Every finding on record at St Josephs Home

Based on observations, record review, and interviews, the facility failed to ensure residents were treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality during meal service in two (2) of two (2) dining rooms (First and Second floor dining rooms). Specifically, residents stated they were not allowed to visit residents at other tables and/or visitors were not allowed to visit in the dining rooms during and after mealtimes. Findings include: The facility policy Resident's Rights Policy, reviewed 11/2025, documented the residents were provided a homelike environment which fully provides their right to a dignified existence. The residents had a right to a homelike environment and to incorporate personal and cultural preferences within their goals of care. Residents have the right to immediate and unlimited access by friends and family. Residents had the right to interact with members of the community both inside and outside the facility and the right to make choices about their life in the facility that were significant to them. The facility policy Dining Room Management, created 02/12/2026, documented the dining room provided space for all admitted residents and may have space for family members who received permission to be in the dining room to assist their loved one or a compassionate care visit. Seating charts were prepared by the interdisciplinary team to consider the physical and social needs of the residents and the ability of the staff to manage the dining room to focus on the needs. Residents can request to move seats, and the change would be evaluated by the interdisciplinary team; the change may not be initiated if determined by the interdisciplinary team to be detrimental to others. The facility reserved the right to limit movement in the dining room during mealtime. Residents often have complications related to medical and social status which can place others at risk. If residents have difficulty with the standards and place others at risk who may not understand the risk, staff will communicate with the residents. Staff were to utilize calm and kind tones when communicating with a resident struggling with the policy and encourage them to meet up with other residents in common areas after the mean. A team approach should be utilized for any difficulty encountered.During an interview on 03/16/2026 at 12:30 PM Resident #26's adult sibling stated the resident always ate lunch in their room because the facility did not allow visitors in the dining room so they could not visit with the resident during meals.During a dining room observation and resident interview on 03/16/2026 at 12:47 PM, Resident #70 was sitting in a chair at a table that was not their assigned table, visiting with Resident #74. Resident #70 stated they wanted to visit other tables while they finished lunch but was told they could not, even if the residents at other tables did not care. Resident #74 stated they did not mind Resident #70 coming to their table to talk and visit. At 12:52 PM, Resident #70 moved their chair next to Resident #23, off to the side from the table. Other residents asked Resident #70 to come sit next to them. Registered Nurse Unit Manager #5 stated to Resident #70 to sit at their own table until lunch was over and then they could visit in the lounge area. The resident declined. Registered Nurse Unit Manager #5 stated Resident #70 should be able to visit.During an observation on 03/19/2026 at 11:57 AM Social Worker #15 was giving a facility tour and stated to the touring family the facility was flexible. The family could bring the resident to dining room, but they could not sit with the resident during the meal.During a dining room observation and resident interview on 03/19/2026 at 12:45 PM, Resident #70 finished their lunch and sat in an open seat at the table next to theirs. At 12:48 PM, Certified Nurse Aide #8 approached Resident #70 and asked the resident to go back and sit in their own seat. Resident #70 asked why, and Certified Nurse Aide #8 stated they were supposed to stay in their own seat. The resident declined to move. Certified Nurse Aide #8 stated they would let Licensed Practical Nurse #9 know. Resident #23 congratulated Resident #70 for not moving and stated they could visit if they wanted. At 12:49 PM Licensed Practical Nurse #9 came over and began speaking quietly with Resident #70. Licensed Practical Nurse #9 stated to the resident they could visit when the other residents were done eating and they were previously told that. Resident #70 stated everyone was done eating; two of the other three residents were done, and the third was picking at chips on a plate. Licensed Practical Nurse #9 stated it was hard because Resident #70 just wanted to visit with the table. At 12:57 PM, Resident #70 stated they were told they were not allowed to visit with their friends during meals due to germs. Resident #32 stated everyone had germs and they did not mind Resident #70 coming to visit. During an interview on 03/19/2026 3:03 PM, Resident #32 stated their adult grandchild came from out of state to visit during the dinner meal last evening on 03/18/2026 and surprised the resident and their spouse, who also resided at the facility. They stated they were just about done with dinner when their adult grandchild came over to say hello and pulled a chair up near the table. Before they could sit or say anything a staff member told their grandchild they could not sit down. Licensed Practical Nurse #9 came over, spoke with their grandchild and went to the phone to call someone about the rule. Their grandchild came back and stated they had to leave, and Resident #32 stated they had just gotten there and to pull up a chair. Their grandchild stated they were not allowed to because people were eating and the person Licensed Practical Nurse #9 had called told them they could not stay. Resident #32 stated they had been at the facility since May 2024, and this was the first time they heard the rule. They felt it was a foolish and nonsense rule. They stated if they were home and someone came to visit, they would have them sit down even if it was mealtime. Their grandchild did not ask for dinner, they just wanted to visit. The resident stated their spouse, who was also in the facility, had dementia and had not been doing well and their grandchild wanted to visit. During an interview on 03/19/2026 at 11:21 AM, Certified Nurse Aide #7 stated there was assigned seating in the dining room. If a resident wanted to sit somewhere else, staff should try and redirect the resident to the right spot. There were a few residents who liked to socialize at other tables in the dining room when they were done eating and there was one table that socialized a lot. There were no complaints from residents about Resident #70 visiting them at their table in the dining room.During an interview on 03/19/2026 at 12:01 PM, Certified Nurse Aide #8 stated if a resident wanted to sit somewhere other than their assigned seat in the dining room staff were to redirect them and explain everyone had their own seat for the dietary staff to follow. Residents were encouraged not to socialize with residents at other tables after they were done eating in the dining room. Once the residents were done eating, the dining room had to be cleared out in a timely manner, so it was best to socialize in the lounge not the dining room. Resident #70 was a very social person and had issues following the guidelines in the dining room and needed a lot of reminding and redirecting. The other residents in the dining room did not complain about Resident #70 visiting their table and they enjoyed Resident #70's company.During an interview on 03/19/2026 at 1:35 PM, Licensed Practical Nurse #9 stated if a resident wanted to sit somewhere else in the dining room the staff should not encourage it because if one resident moved, all the residents would want to move. Residents were allowed to socialize at other tables in the dining room if they were all finished eating. None of the residents at the table Resident #70 visited had any issues with Resident #70 coming to visit their table. They stated they believed the residents had a hard time with the rule because it would be no different than if they were out at restaurant and asked someone to sit down. Families were only allowed to sit with residents in the dining room if the resident was care planned for it. If a family member was just visiting at mealtime they were not allowed to sit down if the residents were eating. During an interview on 03/20/2026 at 9:30 AM, Registered Nurse Unit Manager #5 stated seats were assigned in the dining room for the kitchen flow for meals and based on residents' needs. Table hopping could make things more confusing as well as cause infection control issues. Residents had the right to finish their meal before they had company. If all the residents were done eating, residents could socialize with other tables but they typically tried to clear out the dining room in a timely fashion so the kitchen could be cleaned and intakes done. Residents could visit in the lounge or in activities. The residents at the table may not be concerned with another resident visiting them while they were still eating but the staff must look at the whole picture to minimize risks and prevent issues. Extra visitors in the dining room were also minimized to keep the meal process flowing. Resident #32 could have left the dining room with their grandchild and taken their meal in their room or the grandchild could have waited in the resident's room. If the family visit was going to be on a regular basis, the interdisciplinary team would discuss it, and arrangements could be made. The rules were in place to minimize chaos in the dining room. If every resident wanted to do what Resident #70 did it would create chaos in the dining room and create risks for the residents. It would be difficult for the dietary staff if multiple residents were moving throughout the meal process.During an interview on 03/20/2026 at 10:54 AM Social Worker #15 stated residents could request to move to a different table in the dining room if they wanted but it could not always be accommodated based on care plans, personalities, and hygiene. Family members who wanted to be present during mealtimes had to be approved by the interdisciplinary team. As a standard, they asked families not to be in the dining room unless it was previously approved. Resident #32's grandchild would not have been allowed to stay with them during dinner if the facility was not aware they were coming but they could have gone to the resident's room to wait for them. The policy of no family visitors in the dining was put in place for infection control, for dignity as some residents need assistance for personal hygiene, and for residents to have a meal without interruption or people watching them. The policy for residents not visiting other resident tables in the dining room was for infection control but also because a resident may get upset with another resident for being at their table. Going table to table in the dining room created all sorts of issues. Residents could visit in other areas of facility but were asked to remain at their own table during the dining experience. There was a happy balance between homelike and having residents stay where they were assigned so residents could have their meal in peace. Other areas of the facility were homelike.During an interview on 03/20/2026 at 11:03 AM, the Administrator stated the dining room experience where visitors cannot sit in the dining room or residents visiting other tables began during the COVID-19 pandemic to maximize the experience while protecting residents. Residents visiting other residents in the dining room became a concern regarding space during dining and spreading illness. 10 New York Code Rules and Regulation 415.5(a)

Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for one (1) of three (3) residents (Resident #3) reviewed. Specifically, Resident #3 had diabetes and was responsible for reading their own blood sugar results with a blood glucose sensor device (a small sensor-based system applied to the back of the arm that provides continuous glucose readings without finger sticks). The resident's twice a day weekly blood glucose finger sticks was discontinued without a medical order and their blood glucose levels and sliding scale insulin were not documented as completed two (2) times in March 2026. Findings include:The facility policy Blood Glucose Monitoring, last reviewed 12/2025, documented residents with diabetes mellitus would have their blood glucose monitored by a registered nurse or licensed practical nurse as ordered by the physician and by nursing judgement. The blood glucose would be recorded with the nurses' initials in the medication administration record. There was no documented evidence of a policy for the use of a blood glucose sensor device.The facility policy Physician's Orders, last reviewed 12/2025, documented physician orders were to be signed and dated every 60 days and kept up to date in the resident's medical record. The physician must write an order to discontinue a previous order.Resident #3 had diagnoses including diabetes with diabetic neuropathy (nerve damage). The 2/17/2026 Minimum Data Set documented the resident was cognitively intact; required moderate to set up assistance for most activities of daily living; and received insulin.The 2/12/2026 Comprehensive Care Plan, revised 2/17/2026, documented the resident had multiple medical diagnoses including diabetes with diabetic neuropathy. The resident wanted to utilize their own diabetic monitor, would supply their own sensor patches for glucose checks, and demonstrated the ability to use the monitor for glucose checks. Interventions included monitor for complications and notify the medical provider, vital signs as ordered, provide medications as ordered for medical diagnosis and notify the medical provider as needed, and labs as ordered. The 02/10/2026 physician order documented sliding scale insulin coverage (the amount of insulin administered is based on blood sugar reading) three times a day prior to meals. Administer Novolog (fast-acting insulin) for blood glucose levels as follows: 61-140 milligrams/deciliter = 0 units; 141-200 milligrams/deciliter =3 units; 201-250 milligrams/deciliter =6 units; 251-300 milligrams/deciliter 9 units; 301-350 milligrams/deciliter =12 units; 351-400 milligrams/deciliter =15 units; and greater than 400 milligrams/deciliter 15 units and update physician. The 02/17/2026 Registered Nurse Unit Manager #5 progress note documented Resident #3 had their own glucose monitor sensor with a meter in their room. The resident wished to use the monitor instead of three times a day finger sticks. The provider was updated, and an order was obtained to utilize the glucose monitor with supplies provided by the resident, changing the sensor patch every 15 days, and to use the monitor sensor for glucose checks as ordered, to use the finger stick glucose checks three times a day per the order if the supply was out or the sensor was not working and to have finger sticks twice a day weekly while utilizing the sensor per protocol. The nursing staff were educated, and the sensor patch was applied to the resident's left arm. The sensor meter was charging in the resident's room.The 02/17/2026 telephone physician order documented the resident may utilize their own glucose monitor sensor with their own supplies for their blood sugar checks three times a day and to change the sensors as directed, every 15 days, and to have two times a day weekly finger sticks. The February 2025 Medication Administration Record documented use sensor for glucose checks three times daily and fingersticks twice a day once weekly. The Medication Administration Record did not include an area to document the weekly, twice daily finger sticks.The March 2026 Medication Administration Record documented weekly fingerstick glucose checks to verify sensor at 7:00 AM and 4:00 PM on 03/10/2026 and 03/17/2026. The entry was crossed out with a handwritten error co. There was no documented order to discontinue the two times a day weekly finger sticks. The March 2026 Medication Administration record documented on 03/01/2026 at 4:00 PM the resident had no blood glucose level or units of insulin documented. On 03/06/2026, the resident's blood glucose level was 166 milligrams/deciliter and there were no units of insulin documented as administered per the sliding scale insulin coverage. During an interview on 03/19/2026 at 1:35 PM, Licensed Practical Nurse #9 they knew a resident was diabetic by the diagnosis in their chart and there were diabetic pages in the medication administration record. Resident #3 did their own blood glucose readings through the implanted censor pad, informed the nurse of the number, the nurse wrote the result in the medication administration record, and used the sliding scale to administer the resident their ordered insulin coverage. During a follow up interview on 03/20/2026 at 11:10 AM, they stated they worked the evening shifts of 03/01/2026 and 03/06/2026. They did not know why the blood glucose or amount of insulin given were not recorded. They stated they would have asked the resident their blood sugar result and then give the appropriate insulin. On 03/06/2026, the resident should have received six (6) units of insulin with the recorded blood sugar of 166. They did not know why they did not write it down and it must have just been a slip. They should have recorded the insulin given on both dates. During an interview on 03/19/2026 1:35 PM Registered Nurse Unit Manager #5 stated they were asked by Licensed Practical Nurse #9 if the resident had any quality checks to ensure the sensor pad device was working appropriately. Registered Nurse Unit Manager #5 stated there were orders in the Medication Administration Record. They reviewed the Medication Administration Record and stated the order for the twice a day, once weekly finger sticks must not have been carried over to March 2026. The resident was supposed to have finger sticks weekly to compare to their device. They stated the resident had been using the device but there were issues with insurance, so the resident went back solely to finger sticks until the sensor pads were able to be obtained from the local pharmacy. When they got the new order on 03/03/2026, for the sensors the provider never gave them another order to verify the blood sugar checks with finger sticks. They stated the resident could tell staff if their blood sugar was high or low or if it beeped in the night, so the finger sticks were not needed since the resident did not like them.During a follow up interview on 03/20/2026 at 9:30 AM, Registered Nurse Unit Manager #5 stated the Medication Administration Record should be filled out with the resident's blood sugar level and the number of units of insulin given for a sliding scale. They were unaware the resident did not have the units of insulin given on 03/01/2026 or 03/06/2026. 10 New York Code Rules and Regulation 415.12 (k) (1)

Based on observation, record review, and interviews the facility failed to ensure that residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #12) reviewed. Specifically, Resident #12 received hemodialysis treatments at a community-based dialysis center, and the facility did not have a plan to adequately monitor and care for the resident pre and post dialysis. Findings include:There was no documented evidence of a dialysis policy.Resident #12 had diagnoses including chronic kidney disease and dependence on dialysis. The 12/13/2025 Minimum Data Set assessment documented the resident was cognitively intact, had end stage kidney disease, and was dependent on dialysis treatments.The Comprehensive Care Plan reviewed and revised on 03/15/2026 documented the resident had kidney failure and received hemodialysis on Monday, Wednesday, and Friday at the dialysis center. The care plan did not include any specific care instruction, interventions or potential risk factors related to dialysis. There was no documented evidence of physician orders related to assessing and monitoring the resident's condition post dialysis or how staff were to care for and monitor the resident's dialysis access site. The dialysis and nursing home communication log documented the resident attended dialysis on 02/06/2026, 02/09/2026, 02/11/2026, 02/16/2026, 02/2026, 02/23/2026, 02/25/2026, 02/27/2026, 03/02/2026, 03/04/2026, 0307/2026, 03/09/2026, 03/11/16/2026, 03/13/2026, 03/16/2026.There was no documented evidence of a pre-dialysis evaluation on 02/06/2026, 02/09/2026, 02/11/2026, 02/16/2026, 02/2026, 02/23/2026, 02/25/2026, 02/27/2026, 03/02/2026, 03/04/2026, 0307/2026, 03/09/2026, 03/11/2026, 03/13/2026, 03/13/2026, 03/16/2026, 03/2026, 03/11/2026, 03/13/2026, 03/16/2026. There was no documented evidence of a post-dialysis evaluation on 02/06/2026, 02/09/2026, 02/11/2026, 02/16/2026, 02/2026, 02/23/2026, 02/25/2026, 02/27/2026, 03/02/2026, 03/04/2026, 0307/2026, 03/09/2026, 03/11/2026, 03/13/2026, 03/13/2026, 03/13/2026, 03/16/2026, 03/13/2026, 03/16/2026. During an observation and interview on 03/18/2026 at 12:50 PM, Resident #12 was seated in their wheelchair in their room and stated they recently returned from dialysis. The resident confirmed they received dialysis on Monday, Wednesday and Friday. The resident stated the facility staff did not manage the dialysis access site and did not change the dressing as this was done at dialysis. During a telephone interview on 03/19/2026 at 8:43 AM the Patient Care Coordinator at the Dialysis site stated Resident #12 received dialysis at the dialysis center three days a week. A communication binder was shared between the nursing home and dialysis center to communicate the resident's health status, and any changes in health status, including medication changes. During an interview on 03/20/2026 at 9:16 AM, with the Director of Nursing, stated the dialysis orders were in the resident files stored in the basement. The Director of Nursing could not explain what type of dialysis treatment Resident #12 received. They were also not aware of what type of dialysis access site the resident had, or that the resident required a physician order for dialysis treatments. 10 New York Codes, Rules, and Regulations 415.12(k)

Based on observations, record review, and interviews, the facility failed to ensure a resident was provided medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for one (1) of one (1) resident (Resident #6) reviewed. Specifically, Resident #6 had a history of depression with episodes of night terrors and did not have a person-centered care plan to address the resident's depression and did not have social work follow up to address the resident's history of post-traumatic stress disorder or psychosocial concerns.Findings include:The facility policy Resident's Rights Policy, last reviewed 11/2025 documented the facility would ensure the residents are provided with a home like environment which fully provides their right to a dignified existence including full recognition of their individuality and privacy and to participate in their care possible. The resident has the right to make choices about all aspects of their life. The facility will meet the residents' individual needs and preference to the extent possible through centered care.The facility policy Social History, Trauma Screening, and Psychosocial Assessment and Trauma Informed Consent, last reviewed 11/2025, documented the following:-The social worker was responsible for performing a psychosocial assessment and/or social history related to issues to identify social and emotional problems for each resident admitted .-The social worker will develop an individualized comprehensive assessment and history within seven days of resident admission-The social worker was responsible for the completion of the Trauma Care Screening Tool, with the input from the residents, significant other and family.-Care plans will be updated to show specific psychosocial concerns of the residents and interventions established as needed by resident assessment and choice. Resident #6 had diagnoses including depression and post-traumatic stress disorderwith a history of hallucinations. The 06/30/2025 Minimum Data Set assessment documented the resident's cognitive status was unable to be determined; the resident had no documented behaviors; required moderate to extensive assistance with most activities of daily living; and had psychiatric/mood disorder including depression and post-traumatic stress disorder. The Comprehensive Care Plan- Part 1 initiated on 12/24/2025 documented the resident was alert to self, place, time and confused at times. The section titled, Behaviors did not have anything checked off. The behaviors listed included but were not limited to verbal aggression towards others, resistance to care, or physical aggression toward others. The 01/06/2026 Comprehensive Care Plan completed by the Social Services Manager documented Resident #6 had experienced the following traumatic events: loss of loved ones; parents and stepchild, loss of roles and identity and missed doing things they loved to do such as mowing the lawn. They had a history of post-traumatic stress disorder with regular nightmares. The documented goal was the resident would verbalize their concerns without being troubled by past trauma. There were no specific interventions identified in the resident comprehensive care plan for how to manage the resident's diagnosis. The 01/07/2026 Comprehensive Care plan completed by Registered Nurse Unit Manager #5 documented the resident had depression with post-traumatic stress disorder related to being in the war, with a history of hallucinations; was admitted to the facility on an antidepressant; the resident had made statements and thought of suicide such as going to sleep and not waking up and when asked by staff, they had no plans to harm themself and denied needing changes to their plan of care. Interventions included administering medications as ordered, psychiatry consultations as needed, monitor for hallucinations, and monitor for complications when stopping medications. This care plan documented the resident's Cymbalta (antidepressant) 40 milligrams was gradually reduced starting 10/04/2021 and eventually discontinued on 07/08/2025. The physician orders dated 02/10/2026 did not include any order for psychotropic medications. There was no documented evidence of social work progress notes from 10/01/2025 through 03/18/2026. Nursing progress notes documented:-on 01/18/2026 by Licensed Practical Nurse #10 the resident was found to be ripping their incontinence briefs and throwing them on the floor.-on 01/19/2026 by Licensed Practical Nurse #10 the resident continued to rip their incontinence briefs off during the night and throw them on the floor.-on 01/21/2026 by Licensed Practical Nurse #11 the resident refused their weekly shower and refused breakfast. -on 02/22/2026 by Licensed Practical Nurse #6 the resident was extremely combative at lunch, refusing to get out of bed. The resident was hitting and grabbing at multiple staff. The resident was extremely combative at lunch, refused out of bed, and remained in bed until lunch.-on 02/24/2026 by Licensed Practical Nurse #12 the resident continued to be combative with staff. They were resistive to activities of daily living care, refused to attend the dining room, and refused their supper. During an observation on 03/16/2016 at 3:09 PM, Resident #6 was lying in their bed. The resident was awake and smiled when spoken to but did not respond. The room was dark with no lights on, no television on, and no music. During an observation on 03/18/2026 at 11:09 AM, Resident #6 was lying in their bed on their left side covered in their sheet and appeared to be sleeping. The room was dark. There were no lights, television or radio on. The residents did not respond to greeting. During an interview on 03/16/2026 at 5:01 PM, the resident's representative stated they were there to visit recently and the resident just stared into space. They stated they were unhappy with medications changes, and they did not believe the resident's current medications were effective. During an interview on 03/19/2026 at 12:12 PM, the Director of Nursing stated Resident #6 was initially admitted taking Cymbalta for depression and post-traumatic stress disorder. They stated the facility was obligated to trial reductions in medications and the resident was successful with their reduction trial, and they no longer took medication. They stated the resident's status declined since admission. The resident's symptom management included one-to-one supervision or interaction, and if the resident had a behavioral symptom, staff were directed to retreat and reapproach the resident later. They stated the Comprehensive Care Plan part 1 directed the staff on how to best provide care for the resident. The plan did not address the residents' depression or post-traumatic stress disorder but directed the staff to involve the resident in activities.During an interview on 03/19/2026 12:36 PM, Social Services Manager stated the resident had a trauma care plan. The care plan documented the social worker would see the resident and discuss their feelings. The social worker would consult as needed, and the physician would be updated as needed. The resident was discussed frequently, but not because they presented themself as depressed, but with more of a flat affect. The Social Services Manager stated the resident expressed themself with head shaking and they would do a thumbs up or thumbs down. They stated that part one of the care plan did not include this or any behaviors and the resident did not always participate in activities.During an additional interview on 03/19/2026 at 3:20 PM, Social Services Manager stated they did not review any behavioral notes documented for the resident. They stated they have not known Resident #6 to wake up and have behaviors. They stated television was a trigger, and the resident's significant other shared they had nightmares every night prior to facility admission. They stated everyone had access to resident notes and they would be made aware of anything nursing had concerns about. The standard intervention response to behaviors was for staff to retreat and reapproach and ensure safety. The Social Services Manager explained a resident with this type of history they completed rounds on to see if there was something going on with them. They stated they did not write progress notes about the resident. 10 New York State Codes Rules Regulations 483.40(d)

Based on observations and interview the facility failed to post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for five (5) of five (5) days (03/16/2026-03/20/2026) reviewed. Specifically, the facility did not post staffing information at the beginning of the shift on 03/16/2026 and was posted in the afternoon. The posting included the number of staff only and on subsequent days of survey the posting did not include the current resident census, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care.Findings include: During an observation on 03/16/2026 at 1:08 PM there was no staffing posting displayed in the lobby on the sign in table, on the bulletin board above the sign in table, in the reception area, or in the glass cases down the hall from chapel or in the breezeway.During an observation on 03/16/2026 at 3:42 PM a staffing sheet was posted above the Health Survey Results folder on the bulletin board above the sign in table in the lobby. The staffing sheet did not include the number of actual hours worked, only the number of people in each department which included a breakdown of registered nurse, licensed practical nurse, certified nurse aides, activities, laundry, dietary, maintenance, and physical therapy.During multiple observations from 03/17/2026 to 03/20/2026 the posted staffing sheet only included the date and the number of staff working in each department for applicable shifts. The nursing department numbers were broken down into nurses and certified nurse aides only. There was no facility name, no daily census, and no number of actual hours worked.During an interview on 3/20/2026 at 10:24 AM the Administrator stated they posted the facility staff every day in the morning. The purpose of posting the staff was to notify residents' families of the facility's staffing levels if they had questions. The number of hours staff worked were not posted for families to view. The schedules of the staff were posted by the vending machines if someone wanted to read it and they could get the number of hours by the shifts worked. They acknowledged they were aware of what the posting was to include but most people do not understand what the posting meant.10 New York Code Rules and Regulation 415.13(a)

Based on observation, record review, and interview during the recertification survey conducted 3/25/2024-3/29/2024, the facility did not review the risks and benefits of enabler rails or obtain informed consent prior to the installation of enabler rails with the resident or resident representative for 10 of 10 residents (Residents #2, #4, #81, #41, #60, #71, #59, #23, #80, and #62) reviewed. Specifically, there was no documented evidence the risks and benefits of enabler rails were explained to the residents, or their representatives or consents were obtained prior to bed rail use for Residents #2, #4, #81, #41, #60, #71, #59, #23, #80, and #62 Findings include: The facility policy Physical Restraints last reviewed 9/2023, documented the facility is committed to reducing the use of unnecessary physical restraints and ensuring residents are free of physical restraint unless permitted by federal regulation. Physical Restraint included any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident cannot remove easily, and which restricts freedom of movement or normal access to one's body. Enabler Rails are constructed of metal and are used to aide in bed mobility. Types of devices that may be considered restraints include enabler rails. Physical restraint evaluation was to include the interdisciplinary team must carefully weigh the risks and benefits to the resident with the use of restraints and document all considerations on the physical evaluation restraints form. For the resident to be fully informed, the facility must explain, in the context of the individual resident's condition and circumstances, the potential risks and benefits of all options under consideration including use of a restraint, not using a restraint, and alternatives to restraint use. 1) Resident #59 had diagnoses including legal blindness and left sided hemiplegia (muscle weakness or partial paralysis on one side of the body). The 3/5/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had functional limitation with range of motion with impairment of one arm, was dependent for rolling side to side, sit to lying, lying to sitting on edge of the bed, and transfers, and had no enabler rails or alarms. During an observation on 3/26/2024 at 9:00 AM, the resident was in their room in a recliner. There were bilateral enabler rails on their bed. The resident stated they did not know about the rails on their bed. The 11/1/2023 restraint evaluation form completed by the Director of Nursing documented the use of 2 enabler rails, the resident's physical ability to unfasten the device/ask for help, and their cognitive awareness of the purpose. The form documented the device was not considered a restraint. The care plan part 1 (care instructions) initiated 2/29/2024 documented the resident required physical assistance with positioning in bed or chair, transfers, and toileting, and used enabler rails/assistive device. The comprehensive care plan revised on 3/11/2024 documented enabler rails were used for increased independence with bed mobility and were not considered a restraint. Interventions included quarterly assessment if used. The resident was at risk for falls related to visual disturbance, and the resident was legally blind and required assistance from staff for direction during transfers. The resident had times of moving around in bed, turned sideways in bed, and did not know where the boundaries were. The goal was to have no falls during the quarter. Approaches included keep bed in lowest position while occupied, and use of enabler rails/assistive devices to help with bed mobility/boundaries while in bed. There was no documented evidence the risks and benefits of enabler rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of enabler rails. 2) Resident #80 had diagnoses including cerebral infarction (stroke), multiple bilateral rib fractures, and right sided hemiplegia and hemiparesis (paralysis of one side of the body). The 3/12/2024 Minimum Data Set assessment documented the resident had intact cognition, had functional limitations with range of motion in both legs and arms, was dependent with rolling left to right, sitting to lying, lying to sitting, transfers, and did not use enabler rails. During an observation on 3/27/2024 at 9:44 AM, the resident was lying in bed on their back with the head of bed elevated above 30 degrees with enabler rails on both sides of bed. During an interview on 3/28/2024 at 9:30 AM, the resident did not respond when asked if they utilized the enabler rails or if anyone gave consent for their use. During a phone interview on 3/28/2024 at 2:51 PM, the resident's representative stated they did not recall consenting for the enabler rails on the bed or discussing it with anyone at the facility. The 3/7/2024 restraint evaluation form completed by the Director of Nursing documented the use of 2 enabler rails, the resident's physical ability to unfasten the device/ask for help, and their cognitive awareness of the purpose. The device was not considered a restraint. The resident's care plan part 1 (care instructions) dated 3/5/2024 documented the resident was dependent for positioning, toileting, transfers, and personal care. The comprehensive care plan initiated 3/6/2024 documented the resident was unable to position themself independently and therefore required assistance for positioning. Upon admission the resident was very weak with increased right sided weakness and required a mechanical lift for transfers. Approach for bed positioning included head of bed elevated at least 30 degrees for gastrostomy tube feedings. The resident required enabler rails bilaterally, which provided the resident with the ability to be more independent with bed mobility and they were not considered a restraint. A goal was for the resident to communicate more independence with the use of enabler rails. There was no documented evidence the risks and benefits of enabler rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of enabler rails. 3) Resident #4 had diagnoses including dementia and left sided hemiplegia and hemiparesis (paralysis of one side of the body). The 2/12/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, had functional limitation in range of motion on one side of both upper and lower extremities. The resident was dependent for bed mobility, dependent for transfers, and did not use enabler rails. During an observation and interview on 3/25/2024 at 1:36 PM, the resident was in their room in a recliner with pillows on left and right side of her. They had enabler rails on both sides of the bed and shrugged their shoulders when asked if they could use them. During an observation on 3/26/2024 at 11:34 AM, the resident was in bed with enabler rails up. The 2/28/2024 restraint evaluation form completed by registered nurse #2 documented the use of 2 enabler rails, the resident's physical ability to unfasten the device/ask for help, and their cognitive awareness of the purpose. The device was not considered a restraint. The 2/8/2024 care plan part 1 (care instructions) documented the resident required assistance of 2 for positioning in bed or chair and transfers. The comprehensive care plan dated 2/12/2024 documented the resident was a fall risk related to visual disturbance, left sided hemiparesis, and history of falls prior to admission. The resident required enabler rails bilaterally, which provided the resident with the ability to be more independent with bed mobility and were not considered a restraint. There was no documented evidence the risks and benefits of enabler rails were reviewed with the resident or resident representative, or informed consent was obtained prior to the installation of enabler rails. During an interview on 3/28/2024 at 12:11 PM, physical therapy aide #6 stated new residents were evaluated by the physical therapist on admission. Bed enabler rails were used to help residents with increased independence. They could be dangerous, cause entrapment, or could cause injuries. The interdisciplinary team discussed the need for residents to use enabler rails. There was no consent needed if a device was not considered a restraint. Enabler rails did not restrict mobility and usually aided with mobility. Resident #59 could not use enabler rails independently but used them with cueing. They were not sure if there was a specific assessment tool for enabler rail use. During a phone interview on 3/28/2024 at12:24 PM, social worker #9 stated that therapy and nursing assessed to make sure residents were appropriate for enabler rail use. They also determined if they were a restraint and discussed risks. The only time they obtained consent was if it was determined it could be a possible restraint. During an interview on 3/28/2024 at 12:40 PM, registered nurse manager #2 stated enabler rail use was determined on admission or throughout their stay if there was a change of status, and they thought the resident may benefit from them. Nursing and therapy determined together if they were put on, kept, or removed. A head to toe assessment was performed of the residents'' abilities. If they had good range of motion in their upper extremities, then they could reposition themselves better. There was no specific assessment form used. On admission they discussed risks and benefits and there were very few risks. If they thought there was a risk, they would not use them. No written consent was needed. They evaluated the use on the restraint form, if they thought it was a restraint, they could not use them. During an interview on 3/28/2024 at 12:49 PM, the Director of Nursing stated there were no restraints in the facility. Any devices that could potentially be restraints were assessed. Enabler rails, recliners, low beds, seat belts could all be considered restraints. If mobility was not limited, they were not restraints. There was no specific assessment tool for enabler rails. Therapy and nursing decided on enabler rails. They were discussed with the resident and a physical assessment was done before deciding to use them. Anything added to a bed could pose a risk for injury or entrapment. There was no documented risk/benefit discussion with residents or their representatives. Consent was only needed when a device was considered a restraint. Resident #59 could be appropriate for use of enabler rail with guidance. Their left sided hemiparesis may make it hard for them to use them independently. Risk / benefit should be discussed and usually was during assessment. There was no consent obtained or documentation of risk/benefit discussion. During an interview on 3/29/2024 at 9:51 AM, certified nurse aide #10 stated resident care information was found in care plan books. It contained instructions for transfers, oral care, incontinence, diet, and assistance needed. Bed enabler rails were used for the resident to assist themselves with bed mobility. They could possibly be a danger to residents who were not able to get up safely without assistance. Resident #59 needed staff assistance for positioning, transfers, dressing and toileting. The resident could not see their enabler rails to use them independently and needed guidance to use them. 10NYCRR 415.12(h)(1)(2) 48675 49448 )

48675 Based on observation, record review, and interview during the recertification survey conducted 3/25/2024-3/29/2024, the facility did not ensure storage, preparation, distribution, and service of food in accordance with professional standards for food service safety in 1 of 1 main kitchen. Specifically, the main kitchen had undated and uncovered food, the food slicer and can opener had food debris on them, and ceiling tiles and walls were not clean. Findings include: The facility policy Kitchen Cleaning Standards revised 5/2023 documented cleaning of the kitchen is a difficult task as many things need to occur to prepare meals, meet resident needs, and assure appropriate food temperatures. Cleaning the kitchen is everyone's responsibility. Many areas of the kitchen are high and difficult to reach and may need maintenance to assist. If areas require cleaning, put in a maintenance request. Many areas are subject to spray and soiling, every effort should be made to clean these areas when needed. Any concerns regarding cleaning needs should be communicated to the cook, who can get staff to assist. The facility policy, Food Delivery and Storage revised 5/2023 documented sufficient storage facilities are provided to keep foods safe and wholesome. Food is stored, prepared, and transported at an appropriate temperature and by methods to prevent contamination. Leftover foods are labeled, covered, and dated when stored. Leftover food is used within 3 days or discarded. All storage areas, refrigeration and freezer units are always kept clean and in good working condition. The following observations were made in the main kitchen on 3/25/202 between 9:10 AM and 9:49 AM: - a 1/4 size hotel pan with chicken tenders was uncovered in the walk-in cooler. - a 1/4 size hotel pan with 1 serving of French fries was uncovered in the walk-in cooler. - 4 undated 20-ounce applesauce cups were on the top shelf in the walk-in cooler. - 1 5-pound plastic sour cream container was undated and had dried white/yellow substance on the outside of the container. - 1 5-pound box of chicken nuggets, 1 10-pound box of sausage patties, and 1 bag of frozen rolls were uncovered and left open to air in the walk-in freezer. - the food slicer arm and can opener were unclean with dried brown food debris. - multiple 20-ounce salad dressing cups were undated and placed on a sheet pan with dried food debris in the dry storage room. - 1 plastic quart of butter was left uncovered by the toaster. The following observations were made in the main kitchen on 3/27/2024 between 11:40 AM and 12:15 PM: - there were unclean ceiling tiles in the dish room. - there were unclean walls on the dirty side of the dish room. During an interview on 3/25/2024 at 9:22 AM, food service supervisor/cook #4 stated food should be covered to prevent contamination. Food should be dated to know when it was opened and prepared. They stated the open food in the walk-in freezer should have been kept closed to prevent physical contamination or freezer burn and the undated food should be thrown out. During an interview on 3/29/2024 at 9:47 AM, the Administrator stated all items in the walk-in cooler and freezer should be covered to protect them from contaminants. All open food products must be dated, and frozen items should be stored in a bag within a box. They stated during the observation on the morning of 3/25/2024 staff were preparing for the next lunch meal, and it was usual to prepare lunch items after breakfast was served. All food items identified in the walk-in cooler and freezer were items for the next meal. It was possible that the open butter on the counter was used between meals or for a late breakfast. Ham was sliced for the upcoming lunch special, and the outside layer of the ham had a brownish sugar layer. The can opener would have been used to prepare food for the staff vending machine around 6:30 AM and there was no need to use the can opener for any resident meals that morning. They stated they put in a work order on 3/24/2024 for the kitchen ceiling to be cleaned and the walls in the kitchen were cleaned weekly. 10NYCRR 415.14(h)

Based on observation, record review, and interview during the recertification and abbreviated (NY00297353) surveys conducted 3/25/2024-3/29/2024, the facility did not implement policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 3 residents (Resident #23) reviewed. Specifically, recreation aide #8 witnessed an alleged abuse incident by certified nurse aide #7 towards Resident #23 and did not intervene to stop the interaction and did not immediately report the alleged abuse to Administration per the facility policy. Additionally, certified nurse aide #7 completed their shift after the alleged abuse incident occurred. Findings include: The facility policy Resident abuse, neglect, mistreatment and misappropriation of resident property revised 1/2024 documented the facility encouraged and supported all residents, staff, families, visitors, volunteers, and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion, or misappropriation. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. All employees and volunteers would receive training on the abuse policy prior to direct or indirect resident contact. It was the policy of the facility that residents would be protected from the alleged offender. Employees must always report any abuse or suspicion of abuse immediately to the Administrator. Resident #23 was admitted to the facility with diagnoses including Parkinson's disease (a progressive neurological disease), dementia, and repeated falls. The 4/25/2022 Minimum Data Set Assessment documented the resident had intact cognition, did not reject care, required extensive assistance of 1 with activities of daily living, had no falls since admission or the prior assessment, and used both bed and chair alarms daily. The 5/4/2022 comprehensive care plan documented the resident had Parkinson's disease and required assistance with activities of daily living. On 6/1/2022, the comprehensive care plan was updated to include they were high risk for falls. Interventions included tab (bed/chair) alarms to alert staff if the resident was attempting to ambulate, anticipate the resident's needs and assist as needed, educate on safety needs and document, and a toileting program. The facility's 6/9/2022 investigation completed by illegible name, documented: - between 12:30 PM and 1:00 PM on 6/9/2022, Resident #233 reported to (former) social worker #11 that they observed something violent involving Resident #23 in the dining room after the lunch meal. Resident #23 was in the dining room, and they were standing up from their wheelchair when certified nurse aide #7 entered the dining room and shoved Resident #23 into their wheelchair. They observed certified nurse aide #7 put their hands on Resident #24's chest and stated, I am not going to ask you and pushed the resident down. The resident felt certified nurse aide #7 was upset and overreacted. - Recreation aide #8's undated/untimed statement documented they walked into the dining room and observed Resident #23 standing up from their wheelchair. The resident's tab alarm (chair alarm) was sounding as they went over to assist the resident. Certified nurse aide #7 came into the dining room and pushed the resident down. Certified nurse aide #7 had their hands on the resident's shoulder as they stood in front of the resident. After the incident, certified nurse aide #7 quickly took Resident #23 out of the dining. They stated they did not report the incident when it occurred as they knew another resident would report it. They noted they were trained if they witnessed any abuse they should intervene and report the incident but did not because it happened so quickly. - Certified nurse aide #7's undated/untimed statement documented Resident #23 was standing up in the dining room, their alarm was not sounding, and they asked the resident to sit in their chair three to four times. They assisted the resident back into their wheelchair by placing their hands on the resident's lower back and shoulder. They stated the resident punched them in the stomach and scratched them and was in one of their moods. They did not tell anyone about the incident. After the incident in the dining room, they brought the resident back into their room. Once in the resident's room they pulled the privacy curtain and the resident started standing again and they put them in their recliner chair. - Resident #24's undated/untimed statement documented certified nurse aide #7 pushed them into their wheelchair with both of their hands on their chest. The resident reported no pain at the time of the interview. They felt certified nurse aide #7 was mad because they were trying to stand up and stated, we are not going to do this. The resident also stated once certified nurse aide #7 brought them into their room they pushed them into their recliner chair. - The facility Administrator assessed the resident on 6/9/2022 who denied pain and had no marks evident. - Certified nurse aide #7 was placed on leave pending the investigation and could not return unless instructed. - The facility's investigation concluded there was reason to believe certified nurse aide #7 placed their hands on the resident and moved them in a downward direction into the chair. It was felt the employee acted in anger. On 6/17/2022, certified nurse aide #7 was terminated from the facility. Certified nurse aide #7's timecard for 6/9/2022 documented they punched in at 6:31 AM and punched out at 2:30 PM. During an observation and interview on 3/25/2024 at 11:04 AM, the resident was in their room watching television. They had a tab alarm (chair alarm) on their recliner. They stated an unknown staff member had pushed them into their chair, but they could not recall when the event occurred. They stated they did not get hurt. They remembered facility staff talking to them about the incident and nothing like that had happened since then. During an interview on 3/26/2024 at 1:15 PM, former recreation aide #8 (now a registered nurse) stated they had received abuse training upon hire and annually. They stated they were taught if they witnessed any form of abuse, they should try to stop it and report it immediately. They stated on 6/9/2022, they entered the dining room to assist other residents to their room after the lunch meal. At that time, they had heard Resident #23's tab alarm (chair alarm) sounding. They heard certified nurse aide #7 telling Resident #23 to sit down, but the resident did not do what was asked of them. Certified nurse aide #7 grabbed Resident #24's shoulders while they were standing and pushed the resident back into their wheelchair. After certified nurse aide #23 pushed the resident into their wheelchair, they quickly took the resident out of the dining room. They stated other residents were in the dining room and they knew the residents would report the incident. They did not report the incident and about 15 to 20 minutes later the Director of Nursing came to speak to them. They were reeducated on the abuse policy, and they knew that they should have attempted to intervene and should have reported the incident, but it all happened so quickly. During an interview on 3/27/2024 at 12:02 PM, the Director of Nursing stated they expected if staff observed anything concerning that they should intervene and report the incident immediately. On 6/9/2022, Resident #233 reported to former social worker #11 they observed a serious incident in the dining room between certified nurse aide #7 and Resident #24. Former social worker #11 immediately contacted them, and an investigation was started. During the investigation statements were obtained. Unfortunately, recreation aide #8 did not report the incident and Resident #233 was the one who alerted staff to the incident. Registered nurse/former recreation aide #8 was removed from care when the investigation was started and reeducated on the abuse policy. Certified nurse aide #7 was also placed on leave pending the investigation and was terminated after the investigation was completed. During an interview with the Administrator on 3/27/2024 at 12:29 PM, they stated all staff received abuse training upon hire and annually. They expected any staff who witnessed abuse to intervene and report the incident. They stated activity aide #8 should have attempted to intervene and alert staff to the incident, but the incident happened so quickly, and Resident #233 alerted former social worker #11, and the investigation was started. Certified nurse aide #7 was placed on leave and was terminated after the investigation was completed. Registered nurse/former recreation aide #8 was reeducated on the abuse policy. 10NYCRR: 415.4(b)

Based on observation, record review, and interview during the recertification survey conducted 3/25/2024-3/29/2024, the facility did not ensure residents were free of any significant medication errors for 1 of 9 residents (Resident #14) reviewed. Specifically, Resident #14's prepared medications were left in a cup unattended on their bedside table for over 5 hours and licensed practical nurse #3 documented the medications were administered at 6:00 AM when they were not. Findings include: The facility policy Medication Policies Program reviewed 9/2023 documented medications were administered by a licensed nurse. The person that administered the medication ensured the six rights (right person, medication, dose, route, time, and documentation). Resident medication was accurately acquired, received, dispensed, administered, and documented in a safe and efficient manner. The facility policy Self-Administration Policy reviewed 9/2023 documented residents had the right to self-administer medications. Standards had to be met that included the resident had a secured area the medications were maintained if they were poured and administered in their room and a physician order was obtained. Residents' ability to self-administer medications was evaluated on admission, readmission, at the time of a significant change, and at least annually. If a resident was self-administering their medications, the nurse followed up at the end of their shift and verified if they had taken all their medications. Resident #14 was admitted to the facility with diagnoses including osteoporosis (weakness of the bones), edema (fluid swelling) and gastro-esophageal reflux disease (stomach acid flows up). The Minimum Data Set assessment dated [DATE] documented the resident was cognitively intact, required set up assistance for eating and oral hygiene, and did not reject care. The comprehensive care plan initiated 2/29/2024 and revised 3/6/2024 documented the resident was at risk for complications due to advanced age with multiple medical diagnoses. Interventions included medications were administered as ordered. The 3/8/2024 physician orders documented the resident was to receive the following oral medications at 6:00 AM: - furosemide (diuretic) 20 milligram tablet, one tablet by mouth daily for edema - Ocuvite cap Lutein and Zeaxanhin (helps to protect eye health), one tablet by mouth daily for vision loss - oyster calcium with vitamin D 500/200 (treats osteoporosis), one tablet by mouth daily for supplement - acetaminophen 500 milligram tablet, two tablets (1000 milligrams), by mouth two times a day for pain There was no documented evidence of a physician order to self-administer medications. During an observation and interview on 3/25/2024 at 11:17 AM, Resident #14 was dressed and seated in their recliner chair in their room. There was a plastic medication cup on their bedside table that contained one red pill, one green pill, two large round white pills and one small round white pill. There was no staff present in the room. The resident stated these were their morning medications and the nurses always left them there and did not watch them take the medications. They stated there was always a medication cup there when they woke up in the morning. The Medication Administration Record documented the following medications were administered by licensed practical nurse #3 on 3/25/2024 during the scheduled 6:00 AM medication pass: - furosemide 20 milligram tablet, one tablet by mouth one time a day - Ocuvite cap Lutein and Zeaxanhin one tablet my mouth one time a day - oyster calcium with vitamin D 500/200 one tablet by mouth one time a day - acetaminophen 500 milligram tablet, two tablets (1000 milligrams), by mouth two times a day During an interview on 3/29/2024 at 5:56 AM licensed practical nurse #3 stated they were assigned to Resident #14 on the morning of 3/25/2024 and gave them their 6:00 AM scheduled medications. They had one hour before and after the administration time to give the medications. Medications were signed off after watching the resident take the medications and a medication signed as given meant they watched the resident swallow the medications. If they did not watch the resident swallow the medications, they could not be certain if they were taken. It was important for residents to take their ordered medications to keep them medically stable and safe. The nurse stated the routine medication administration process for Resident #14 was they woke the resident up in the morning and let them know their medications were on the bedside table. It was not appropriate medications were left at bedside. They were not aware the medications were still on the bedside table hours after the scheduled administration time and hours after their shift was over. They should not have documented them as given and if another resident had taken the medications an adverse reaction could have occurred. During an interview on 3/29/2024 at 10:07 AM registered nurse Unit Manager #2 stated when medications were administered and signed on the Medication Administration Record, it meant the nurse ensured the medications were taken by watching that the resident. It was acceptable to administer medications an hour before or after the scheduled administration time. They stated if residents were alert and oriented, prepared medications could be kept at the bedside if there was an appropriate physician order. If that was the case, the nurse went back to their room within the acceptable administration time parameters and ensured medications were taken and verified this by the end of their shift. There was a medical need for medications, and it was important they were taken as ordered. If the resident had not taken the medications at 11:17 AM, it was not appropriate the nurse documented them as given at 6:00 AM. During an interview on 3/29/2024 at 10:48 AM the Director of Nursing expected the nurses to make sure medications were taken by the resident and it was not appropriate to leave the medications in Resident #14's room. There was one hour before and after the medication administration time to give the medications and if they were given outside of the acceptable time frame, the time given was documented on the medication administration record. If a resident had a self-administer order the nurse poured the medications and put them in their room but then returned to the room within an hour to ensure the medications were taken. Self-administration required a physician order. Resident #14 did not have an order to self-administer, and medications should not have been left in their room. If medications were being left in their room, the proper process should have been followed and a physician order to self-administer medications should have been obtained. Medications were important to control medical issues and disease processes. An adverse reaction could occur if anyone other than the intended recipient took the medications. 10NYCRR 415.11(c)(3)(i)

Based on observation, interview, and record review during the recertification survey conducted 12/7/21-12/10/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one isolated area (kitchen exhaust hood area) in the main kitchen. Specifically, the kitchen exhaust hood and Ansul lines (special hazard fire protection products) over the oven and stoves were grease and dust laden. Findings include: The semi-annual hood cleaning logs documented the kitchen hoods were last cleaned on 9/9/21 and 5/11/21. When observed on 12/7/21 at 10:18 AM, the ventilation filters under the kitchen exhaust hoods over the cooking appliances (stove, fryer, and ovens) contained grease and were dust laden in sections. The Ansul suppression lines were observed with grease and were dust laden. When interviewed on 12/8/21 at 11:40 AM, the Food Service Manager stated maintenance should be cleaning hoods semi-annually by taking the vents outside to power wash and degrease them. The Manager stated 9/2021 was the last time the hood cleaning maintenance was completed. When observed on 12/8/21 at 12:03 PM, the kitchen hoods over the oven had gaps between filters and the hoods and suppression lines were observed with grease and were dust laden. When interviewed on 12/8/21 at 1:45 PM, the Facility Manager stated they cleaned the kitchen hood vents semi-annually by taking them out and power washing them. They did not clean the Ansul suppression lines/piping. They did put the filters back into place when clean, but they did not notice the filters were not fitting tightly in line together. The last time they cleaned the hood vents and filters was in 9/2021. If it needed more cleaning the kitchen would need to notify them, and they had not been notified. 10NYCRR 415.29 (j)(1)

Based on observation, interview, and record review during the recertification survey conducted from 12/7/21-12/10/21 the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 2 of 2 nursing units (Units 1 and 2) reviewed. Specifically, the facility policy Food Brought in From Home did not document how long food items could be kept before discarding, how to safely reheat and serve residents' personal food including how to properly take food temperatures and what appropriate reheating temperatures were. Finding include: The facility policy Food Brought in From Home dated 7/12/21, did not document how to safely reheat food for residents, how to take temperatures of the food, what temperature foods must be reheated to, or how long residents' food brought in from outside the facility should be kept before being discarded. During an observation on 12/7/21 at 11:47 AM, the Unit 2 nourishment refrigerator had 3 resident food items that were properly labeled. There was a Tupperware container with a slice of pie, a lidded paper cup container of soup, and a Tupperware container with meat sauce. All the items were dated 12/7/21. There was no probe thermometer observed in the small kitchenette where the nourishment refrigerator was located. When interviewed on 12/7/21 at 11:47 AM, licensed practical nurse (LPN) #3 stated the staff who received the food brought in by a family was supposed to label and date the food items and store them in the unit refrigerators. Staff on the floor could heat up food items to the desired temperature at the resident's request. They did not take temperatures of the food before serving it to the resident. The LPN was not aware of thermometers being available and they were not trained to use them when microwaving food. When interviewed on 12/7/21 at 11:49 AM, the Director of Nursing (DON) stated the food items brought in from the outside should have labels with resident names and dates. When the resident wanted to eat the items staff would heat them up using the facility microwave. The staff would warm up the food and ask the resident how it was and if they would like it hotter. The temperature would be the resident's preference. The DON stated they did not use thermometers to measure the specific temperature of food items. When interviewed on 12/8/21 at 11:40 AM, the Food Service Manager stated nursing staff used the microwave to reheat food. They did not believe nurses were looking for a specific temperature and were not using thermometers when reheating food. The Manager stated staff would ask residents if items were hot enough. The Manager stated staff discarded food items older than three days. This was checked daily, and they did not know if nursing was trained on these processes. When interviewed on 12/9/21 at 11:30 AM, the Administrator stated the temperature of foods was determined by residents when foods were given to them based on the resident's preference. The nurses did not use thermometers when reheating food for residents. Nursing had never been trained on how to take food temperatures or what temperatures food should be reheated to. 10NYCRR 415.14(h)

Based on observation, record review and interview during the recertification survey the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 of 13 residents (Residents #24, 40, 59, and 71) observed during medication administration. Specifically, the nurse did not perform hand hygiene between residents during medication administration. Findings include: The facility 9/20/18 Hand Hygiene Policy documented that all staff will be expected to wash hands with soap and water if alcohol-based hand rub is not available before direct contact with a person, after contact with objects (including equipment) in the person's care setting. Using hand sanitizer is acceptable when hands are not visibly soiled. 1) Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/5/19 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition. The 5/9/19 physician order [REDACTED]. 2) Resident #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/8/19 MDS assessment documented the resident had intact cognition. The 6/1/19 physician order [REDACTED]. 3) Resident # 59 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The 4/30/19 MDS assessment documented the resident had severely impaired cognition. The 6/1/19 physician order [REDACTED]. 4) Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 5/13/19 MDS assessment documented the resident had intact cognition. The 6/1/19 physician order [REDACTED]. During an observation on 6/5/19 at 3:32 PM licensed practical nurse (LPN) #6 was observed sitting at the nursing station prior to the medication administration. She proceeded to the medication cart and did not perform hand hygiene before preparing medications for Resident #24. Before she administered medications to Resident #24 she was observed positioning the resident's head with her bare hands. She administered Resident #24's medications, did not perform hand hygiene and proceeded to prepare medications for Resident #71. She administered the medications to Resident #71, returned to her medication cart, did not perform hand hygiene, and prepared medications for Resident #59. She then locked her medication cart, went to get hand sanitizer, returned to medication cart and performed hand hygiene with the hand sanitizer. After medication administration to Resident #59, she touched the resident's personal property while in the room and did not perform hand hygiene before preparing medications for Resident #40. She completed Resident #40's medication administration and did not perform hand hygiene when finished. During an interview on 6/5/18 at 8:23 AM, LPN #6 stated that the process was to wash hands or use sanitizer between administering medications to residents. She stated that she forgot and normally she would have done so. During an interview on 6/6/19 at 9:50 AM, the Director of Nursing stated the expectation when passing medications was for staff to wash their hands or use hand sanitizer before and between residents to prevent the spread of germs. She stated a rule of thumb was after using hand sanitizer three times, staff should wash their hands with soap and water. 10NYCRR 415.19 (b)(4)

Based on record review, observation, and interview conducted during the recertification survey, it was determined for 1 of 2 residents (Resident #8) reviewed for restraints, the facility did not ensure residents were free from physical restraints not required to treat medical symptoms. Specifically, Resident #8 had a seatbelt restraint and there was no evidence it was assessed to be the least restrictive treatment. Findings include: Resident #8 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] documented the resident had severely impaired cognition. She walked in her room independently and required supervision when walking in the hallway or on the unit. The MDS documented the resident had no falls since the previous assessment. A nursing progress note dated 7/13/2016 at 11:25 AM documented the resident was found by the LPN (licensed practical nurse) on the floor in the East hallway. The resident's status was changed to a 1 person assist with a gait belt due to unsteady gait, and she was put on 1:1 supervision. A nursing progress note dated 7/14/2016 at 3:25 PM documented the resident's 1:1 supervision was discontinued and she remained safe as independent with transfers and ambulation. A nursing note dated 7/22/2016 at 12:51 PM documented the resident fell coming out of the bathroom that morning at 7:45 AM. Ambulation was assessed at that time and she was crossing her feet and had difficulty with ambulation. The note documented the resident's care was changed to a 1 person assist with a gait belt, and she required 1:1 supervision related to her inability to follow instructions and her ambulation ability. A social worker note dated 7/22/2016 at 1:35 PM documented the resident's health care proxy (HCP) was called, who agreed to the resident using a wheelchair with a seatbelt. A nursing progress note dated 7/22/2016 at 3:14 PM documented the Director of Nursing (DON) and registered nurse (RN) Manager determined the resident was not safe with 1:1 supervision related to her unsteadiness and a restraint was needed. A lap buddy (inflatable lap cushion) was tried and the resident was able to remove it. The resident was able to release a seatbelt, and the seatbelt was buckled under the wheelchair and she could not release it. The 1:1 supervision was discontinued. The note did not document a rationale for how 1:1 supervision was determined unsafe. The physician orders [REDACTED]. A restraint evaluation dated 7/22/2016 documented the resident was evaluated for use of a seatbelt that was considered a restraint, and she was not physically able to release the seatbelt. The medical condition listed warranting the use of restraint was dementia - not able to maintain safety on 1:1 supervision. The comprehensive care plan updated 7/22/2016 documented the resident required a seatbelt as a restraint while in a wheelchair related to dementia and inability to recognize limitations, and safety not able to be maintained on 1:1 supervision. A nursing progress note dated 7/22/2016 at 7:47 PM documented the resident was observed multiple times holding the rails in the hallway, standing up with the wheelchair folding behind her with the seatbelt intact. An incident report dated 7/23/2016 at 9:15 AM documented the resident stood up in her wheelchair, and upon sitting back down, pinched a finger on her right hand between the seat and the frame of the wheelchair. The 4th finger had a red area on the 2nd knuckle and was swollen. A nursing progress note dated 7/28/2016 at 5:43 AM documented the resident was on 1:1 supervision the majority of the night as she attempted to stand up from the wheelchair with the seatbelt on, causing the wheelchair to fold. When observed on 8/9/2016 from 5:55 PM to 6:25 PM, the resident was in bed sleeping. At 6:25 PM, a certified nurse aide (CNA) brought the resident's supper tray to her room. Two CNAs woke the resident and transferred her to the wheelchair using a gait belt. The seatbelt was fastened and she was taken to the dining room with her supper tray. In the dining room, the seatbelt was released and a CNA assisted her with her meal. When observed on 8/10/2016: - At 1:40 PM, the resident was in the lounge by herself in her wheelchair with the seatbelt on and a personal alarm attached. She stated come here to the surveyor, and touched the surveyor's hand and felt the material of the surveyor's clothing. Her speech was incomprehensible with the exception of come here. - From 1:45 PM to 2:45 PM, the resident was observed on the front porch in her wheelchair with the seatbelt on. When interviewed on 8/10/2016 at 3:20 PM, the physical therapy assistant (PTA) stated the resident's restraint was released every 2 hours and she was ambulated. She stated ambulation was documented on the restraint release form. When interviewed on 8/10/2016 at 4:00 PM, the RN Manager stated the resident's restraint was released every 2 hours. The RN Manager reviewed the restraint release record with the surveyor (the day shift for that day had not been completed), and stated there was no documented evidence the resident was ambulated when the restraint was released from 8/1/2016 to 8/9/2016 on the day or evening shifts. She stated the seatbelt was necessary for the resident's safety and there was no other way to keep the resident safe. She also stated PT (physical therapy) was involved in the restraint assessment, and a PT referral was not made for ambulation. When interviewed on 8/10/2016 at 11:35 AM, the PTA stated if a resident fell and a PT evaluation was ordered, the physical therapist would do the evaluation. She stated the resident was on the maintenance ambulation program to be done by nursing. She stated she also walked the resident at times and the resident did very well. She stated she walked with the resident for 850 feet on 8/9/2016. When interviewed on 8/11/2016 at 12:50 PM, the DON stated the resident was restrained in a wheelchair with a seatbelt buckled under the chair. She stated 1:1 supervision was tried in the past and was effective after her fall on 7/13/2016, and was discontinued as she was ambulating well on her own. She stated it was ineffective after the fall of 7/22/2016, as the resident's gait was extremely unsteady. She stated 1:1 supervision would not keep her safe as she tipped when walking. She stated she did not have PT evaluate the resident for ambulation. PT did assist in the restraint assessment. The DON also stated the incident of 7/23/2016 would not have happened if the resident was not in the wheelchair, and a wheelchair with a seat belt was the only way to maintain her safety. 10NYCRR 415.4(a)(2)(iv)

Based on record review, interview, and observation conducted during the recertification survey, it was determined for 2 of 8 residents (Residents #7 and 8), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated. Specifically, for Residents #7 and 8 the facility did not thoroughly investigate bruises of unknown origin, and Resident #8 had multiple falls and the facility did not thoroughly investigate to prevent recurrence. Findings include: 1) Resident #8 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. She was independent with walking and wandered daily. An incident report dated 5/6/2016 documented a bruised area was found on the resident's right axilla (armpit) and breast during a shower. The bruise was yellow and First Aid was provided. For the resident's version of the incident, the word no was documented. On 5/9/2016, the resident denied harm when asked was added to the report. The report concluded the resident self-ambulated and may have bumped into something. There were no written statements or evidence that an investigation was conducted. A nursing progress note dated 5/19/2016 at 12:00 PM documented the resident was alert with confusion. She was able to communicate basic needs such as toileting, pain, hunger, and thirst. The note also documented much of what she said was nonsensical. When interviewed on 8/11/2016 at 8:10 AM, licensed practical nurse (LPN) #10 stated the certified nurse aide (CNA) called her to the shower on 5/6/2016 when she noticed the bruise. She stated the resident was able to communicate some days depending on her mood. She stated the resident was mobile and could have bumped something. She stated she did not know if there were any written statements. When interviewed on 8/11/2016 at 10:15 AM, registered nurse (RN) Manager #4 stated the resident could give accurate yes/no answers. She stated LPN #10 found the bruise on 5/6/2016 and initiated the report. She stated if the CNA found the bruise, there would be a statement attached to the report. She also stated the Director of Nursing (DON) made the final determination as to how the bruise occurred. When interviewed on 8/11/2016 at 12:50 PM, the DON stated she asked 2 CNAs about the bruising. She did not get written statements for the incident on 5/6/2016, as the CNAs did not see the bruise and did not mention the resident bumping anything. She was also unsure which CNAs she asked. An incident report dated 7/7/2016 documented an 8 centimeter (cm) x 6 cm bruise was found on the resident's left hip during care. The RN initiating the report documented the resident could not tell the cause of the bruise; the resident was independent for transfers and ambulation and may have bumped it on something when walking around the unit. The DON signed the investigation as completed on 7/8/2016, and documented the resident continued to ambulate independently and bumped into things. There were no written statements or evidence that an investigation was conducted. When interviewed on 8/11/2016 at 12:50 PM, the DON stated she did not think an investigation or statements were necessary for the bruise of unknown origin found on 7/7/2016. She stated the resident was ambulatory and often leaned against the nurse's desk, which was at hip level. An incident report dated 7/13/2016 at 7:05 AM documented the resident was found by the LPN on the floor in the East hallway. Another resident witnessed the fall. A statement was written by the LPN, and the report included the resident was incontinent earlier that morning, which was unusual. An order was received for a urinalysis and the resident's comprehensive care plan (CCP) was changed to 1 assist and 1:1 supervision. A nursing progress note dated 7/13/2016 at 11:25 AM documented the resident's fall and the resident was made a 1 person assist with a gait belt due to unsteady gait and put on 1:1 supervision. A nursing progress note dated 7/14/2016 at 3:25 PM documented the resident was taken off 1:1 supervision and able to ambulate independently. An incident report dated 7/22/2016 at 7:45 AM documented the resident had an observed fall. The resident was unable to say what happened. RN Manager #4 initiated the incident report and documented the resident fell while ambulating from her bathroom. The report documented contributing factors included confusion, inability to follow instructions, and aggressiveness. The report also documented the resident was independent in mobility and the CCP was followed. The DON completed the report on 7/22/2016 and documented 1:1 supervision was not effective in maintaining the resident's safety, and she would be placed in a wheelchair with a seatbelt to be fastened under the chair. The report did not document who witnessed the fall or any other contributing factors such as the resident's foot wear or condition of the floor. When interviewed on 8/11/2016 at 10:15 AM, RN Manager #4 stated she was not sure who witnessed the resident's fall on 7/22/2016. She also stated she was unsure if the resident was on 1:1 supervision at the time, as she had been on and off 1:1 supervision frequently. When interviewed on 8/11/2016 at 12:50 PM, the DON stated RN Manager #4 witnessed the fall on 7/22/2016. She and RN Manager #4 assessed the resident's ambulation and noticed the resident had difficulty advancing the right foot, as it would hit the left heel. They decided 1:1 supervision would not work and she needed a wheelchair with a seatbelt. She stated they did not make a referral to physical therapy and were hoping the resident would return to her normal. A nursing progress note dated 7/22/2016 at 7:47 PM documented the resident was observed multiple times holding the side rails in the hallway, standing up with the wheelchair folding behind her with the seat belt intact. An incident report dated 7/23/2016 at 9:15 AM documented the resident stood up in her wheelchair, and upon sitting back down, pinched a finger on her right hand between the seat and the frame of the wheel chair. The 4th finger had a red area on the 2nd knuckle and was swollen. On 7/25/2016, the incident report was signed by the DON and documented the finger was no longer swollen and a small abrasion was noted on the 4th right finger to be monitored weekly. There were no written statements or evidence that an investigation was conducted. The incident report did not document if the resident had a seatbelt (ordered 7/22/2016) on, or if the CCP was followed. When interviewed on 8/11/2016 at 10:15 AM, RN Manager #4 stated she was not sure if the resident's seatbelt was on when she sat on her finger. She stated the LPN must have witnessed the incident or there would have been statements. When interviewed on 8/11/2016 at 12:50 PM, the DON stated she did not think the incident was witnessed and the LPN had to get the finger unstuck. She then stated the seatbelt was on and the resident was rocking in the wheelchair. She stated the incident would not have happened if the resident was not in the wheelchair, and a wheelchair with a seat belt was the only way to maintain her safety. When observed on 8/10/2016 at 1:40 PM, the resident was in the lounge by herself in her wheelchair with the seatbelt on and a personal alarm attached. She stated come here to the surveyor and touched the surveyor's hand, attempted to take the surveyor's pen, and felt the material of the surveyor's clothing. Her speech was incomprehensible with the exception of come here. 2) Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments dated 3/21/2016 and 6/20/2016 documented the resident's cognition was severely impaired and a [DIAGNOSES REDACTED]. She required extensive assistance for dressing, hygiene, and bathing. The MDS also documented the resident was non-ambulatory. A nursing progress note dated 6/1/2016 at 4:24 AM documented a bruise was noted on the resident's anterior (front) forearm at 12:30 AM during incontinence care. The bruise was purple and measured 2.5 centimeters (cm) x 2.5 cm. The resident denied pain or discomfort and denied anyone harmed her. The note documented the resident flailed her arms sometimes during transfers and that it was possible the resident hit her arm on the Hoyer (mechanical) lift causing the bruise. The incident report dated 6/1/2016 documented the resident had a bruise on the right anterior forearm. The report documented the resident did not state how the bruise occurred and she denied harm from another. The report documented the resident utilized a Hoyer lift for transfers and may have hit her arm on the lift bars causing the bruise. There were no staff statements with the incident report. The comprehensive care plan (CCP) dated 6/30/2016 documented the resident was non-ambulatory, required assistance of 2 staff for positioning, was not to be left unattended in the hall or lounge, and a nurse was to assist with all care. When observed on 8/9/2016: - At 3:00 PM, the resident was alone in her room with the TV on. She was wide awake in her geri-chair pulling on the Hoyer (mechanical lift) pad straps. - At 4:20 PM, the resident remained in her geri-chair and was pulling the covers off her bed and covering herself. - At 5:15 PM, the resident was taken to the dining room in her geri-chair and put in front of a table with 2 other residents. There was an overbed table on her right side with 2 drinks; she reached to the table and took one of the drinks and started drinking. - At 5:20 PM, she was observed with both plastic glasses on her lap and a large puddle of liquid under her chair. - At 5:21 PM, a certified nurse aide (CNA) took the resident back to her bedroom. Another CNA went in and pulled the curtain to provide care; and - At 5:55 PM, the resident remained in her room in the geri-chair. She was wide awake and did not respond verbally to the surveyor when spoken to. When interviewed on 8/11/2016 at 9:50 AM, licensed practical nurse (LPN) #7 stated when a bruise was reported, the registered nurse (RN) Supervisor or Manager was called to do an assessment. She stated the RN was responsible for the investigation, and she thought statements were obtained. When interviewed on 8/11/2016 at 10:15 AM, RN Manager #4 stated when a bruise was found, the RN Supervisor was notified, who completed the incident report and obtained statements. The report then was forwarded to the RN Manager for review and then forwarded to the Director of Nursing (DON). She stated the DON was responsible for completing the investigation and determining the root cause. She stated Resident #7 was able to answer yes/no questions, and stated no when asked if anyone hurt her. She stated if statements were needed from staff caring for the resident prior to the bruise, the DON would obtain them. When interviewed on 8/11/2016 at 1:20 PM, the DON stated she and the RN Manager decided the bruise was related to the Hoyer lift, as the resident often flailed her arms. She stated she did not get statements from the staff and felt the investigation was complete. 10NYCRR 415.4(B)(1)(ii)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection, for 1 of 1 residents (Resident #18) reviewed for blood glucose monitoring. Specifically, for Resident #18, the glucometer (device used to determine blood sugar) was not cleaned after use. Findings include: Resident #18 had [DIAGNOSES REDACTED]. The facility policy Blood Glucose Monitoring, revised 11/2015, documented that blood glucose levels were to be measured no more than 30 minutes prior to insulin administration, and that it was important to follow the manufacturer's instructions for each particular glucose monitor. The facility policy Disinfection of Equipment, revised 11/2015, documented glucometers were to be cleaned after each use with a CaviWipe (disinfectant towelette). Physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired. She required extensive assistance with most activities of daily living. She was diabetic and received insulin injections. The comprehensive care plan (CCP) revised 7/21/2016 documented the resident had diabetes. Interventions included monitoring the resident's blood sugar as ordered and notifying the physician as needed. During observation of the resident's fingerstick for blood glucose monitoring on 8/9/2016 at 5:05 PM, the registered nurse (RN) #6 took the glucometer out of the top drawer of the medication cart and set it on top of the cart. She prepared her other supplies, gloved, entered the room, set the glucometer on the resident's lap, performed the fingerstick, and left the room with the supplies. She placed the glucometer directly on the cart, ungloved, disposed of the supplies, and set the glucometer back in the top drawer of the cart without sanitizing the glucometer. During an interview on 8/11/2016 at 9:50 AM, licensed practical nurse (LPN) #7 stated glucometers were shared between residents and the policy was to cleanse the glucometer after each use with a CaviWipe. RN #6 was not on duty at the facility during the rest of survey. A telephone call was placed for an interview on 8/11/2016 at 2:10 PM; RN #6 did not return the call. 10NYCRR 415.19(b)(2)

Based on record review, observation, and interview conducted during the recertification survey, it was determined for 2 of 2 residents reviewed for Foley catheters (urinary drainage tube), the facility did not ensure appropriate treatment and services were provided. Specifically, Resident #1's Foley catheter tubing was observed resting directly on the floor and the catheter drainage bag was observed hanging uncovered on a trash can. For Resident #2, a comprehensive assessment was not conducted to ensure the continued use of an indwelling Foley catheter was medically justified, and to ensure the resident's normal bladder function could be restored if possible. Additionally, Resident #2's Foley catheter was observed hanging from the arm of the geri-chair, above the level of the bladder. Findings include: 1) Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. She was totally dependent for toileting and was always incontinent of bladder and bowel. The nursing progress note dated 1/18/2016 at 8:52 PM documented the resident had not urinated for two shifts. The physician was notified, who ordered the resident to be straight catheterized, and to leave the catheter in place if output was greater than 300 cubic centimeters (cc, a volume measurement). The resident had an output of 525 cc and the indwelling catheter remained in place. The comprehensive care plan (CCP) revised 1/18/2016 documented the resident had a Foley catheter related to not urinating for two shifts. Interventions included changing the catheter per order, monitoring for signs of infection, vital signs as needed, and notifying the physician as needed. The plan of care did not include interventions to reassess the need for the catheter or the ability to remove the catheter. The physician progress notes [REDACTED]. The note did not document the resident had a Foley catheter or a [DIAGNOSES REDACTED]. The physician progress notes [REDACTED]. The note documented the resident had a Foley catheter for [MEDICAL CONDITION]. The note did not document the underlying cause of the [MEDICAL CONDITION], attempts or a plan to discontinue the catheter, or any urology consultations. The nursing progress note dated 2/20/2016 at 9:59 AM documented a new order to change the size of the Foley catheter to 16 Fr. (French, a size) with 10 cc bulb. The note documented the Foley catheter was changed at this time. The nursing progress note dated 3/1/2016 at 12:07 PM documented the Foley catheter was changed due to unsuccessful attempts to flush the catheter. The MDS assessment dated [DATE] documented the resident's cognition was severely impaired. She required total dependence for toileting, had an indwelling urinary catheter, and was always incontinent of bowel. The MDS did not document that the resident had a [MEDICAL CONDITION] bladder (inability of the bladder to empty effectively) or [MEDICAL CONDITION] (inability of urine to flow effectively). The nursing quarterly assessment dated [DATE] at 11:08 AM documented the resident was noted with [MEDICAL CONDITION] during the past quarter and a Foley catheter was placed. The CCP revised 3/31/2016 documented the resident was bypassing urine around the Foley catheter, and the physician had ordered to irrigate the Foley catheter with sodium chloride every shift and as needed to maintain patency. The plan of care did not include interventions to reassess the need for the catheter or the ability to remove the catheter. The nursing progress note dated 4/19/2016 at 3:32 PM documented a new order to change the size of the Foley catheter to 18 Fr. with 10 cc bulb. The CCP revised 4/19/2016 documented the resident was bypassing urine around the Foley catheter and the physician had ordered the Foley catheter size changed to 18 Fr. with a 10 cc bulb. The physician progress notes [REDACTED]. The note documented the resident refused medications at times, had poor oral intake, and had a Foley catheter. The note did not document the underlying cause of the [MEDICAL CONDITION], attempts to discontinue the catheter, or any urology consultations. The physician progress notes [REDACTED]. The note documented the resident was doing well, and to continue the current treatment. The note did not document the resident had a Foley catheter. The MDS dated [DATE] documented the resident's cognition was severely impaired. She had total dependence for toileting, had an indwelling catheter, and was always incontinent of bladder and bowel. The CCP dated 6/22/2016 documented the resident had a Foley catheter related to not urinating for two shifts. Interventions included to change catheter per order, monitor for signs of infection, vital signs as needed, and notify physician as needed. The plan of care did not include interventions to reassess the need for the catheter or the ability to remove the catheter. The physician progress notes [REDACTED]. The note documented the resident was at baseline, and to continue comfort care. The note did not document that the resident had a Foley catheter. The nursing quarterly assessment dated [DATE] at 10:26 AM documented the resident continued with a Foley catheter related to [MEDICAL CONDITION]. The physician order [REDACTED]. The nursing progress note dated 6/29/2016 at 11:01 AM documented the Foley catheter was removed for a trial to monitor the voiding pattern. The nursing progress note dated 6/30/2016 at 5:33 AM documented the resident urinated a moderate to large amount three times during the night. The nursing progress note dated 6/30/2016 at 1:39 PM documented the resident urinated moderate amounts three times during the shift. The physician progress notes [REDACTED]. The note documented the resident was urinating well after the Foley catheter removal, and to continue current treatments. The nursing progress note dated 7/10/2016 at 1:00 PM documented the resident was straight catheterized due to no urination for eight hours. The note documented the physician was called, who ordered an 18 Fr. with 10 cc bulb Foley catheter be placed. The physician order [REDACTED]. 10 cc balloon, change every month and as needed. The physician progress notes [REDACTED]. The note documented the resident was at baseline, and to continue comfort care. The note did not document that the resident had a Foley catheter. When observed on 8/11/2016 at 11:57 AM, the resident was in her geri-chair in the dining room. The Foley catheter bag was hanging on the arm rest of the geri-chair, covered and above the the level of the resident's bladder (which can lead to urine backflow). The drainage tubing, with urine in it, was looped above the Foley catheter bag. When observed on 8/11/2016 at 12:40 PM, the resident was in the geri-chair in her room. The Foley catheter bag was covered and hanging from the foot rest of the geri-chair. When interviewed on 8/11/2016 at 12:45 PM, CNA #3 stated she was taught to keep the Foley catheter bag low so that the urine drained into the bag. She stated that Resident #2's bag was put on the arm of the geri-chair because there was nowhere else to hang it. When interviewed on 8/11/2016 at 1:25 PM, the Director of Nursing (DON) stated Foley catheters were used for residents with [MEDICAL CONDITION] bladder, [MEDICAL CONDITION], and Stage IV (full thickness skin loss) pressure ulcers. She stated the resident had [MEDICAL CONDITION], which was determined when the resident did not void for 2 shifts in January 2016. She stated they tried to remove the Foley on 6/29/2016, and the removal was successful until 7/10/2016. On 7/16/2018, the resident went 8 hours without voiding, had a urinary tract infection [MEDICAL CONDITION], and the catheter was reinserted without plans for discontinuing. She stated there were no attempts to discontinue the catheter between 1/18/2016 and 6/29/2016. She stated there was no testing done to find an underlying cause for [MEDICAL CONDITION]. There were no bladder scans, trials of intermittent catheterization, or urology consults. She stated there were no attempts at bladder training and the resident was not physically or cognitively able to participate. She also stated the drainage bag should hang below the level of the bladder and be attached under the geri-chair. 2) Resident #1 had [DIAGNOSES REDACTED]. The policy and procedure dated 11/20/2015 for indwelling urinary catheters documented the catheter tubing should be kept from kinking and placed securely, and that the catheter bag should be placed in a catheter bag cover when the resident is out of their room. The physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. She required extensive assistance with toileting, had a Foley catheter, was frequently incontinent of bowel, and had a pressure ulcer (skin impairment). The comprehensive care plan (CCP) dated 8/3/2016 documented the resident had a Foley catheter for [MEDICAL CONDITION] bladder. Interventions included to change catheter per order, irrigate catheter per order to maintain patency, monitor complications related to catheter use and notify the physician, and use drainage bag. The certified nurse aide (CNA) care card (care instructions) dated 8/3/2016 documented the resident had a Foley catheter with drainage bag. When observed on 8/10/2016 at 8:55 AM, the resident was sitting in her room in the recliner. The Foley catheter drainage bag was covered and hung from the trash can near the recliner, with urine in the tubing. When observed on 8/11/2016 at 11:45 AM, the resident was sitting in the dining room in her wheelchair. The Foley catheter drainage bag was hung under the wheelchair, and the tubing was on the floor. When observed on 8/11/2016 at 12:30 PM, the resident was sitting in her room in the wheelchair. The Foley catheter drainage bag was hung under the wheelchair, and the tubing was on the floor. When observed on 8/11/2016 at 1:13 PM, the resident was sitting in her room in her recliner. The Foley catheter drainage bag was hanging from the trash can uncovered near the recliner, with urine in the tubing. When interviewed on 8/11/2016 at 1:05 PM, CNA #2 stated she was taught to hang the Foley catheter drainage bag low so that it drains. She stated that the drainage bag should hang underneath the wheelchair on the metal crossbars. She stated that the tubing should not touch the floor. When interviewed on 8/11/2016 at 1:20 PM, the registered nurse (RN) Manager stated the Foley catheter drainage bag was supposed to hang underneath the geri-chair or wheelchair, be covered in a bag and not visible, and the tubing should not touch the floor. When interviewed on 8/11/2016 at 1:35 PM, the Director of Nursing (DON) stated when a resident was in a recliner, it was inappropriate to hang the urine drainage bag from the trash can. 10NYCRR 415.12(d)(2)

Based on record review, observation, and interview conducted during the recertification survey, it was determined for 1 of 14 residents (Resident #7) reviewed for activities of daily living (ADLs), the facility did not provide the necessary services to maintain ADLs to residents who were unable to carry out ADLs on their own. Specifically, Resident #7 spilled drinks on her pants and the pants were not changed in a timely manner. Findings include: Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. She required supervision with eating and extensive assistance with dressing. The comprehensive care plan (CCP) dated 6/30/2016 documented the resident required the assistance of 2 staff for dressing. When observed on 8/9/2016: - At 5:15 PM, the resident was taken to the dining room in her geri-chair (for positioning) and put in front of a table with 2 other residents. There was an overbed table on her right side with 2 drinks. She reached to the table and took one of the drinks and started drinking. - At 5:20 PM, she was observed with both plastic glasses on her lap and a large puddle of liquid under her chair. - At 5:21 PM, a certified nurse aide (CNA) took the resident back to her bedroom. A nother CNA went in and pulled the curtain to provide care. - At 5:55 PM, the resident remained in her room in the geri-chair. The pillow under her right arm and her pants were wet; she was wearing a different shirt. - At 6:25 PM, CNA #8 brought the resident's tray to her room and set it on the overbed table behind the resident. He left to assist the resident's roommate. - At 6:30 PM, CNA #8 returned to the resident's room and was interviewed. He stated the resident was eating in her room, since she threw her drinks in the dining room. He stated the resident was brought back to the room to have her clothes changed. He felt the resident's pillow and pants when asked by the surveyor, and stated they were wet and that only her shirt was changed earlier. He then took the resident to the dining room, leaving the wet pants on, and placed her at the table. He went back to her room and brought the tray to the dining room. When interviewed on 8/10/2016 at 4:00 PM, the registered nurse (RN) Manager #4 stated the resident was taken back to her room on 8/9/2016 after spilling drinks in the dining room. She stated she thought CNAs #8 and 9 changed the resident's shirt, pants, and brief. CNA #9 walked by and joined the interview. CNA #9 stated they only changed the resident's shirt and she did not notice the pants were wet. RN #4 stated she would have expected the resident's pants to have been changed. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted during the standard survey, it was determined that the facility did not ensure food was prepared under sanitary conditions in the main kitchen. Specific concerns included the concentration of the sanitizer solution in the 3 bay sanitizer sink was too low; pots were not fully immersed in the sanitizer solution; and there was no documentation the facility consistently checked the sanitizer concentration in the 3 bay sanitizer sink. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: A surveyor observed Food Service Worker #1 washing pots in the kitchen 3 bay sink at 9:10 AM on 6/3/2015. At the surveyor's request, Food Service Worker #1 tested the concentration of the sanitizer in the 3 bay sanitizer sink using the facility's test strips. The test strip did not change color after being dipped, indicating inadequate sanitizer concentration. During an interview with Food Service Worker #1 at 9:10 AM on 6/3/2015, she stated the sanitizer concentration should be between 150 and 200 ppm (parts per million). When asked to interpret the result of the sanitizer solution test, Food Service Worker #1 did not respond. At 9:15 AM on 6/3/2015, the surveyor rechecked the concentration of the sanitizer solution using the facility's test strips and there was no color change. During the observation, the sanitizer bottle on the floor was partially full and the hose from the bottle to the tap was filled with sanitizer; the connection appeared adequate. Food Service Worker #1 continued washing pots in the 3 bay sink without draining and refilling the sanitizer sink until at least 9:20 AM on 6/3/2015. During the second observation of the kitchen 3 compartment sink at 1:03 PM on 6/3/2015, the surveyor observed the sanitizer solution in the potwash sanitizer sink was low, the sink was full of pots, and 3 pots were only half submerged in the sanitizer solution, and 1 half pan was not submerged at all under the sanitizer solution (the food contact surface of the pan was not in contact with the sanitizer solution). During an interview with Food Service Worker #2 at 1:13 PM on 6/3/2015, she described the process of using the sanitizer sink: - fill the sink half full of water; - run the sanitizer solution for 30 seconds; - soak the pots in the sanitizer solution for 1 minute. Food Service Worker #2 stated she was unsure how frequently the sanitizer solution was tested and she tested the concentration of the sanitizer solution approximately weekly. At the end of the interview, the 3 pots and half pan in the sanitizer solution remained either partly submerged or not submerged at all. Food Service Worker #3 was interviewed at 3:55 PM on 6/3/2015. She described the process of filling the sanitizer sink as the same process verbalized by Food Service Worker #2. She stated she tested the concentration of the sanitizer solution each time she washed items manually in the 3 bay sink. Food Service Worker #3 was in the dishroom and was not washing pots during the observation. During an interview/observation with the Food Service Director on 6/3/2015 at 4 PM, the Food Service Director explained that he developed the process for filling the sanitizer sink. Testing the concentration of the sanitizer solution in the 3 bay sink sanitizer sink was not done at a routine interval. The facility did not have a log documenting when/if the concentration of the sanitizer solution was tested , or of any results. He did not believe the chemical supply company that provided the test strips tested the concentration. There was no black line observed any longer in the sanitizer sink to indicate the fill level. When the Food Service Director filled the sanitizer sink (partially per the directions) and the sanitizer concentration was tested (twice), the test strip only changed color at the edges and the color change indicated less than 150 ppm. He stated staff had not reported a problem with the concentration of the sanitizer solution, and food service staff had not reported a problem earlier in the day. The undated directions posted above the 3 bay sink for the sanitizer bay documented: - to fill the sink up to the black line (25 gallons of water); and - run the sanitizer solution for 30 seconds. Between 4 and 4:30 PM on 6/3/2015, the Administrator volunteered that there was no policy regarding manual washing of pots and pans. 10NYCRR 415.14(h), 14-1.112(a)(4)

Based on observation, interview, and record review conducted during the standard survey, it was determined the facility did not ensure 1 of 17 sampled residents (Resident #2) consistently received the adequate supervision. Specifically, Resident #2 was not consistently monitored every 15 minutes for safety as planned; direct care staff were unaware the resident required this intervention; and no oversight was consistently provided to ensure the resident's safety intervention was implemented as planned. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Resident #2 had [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) assessment, dated 2/25/2015, documented the resident was cognitively intact, was independent with her transferring ability and independent for ambulation with a walker; the resident required limited assistance for dressing and personal hygiene, and extensive assistance for bathing. The nursing progress note dated 3/29/2015 at 6:03 AM documented the resident was found on the floor and stated she slid out of the chair onto the floor. She stated she saw people around her bed passing around pictures and wanted to join them. The registered nurse (RN) progress note dated 3/29/2015 at 11:44 PM documented the resident self-transferred 3 times; attempted to self transfer and ambulate; and staff intervened. The nursing note documented the resident's comprehensive care plan (CCP) was changed to reflect the resident's need for assistance of one with a gait belt for mobility and transfers, and also placed the resident on 15 minute checks as a safety precaution. The nursing progress note dated 4/22/2015 at 2:48 AM documented the resident had increased confusion throughout the shift and was wandering around stating she was looking for the kids that were acting up. The nursing progress note dated 4/22/2015 at 1:51 PM documented the resident continued with confusion, was looking for her mother's phone number, and a wanderguard bracelet was applied to the left ankle that morning for unsafe wandering. Nursing notes dated 4/22/2015 at 4:19 PM documented the resident was found downstairs during the night hours, attempting to go though the door leading to the employee corridor, triggering the door alarm. The nursing notes documented a wander alarm had been placed on the resident. On 4/22/2015, the CCP documented the resident was at risk to wander into an unsafe area without being able to communicate what she was doing. Approaches included a "Wander" bracelet to monitor the resident for episodes of wandering and for periods of restlessness. The CCP documented if resident's attempts are not easily altered, the resident should be on 1:1. Nursing notes dated 4/23/2015 at 1:38 PM documented the resident was ambulating outside her room, had her winter coat on, and thought she had an appointment. The nursing progress note dated 4/24/2015 at 9:29 PM documented the resident was on an antibiotic and respiratory treatment. The resident was found lying on her right side on the floor, with her head resting on the base of the overbed table. The nursing note documented Tabs alarm, neuro checks, and assistance of one with a gait belt were initiated. On 4/24/2015, the CCP noted the resident's fall and documented prevention strategies were to have the resident on 15 minute checks. The nursing progress note dated 4/26/2015 at 4:22 AM documented the resident was ambulating independently in the hallway and stated she cut her Tabs alarm with scissors. The nursing progress notes dated 4/26/2015 at 10:29 AM documented the resident was frequently pulling the Tabs alarm and the alarm was found with the string cut. The note documented another pair of scissors were found in the resident's room and were removed. The resident's Care Plan Part I (care guide for staff), initiated 4/30/2015, documented safety interventions were the resident's "Wander" bracelet and 15 minute checks. The CCP was updated 5/8/2015 and documented the resident's history of falls with fractures, and risk to wander into an unsafe area. Prevention strategies included use of a "Wander" bracelet and 15 minute checks. On 5/29/2015, the physical therapy annual assessment documented the resident was now independent with transfers and ambulation using a four wheeled walker. On 6/3/2015 at 1:40 PM, the resident was observed sitting on the seat of her four wheeled walker outside the building entrance. Staff were observed to approach the resident and ask her if she would like to ambulate around the building or, use a wheelchair. The resident stated she would like to use a wheelchair. The resident was observed to transfer herself into the wheelchair independently. On 6/4/2015 at 9:45 AM, certified nurse aide (CNA) #4 was interviewed and stated she was assigned to take care of the resident during the week. She stated she referred to the care plan for instructions on what each resident needed. She stated she checked on the resident to make sure she did not leave and. CNA #4 said there was no set time to check the resident, that it usually was every two hours. She stated she did not think the resident was currently on 15 minute checks. CNA #4 said the CNAs did not have any documentation for the monitoring checks and the nurses may have it. She stated the resident had gone downstairs in the past and that was why she had the Wanderguard. On 6/4/2015 at 10:08 AM, licensed practical nurse (LPN) #5 was interviewed and stated the resident had a Wanderguard bracelet on and was on 15 minute checks. She stated the CNAs would document care in the care plan book and there was a sheet normally in the book for them to document the 15 minute checks. The RN Manager was interviewed on 6/4/2015 at 11:20 AM and stated the resident was on 15 minute checks. The RN Manager stated it was the responsibiliy of the CNAs to check on the residents as scheduled, with help from the nurses at times. She stated there was no separate sheet to document the 15 minute checks and when a CNA signed the care plan book, documenting that they provided care for the shift, that included providing 15 minute checks during their shift. 415.12(h)(2)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure food was stored under sanitary conditions in 2 of 10 sampled Unit 2 resident rooms, rooms of Residents #18 and 19. Specifically, in Resident #18's room a spoiled food item was present in the refrigerator, and in Resident #19's room, the refrigerator thermometer was inaccurate/not operating properly. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1) Resident #18 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognitive status was severely impaired. A surveyor observed the resident's refrigerator twice on 5/14/2013 between 2:10 PM and 3:45 PM. At approximately 2:15 PM, the surveyor observed a Ziploc type bag with an unidentified food (it was unlabeled and appeared to be cherries) that was spoiled and frozen (it had been in the refrigerator directly under the freezer compartment); black mold was evident inside the bag with the food, upon observation. When the Environmental Services Director was interviewed on 5/14/2013 between 2:10 and 2:30 PM, he stated he believed if a resident had a refrigerator, the resident's family was to maintain the refrigerator. The RN (registered nurse) Unit Manager was interviewed on 5/14/2013 at 3:15 PM. She stated it was the responsibility of the resident and the resident's family to maintain a refrigerator in a resident's room. During the interview she observed the spoiled food item in the resident's refrigerator, and discarded it with the resident's permission. When the Unit Manager asked the resident about the food item, the resident stated she did not know what it was. 2) Resident #19 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was cognitively intact. The certified nurse aide care plan (used to by staff to direct resident care) dated 2/13/2013, documented the resident was confused at times. A surveyor observed the resident's refrigerator in the room on 5/14/2013 between 11:25 AM and 12 PM. The thermometer inside the refrigerator indicated the air temperature was 19 degrees F. and the food inside the refrigerator did not appear to be frozen. Another surveyor observed the air temperature in the resident's refrigerator on 5/16/2013 was 20 degrees F. The refrigerator contained an unlabeled plastic container with food and soda. The facility policy Resident Refrigerators dated 2/1/2011, documented one purpose of the policy was to prevent foodborne illness. The policy documented housekeeping staff would maintain a daily refrigerator temperature log to ensure the refrigerator maintained food between 32 and 40 degrees F. During interviews with the Environmental Services Director and Administrator on 5/15/2013 between 1 and 1:20 PM, the Environmental Services Director stated housekeepers did not check resident refrigerators. The Administrator explained that the facility policy was no longer current, housekeepers no longer checked resident refrigerators, and residents' family members were responsible to maintain residents' refrigerators. 10NYCRR 415.1.40(a)