9/13/2021 had no documented evidence of floor mats intervention. The A/I dated 7/1/2021 at 2:40 AM and NPN dated 7/1/21 at 6:32 AM documented the resident was observed lying on the floor beside the bed in his room. The Resident with unwitnessed fall with no injury. No bumps/ bruises were noted or sign of pain. The recommendations included neuro checks every 4 hours for 24 hours, 30 mins checks for the rest of the night. The facility's investigative worksheet dated 7/1/21 documented the resident was last seen at 11:30 PM uncomfortable in bed and moving a lot. The Resident had no floor mats in place. The new intervention added 7/1/21 was to place the resident on 30 minutes visual checks The Certified Nursing Assistant Accountability Record (CNAAR) for 7/1/2021 to 9/13/2021 lacked documented evidence that the floor mats and 30-minute visual checks were part of resident's safety protocol to prevent falls. Resident #1 was observed on 9/13/2021 at 12:45 PM in a semi-lying position in bed there were no floormats observed on either side of the bed. 2) Resident #2 was admitted [DATE] with diagnoses including Transient Cerebral Ischemic Attack, Anxiety Disorder, Dementia and Heart Failure. The MDS dated [DATE] documented the resident with BIMS score of 10 indicating moderately impaired cognition. The resident required extensive assistance of two persons for bed mobility. The admission falls risk review dated 7/15/2021 documented a score of 29 indicating high risk for falls. The CCP dated 7/16/2021 documented the resident is at risk for falls related to gait and balance problems. Interventions included anticipate and meet resident's needs, be sure call light is within reach and encourage use of it for assistance as needed, provide safe, secure and clutter free environment, provide toileting assistance as per resident's needs. The A/I report dated 7/20/2021 at 1:20 AM and NPN dated 7/20/2021 at 7:44 AM documented the RN was called to assess the resident that was observed lying on the floor on the left side of the bed at 1:20 AM. The resident with no change in mental status. The resident denies pain or discomfort and no injuries were noted. The resident was assisted back to bed and peripheral mattress was requested from maintenance. A post fall unit huddle was done on 7/20/2021 indicating the root cause of the incident was poor bed mobility and the team instituted a peripheral mattress as immediate plan of correction. The CCP dated 7/20/2021 documented the resident had an actual fall with no injury related to poor bed mobility. The interventions included continue with interventions on at risk plan, peripheral mattress and determine causative factors of the fall. The CNAAR dated 9/13/2021 documented a peripheral mattress as one of the safety interventions. A review of the CNAAR dated 7/2021 to 9/13/2021 lacked documented evidence that the presence of peripheral mattress was checked every shift. Resident #2 was observed on 9/13/2021 at 12:10 PM sitting in a wheelchair in her room. The mattress was observed to be a regular mattress and not a peripheral mattress. An interview was held with CNA #1 on 9/13/2021 at 12:30 PM while in Resident #2's room. CNA #1 did not know what type of mattress Resident #2 had and was not sure what was written in the accountability record. An interview and observation were held with the Registered Nurse Manager (RNM) on 9/13/2021 at 12:35 PM. The RNM stated that Resident #2' mattress is not a peripheral mattress. The RNM checked the medical record and stated the plan of care documented an intervention for peripheral mattress. An interview and observation were held on 9/13/21 at 12:45 PM with the RNM. The RNM stated resident #1 did not have floormats in place. The RNM checked the medical records and stated the plan of care documented an intervention for floormats but it was not documented in the CNAAR. A subsequent interview was held on 9/13/21 at 2:00 PM with the RNM. The RNM stated Resident #1 had a second fall but was not sure what the updated intervention was. The RNM stated there is no documented evidence the 30-minute monitoring was documented in the CNAAR. The RNM stated the RN who did the incident report was responsible to ensure the intervention for falls was in place, documented in the progress notes, care plans and CNAAR then pass it along to the next shift. The RNM stated she is responsible to perform audits of the care plans and ensure that interventions were in place, but she did not do the audit. CNA #2 was interviewed on 9/13/2021 at 12:45. CAN #2 stated Resident #1 used to have floormats but does not have them now. In the beginning Resident #1 tried to get up, but now stays in bed majority of the time. CNA #2 stated Resident #1 had history of falls and could not remember the interventions put in place. Additionally, CNA #2 stated Resident #1 was not on 30 minutes visual checks. A subsequent interview was held with CNA #2 on 9/17/2021 at 2:11 PM. CNA#2 stated Resident #2 was not on a mattress with wings (peripheral mattress) and could not recall if the CNAAR documented a peripheral mattress. The Director of Nursing Services (DNS) was interviewed on 9/13/21 at 2:24 PM. The DNS stated the A/I is generated by RN Supervisor (RNS). The RNS would place intervention to prevent the fall from recurring depending on the cause of the fall. The RNS is responsible to get the supply needed (i.e.): floormats, which are available in RNS supply room. The DNS stated If a peripheral mattress is implemented Housekeeping would provide it. The RNS is responsible to update interventions in the A/I, care plan and CNAAR. The DNS reviewed the A/I and stated on 6/26/21 Resident #1 had a fall from bed and the intervention was to initiate floormats. The DNS did not know why Resident #1 did not have floormats in place. The DNS reviewed the A/I dated 7/1/2021 for Resident #1 on 9/13/21. The DNS stated Resident #1 should have had the floormats in place when he fell , but the investigation documented there were no floormats. The DNS stated the RNS documented to initiate 30 minutes visual checks as a new intervention, but did not see the 30 minutes checks documented in CNAAR and should have been. The DNS reviewed the A/I dated 7/20/21 for Resident #2 on 9/13/21. The DNS stated the RNS initiated a peripheral mattress as a new intervention which was documented in the CNAAR. The DNS stated Resident #2 should have had the peripheral mattress and the CNA should have been aware and signing that the peripheral mattress was in place. An interview was held with the evening shift CNA #4 on 9/13/21 at 3:45 PM. CAN#4 stated Resident #1 was not at risk for falls, did not have floormats and was not on 30 minutes visual checks. CNA #4 stated it was not documented in the CNAAR, so was not aware. 415.12(h)(2)

Based on record review and staff interviews during an abbreviated survey (Complaint # NY 328) conducted on 7/15/2021, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that were complete and accurately documented for one (Resident #1) of three residents reviewed for nutrition and hydration. Specifically, Resident #1's medical record lacked documented evidence of food and fluid intake. The findings were: The facility's policy titled Charting and Documentation undated documented all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. Resident #1 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment tool dated 1/26/2021 documented a Brief Interview for Mental Status (BIMS) score of 5 indicating severely impaired cognition. Required extensive assistance of one person for eating. The Comprehensive Care Plan (CCP) dated 1/28/2021 documented resident has a nutritional/hydration problem related to [CONDITION(S)], Dementia, and Hypertension. Interventions included to monitor intake and record every meal. The Certified Nursing Assistant Accountability Record (CNAAR) from 1/19/2021-1/31/2021 lacked documented evidence of meal intake for 9 out of 12 breakfasts, 11 out of 12 lunches, 7 out of 13 dinners. On 5 out of 13 days there was lack of documented evidence of fluid intake. The Dietitian Progress note dated 1/20/2021 at 4:49 PM documented that meals are served in resident's room and Resident #1 requires assistance as needed with meal tray set up and feeding for completion of meal. The Certified Nursing Assistant (CNA) was interviewed on 7/23/2021 at 1:25 PM and stated they are to document how much a resident eat or drink in the kiosk - the electronic medical record (EMR). If the resident eats less than 50%, that information should be reported to the charge nurse and documented in the kiosk. The Licensed Practical Nurse (LPN) was interviewed on 7/23/2021 at 2:15 PM and stated when CNA's feed residents they are to document and report meal intake of less than 50%. The Registered Nurse (RN) Supervisor monitors the documentation of meal and fluid intake. Stated that they were not aware that Resident #1 had eaten less than 50% for 3 consecutive meals. The Registered Nurse (RNS) Supervisor #2 was interviewed on 8/2/2021 at 12:36 PM and stated that when CNA's document that residents eat less than 25% for 3 consecutive meals, then they will receive an alert on the EMR. The RNS stated that if CNA's do not document or report meal and fluid intake, then they will not get an alert to address poor intake. The facility's current Registered Dietitian (RD) was interviewed on 8/18/2021 at 9:39 AM and stated that if a resident ate less than 50% for 3 consecutive meals, then they would recommend high calorie meals, high calorie shakes or both. The Director of Nurses (DON) was interviewed on 8/2/2021 at 2:44 PM and stated if residents eat less than 50%, the nurse should be informed. Stated that the CNA did not document meal and fluid intake on the CNAAR for Resident #1. 415.22(a)(1-4)

Based on record review and staff interview during the recertification survey the facility did not ensure that each resident was assessed using the quarterly review assessment tool specified by the State and approved by CMS not less frequently than once every 3 months. This was evident for one quarterly MDS assessment review identified for 1 (Resident #3) of 38 sampled residents. Specifically, Resident # 3's Quarterly Minimum Data Set (MDS) Assessment was due 9/1/19 but was not completed within the 3 month required time frame. The previous quarterly MDS completion date was 6/1/19. The finding is: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly MDS assessment dated [DATE] documented the resident had long and short term memory loss and modified independence in making decisions. Review of the medical record revealed there was no documented evidence the quarterly MDS assessment due by 9/1/19 was completed timely. An interview was held with the Registered Nurse (RN) MDS Coordinator on 10/8/19 at 9:42 AM. The RN reviewed the medical record and stated there was no documented evidence the Quarterly MDS that was due 9/1/19 was completed. The RN stated the last documented quarterly MDS was dated 6/1/19 and a quarterly MDS should have been completed by 9/1/19 and could not explain why it was not. 415.11(a)(4)

Based on record review and interviews during the recertification survey, the facility did not ensure each resident had a person-centered Comprehensive Care Plan (CCP) developed and implemented to meet preferences and goals, and address the resident's medical, physical, mental and psychosocial needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. This was identified for 2 (Residents #222 and #18) of 7 residents reviewed for Cognition out of a total sample of 38 residents. Specifically, Resident # 222 and # 18 did not have a CCP developed for Cognition. The findings are: 1) Resident #222 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the Brief Interview for Mental Status was not completed. The directions under C0500 documented enter 99 if resident was unable to complete interview. No code was documented. The resident was assessed under section c1000 with Severely Impaired Cognition. There was no CCP to address the resident's impaired cognition. 2) Resident # 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the Brief Interview for Mental Status was not completed. The directions under C0500 documented enter 99 if resident was unable to complete interview. No code was documented. The resident was assessed under section c1000 with Severely Impaired Cognition. There was no CCP to address the resident's impaired cognition. The Social Worker who had completed the cognition MDS section was interviewed on 10/07/19 at 2:38 PM and stated residents with cognitive impairment should have had a CCP developed and could not comment why the CCP was not in the resident's medical record. The MDS Coordinator was interviewed on 10/08/19 at 9:42 AM and stated that the social workers were coding the MDS incorrectly and this may not have triggered a Cognition CCP. The MDS Coordinator stated a Cognition CCP should be in the medical record. 415.11(c)(1)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure that a resident who required assistance with Activities of Daily Living (ADL) received the necessary services for Toileting and Bladder Incontinence. This was identified for one (Resident # 171) of one resident reviewed for ADLs. Specifically, Resident # 171 stated on 10/03/19 that incontinent care had not been completed from the 11:00 PM - 7:00 AM night shift (starting on 10/02/19). The resident was observed on 10/03/19 at 10:30 AM in bed in a urine soaked diaper despite the call bell being initiated. The finding is: Resident # 171 was admitted to the facility on [DATE] for short term rehabilitation with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was independent in decision making with no memory problems. The resident required extensive assistance of one staff member for toilet use, and limited assist of one staff member for personal hygiene. The MDS documented the resident was frequently incontinent of urine and occasionally incontinent of bowel. The resident was not on a toileting schedule. The Comprehensive Care Plan (CCP) for ADLs, initiated on 7/22/19 and updated 8/7/19, documented the resident required limited assist of one staff member for toileting and personal hygiene. The CCP for Bladder Incontinence, initiated on 7/30/19, documented the resident was incontinent of bladder and was to be checked for incontinent care as needed. The CCP did not address that the resident was toileted on request. On 10/03/19 at 10:30 AM the resident's call bell was observed lit. The resident was in bed and the resident's diaper was observed by the surveyor to be heavily soaked with urine. There was a strong urine odor in the room. The resident stated at that time (10:30 AM) that she was wet and had not been changed since the 11:00 PM-7:00 AM shift that day. The Certified Nursing Assistant (CNA) Accountability Record documented on 10/03/19 that the resident had incontinent care by the 11:00 PM-7:00 AM shift at 5:10 AM. The 7:00 AM-3:00 PM CNA documented the resident had incontinent care at 1:03 PM (13:03). There was no documentation that the resident was toileted or received incontinence care between the night shift at 5:10 AM and the day shift at 1:03 PM. The Licensed Practical Nurse (LPN)/Charge Nurse on the resident's unit was interviewed on 10/08/19 at 11:01 AM. The LPN stated that Resident # 171 is toileted on request and is incontinent overnight. On that day (10/03/19) the resident was scheduled for a shower and that is why she was in bed. The LPN stated that care would not have been rendered unless the resident had used the call bell. The LPN further stated that the breakfast trays are served on the unit at 7:00 AM and that unless a resident needs care and the call bell is ringing, the morning care starts after breakfast. The LPN did not recall if the call bell was on for the resident's room. CNA # 1 was interviewed on 10/08/19 at 12:45 PM. The CNA stated that she was not the regular CNA for Resident # 171. The CNA stated that when the staff comes in on the day shift at 7:00 AM, the breakfast trays are up and staff immediately start handing out the trays. The CNA stated that if the resident is ringing the call bell the care will be rendered, otherwise, care does not start until after breakfast. CNA #2, who showered the resident on 10/03/19 was interviewed on 10/08/19 at 1:00 PM. The CNA stated that her assignment was to shower the resident and the CNA did not administer any morning care. The CNA stated that the resident had been toileted prior to the shower. The shower was documented to have been completed at 1:03 PM. The CNA #3 who was responsible for the resident's care that day was interviewed on 10/08/19 at 1:11 PM. The CNA stated that she was not the resident's regular aide. The CNA stated that she was assigned to the resident on 10/03/19, day shift. The CNA stated that if the resident had not used the call bell prior to breakfast there would not have been any care administered. The CNA stated that rounds and care are not started until after breakfast and that the resident was changed when the call bell was initiated, around 10:30 AM. The CNA further stated that she had not served the resident her breakfast tray that morning and did not know who had. 415.12(a)(3)