Every finding on record at Sunnyside Care Center

Based on observations and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for two (2) of four (4) medication carts (East Hall North cart and [NAME] Hall North cart) and one (1) of two (2) medication rooms (East Hall) reviewed. Specifically, the East Hall North and [NAME] Hall North medication carts contained resident medications without pharmacy labels; opened undated medications; and expired medications; and the [NAME] Hall North medication cart was unlocked and contained three cups of medication in the top drawer. Findings include: The facility policy Medication/ Treatment Labeling and Storage, reviewed 4/2025, documented medications were stored in a safe, secure, and orderly manner. Medications should be labeled accordingly and missing, incomplete, improper, or incorrect containers shall be returned to the dispensing pharmacy or destroyed. The facility did not use any discontinued, outdated, or deteriorated drugs or biologicals. During an observation on 9/8/2025 at 9:07 PM the East Hall North medication cart contained the following:-two bottles of Latanoprost eye drops for Resident #23. One bottle was not dated when opened, and the second bottle was opened 8/1/2025. -one bottle of Latanoprost eye drops for Resident #15 was opened on 8/1/2025. -one bottle of artificial tears for Resident #60 opened 7/9/2025. -two Ozempic pens without resident names, additionally one was not dated when opened. -one Basaglar insulin pen without a resident name and no date when opened. -one Humalog insulin pen for Resident #7 that was not dated when opened. -Resident #7 had one Trelegy inhaler not labeled when opened. -Resident #7 had one Albuterol inhaler not dated when opened with a pharmacy dispense date of 7/26/2025.-Resident #7 had one Albuterol inhaler not dated when opened with a dispense date of 3/6/2025. -Resident #37 had one Spiriva inhaler opened 6/17/2025. During an interview on 9/8/2025 at 9:07 PM, Licensed Practical Nurse #6 stated eye drops should be labeled when opened and were good for either 30 days or until the bottle was gone, depending on the medication. Resident #15 Latanoprost eye drops were administered and had been opened on 8/1/2025. They thought the eye drops expired 9/1/2025 and it should have been discarded. Ozempic pens should be dated when opened and placed in a small plastic bag with the resident's name. The Basaglar insulin pen did not have a pharmacy resident name label, was not in a bag with the resident's name, or dated when opened. They did not administer the Basaglar insulin pen, but it was nearly empty. Without the label staff would not know which resident the pen belonged to. The Humalog insulin pen for Resident #7 should have been dated when opened as insulin expired in 28 days and should be discarded. All inhalers required an open date and were used until they were empty. Resident #7 had a Trelegy inhaler opened and not dated when opened; an Albuterol inhaler not dated when opened with a dispense date of 3/6/2025; and an undated Albuterol inhaler with a dispense date of 7/26/2025. Resident #37 had a Spiriva inhaler opened 6/17/2025. Medications should be discarded when expired because they were not as effective and could grow bacteria. Every nurse working the medication cart was responsible for making sure all inhalers, insulin pens, and eye drops were labeled when opened and discarded when expired. During an observation of the [NAME] Wing North cart on 9/9/2025 at 8:15 AM, the cart contained:-two Basaglar insulin pens without resident names and not dated when opened.-Resident #10 had a Basaglar insulin pen not dated when opened.-Resident #40 had Lantoprost eye drops not dated when opened.-Resident #10 had a Spiriva inhaler opened 7/11/2025. -Resident #13 had an Albuterol inhaler with an open date of March 2025. During an interview on 9/9/2025 at 8:25 AM, Licensed Practical Nurse #16 stated insulin pens were dated when opened and expired in 28 days. They stated no one received insulin in the morning and was last administered the prior evening. The eye drops were also dated when opened and good for 28 days. It was every nurse's responsibility to ensure all medications in the cart were dated when opened and discarded when expired. They did not check the medication cart for expired medications and should have. Medications were discarded when expired because they were not as effective and were not safe to administer. Unlocked Medication CartDuring an observation on 9/8/2025 at 6:10 PM, the [NAME] Wing North Cart was unlocked. There was one medication cup with several white round pills, another medication cup with several orange round pills, and a third cup with a variety of medications (two small brown pills, one oval orange pills that covered other medications in the cup). Resident #21 was wheeling themselves around and grabbed the top drawer of the unlocked medication cart. During an interview on 9/11/2025 at 12:20 PM, Licensed Practical Nurse #18 stated they were assigned to the medication cart on 9/8/2025 for the day and evening shifts. They were trained on medication administration by Licensed Practical Nurse #20 and the medication cart should be always locked, for the safety of all residents. They did not lock it because they were very busy. They stated there were three cups of medications in the top drawer; one was Tylenol, one was senna, and one was for a resident who refused their medication. They were trained to put Tylenol and Senna in medication cups because the bottles were too big to fit in the top drawer. It was easier to put the medication in the medication cup in the top drawer because it required a lot of bending to get the medication out of the bottom drawer. During an interview on 9/11/2025 at 5:08 PM, Licensed Practical Nurse #20 stated they trained new employees on administering medications to residents. The medication cart should always be locked when unattended for safety reasons. Medications should not be in unlabeled medications cups because the wrong medication could be administered to the wrong person. They instructed new staff to move Tylenol from the large bottle into smaller, unlabeled medications cups to prevent nurses from bending over multiples times reaching for the lower drawer. This was a short cut nurses should not take, and they should not teach orientees. There were residents that wandered on the unit who could open the cart and take the unsecured medications. Resident #21 wandered and was often reaching for things. During an interview on 9/12/2025 at 9:40 AM, the Assistant Director of Nursing stated they taught the general nursing orientation and trained all nurses on medication administration. The nurses also received two days of training by nursing staff on the medication cart. They expected the medication cart to always be locked when unattended so residents or anyone in the building could not have access to medications. All medications should be kept in the labeled container for safety reasons and so medications could be easily identified. Eye drops, insulin, and inhalers should be labeled when opened and discarded within 28 days. Expired medications were not as effective. 10NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification and abbreviated (576137/ NY00340739 and 576142/ NY00346243) surveys conducted 9/8/2025 - 9/12/2025, the facility did not ensure resident menus were followed for two (2) of seven (7) meals observed. Specifically, the facility ran out of preplanned menu items and substituted with items that were not nutritionally equivalent; and did not inform Registered Dietitian #5 there was no orange juice, and an orange-flavored citrus punch was substituted. The Foodservice Director did not submit food orders timely to ensure food items were available for the preplanned lunch meal for 9/9/2025. Additionally, Residents #24, #64, and #66 did not receive food items at meals as planned; and Residents #7 and #48 stated the facility sometimes ran out of food.Findings include: The facility policy Food Procurement, revised 10/2024, documented orders would be placed by the Dietary Manager/ Food Service Director or designated staff according to menu requirements and inventory needs. All deliveries would be checked against invoices to ensure accuracy, quality, and condition. The Dietary Manager/ Food Service Director was responsible for ordering and oversight of procurement. Administration would review procurement practices quarterly to ensure compliance. The undated Food Service Director job description documented they would complete supply orders and maintain appropriate par levels. They were to ensure the food service department operated within weekly budget for staffing and supplies. Additionally, monitor food control systems, such as food temperatures, portion control, preparation, and presentation of food. The facility policy Tray Identification, revised 4/2025, documented the Food Service Manager or supervisor would check trays for correct diets before food carts were transported to the units. Nursing staff would check each tray for correct diets prior to serving the residents.The facility policy Substitutions, revised 5/2024, documented The Food Service Manager, in conjunction with the Clinical Dietitian, may make food substitutions as appropriate or necessary. All substitutions would be noted on the menu and filed in accordance with established dietary polices. Notations of substitutions must include the reason for the substitution. The facility's week three food par list did not document the quantity of potato tots, pineapple, ketchup or mustard. The week three par list documented 30 dozen shelled eggs, six orange juice, six apple juice, and one American cheese. The food par list did not indicate the product size or quantity needed for orange juice, apple juice or American Cheese. The facility's September 2025 food purchase orders did not document regular orange juice, apple juice, pineapple, or tater tots were ordered. The 9/5/2025 food purchase order for delivery on 9/11/2025 documented six #10 cans of ketchup and four 1-gallon containers of mustard were ordered. During an interview on 9/8/2025 at 7:32 PM, Resident #7 stated the facility sometimes ran out of food items.During an interview on 9/8/2025 at 8:54 PM Resident #46 stated the facility often ran out of food items. A receipt from a local grocery store dated 9/9/2025 at 6:42 AM, documented 120 shelled eggs, six bottles of juice, six bottles of orange-flavored citrus punch, American Cheese, shredded cheese, three packages of potato tots, two yellow mustards, and two ketchups were purchased. The facility's week three preplanned menu documented the 9/9/2025 lunch meal was a cheeseburger on a bun, broccoli salad, banana, and potato tots. The alternative entree was baked chicken.During an observation on 9/9/2025 at 12:29 PM, the main kitchen walk-in cooler contained five 1-gallon plastic containers of orange-flavored citrus punch, six 96-ounce plastic bottles of apple juice, and one 5-pound block of American cheese. During an interview on 9/9/2025 at 12:49 PM the Food Service Director stated they were responsible for ordering food supplies. They did not order apple juice or orange juice because they missed it. They reviewed the food inventory on the evening of 9/8/2025 and noticed other items were missing. They asked [NAME] #22 to go a local store the morning of 9/9/2025 to purchase items such as juice, cheese, potato tots, and condiments. Any menu substitutions should be approved by Registered Dietitian #5. They did not alert Registered Dietitian #5 the orange-flavored citrus punch was substituted for orange juice. During an interview on 9/9/2025 at 1:21 PM, [NAME] #22 stated they went to a local grocery store weekly to purchase items needed for the preplanned menu. The Food Service Director was responsible for ordering, and they were unsure why items were not stocked. The Food Service Director called them on the evening of 9/8/2025 at 10:00 PM asking them to go to a local store to purchase orange juice, apple juice, cheese and potato tots. While at the store they decided to purchase the orange -flavored citrus punch. All menu substitutions should be approved by Registered Dietitian #5. They stated they did not tell Registered Dietitian #5 they bought orange -flavored citrus punch instead of orange juice. The week three preplanned menu documented the 9/10/2025 lunch meal included an open-face roast pork sandwich with gravy, mashed potatoes, carrots, and banana cake with frosting. The alterative entree was baked ham.During a meal observation on 9/10/2025 between 12:50 PM and 12:52 PM, Residents #66's and #64's meal tickets documented they were to receive two ounces of pineapple sauce with their baked ham. Neither resident had pineapple sauce.During a meal observation on 9/10/2025 at 1:14 PM, Resident #24's meal ticket documented they were to receive eight fluid ounces of an oral nutrition supplement. The resident did not receive the oral nutrition supplement. During a follow up interview on 9/10/2025 at 4:39 PM, the Food Service Director stated they completed the food ordering for the facility and ordered items weekly. They reviewed the menu, production lists, facility census, and inventory on hand to ensure all the food needed was on hand when needed. Sometimes they forgot to order food items and went to a local store to purchase the items. The production sheets did not indicate which type of juices or quantity needed for specific types of juice and only listed the total of number of assorted juices needed. They reviewed the food inventory on hand the evening of 9/8/2025 and saw items were needed. They called [NAME] #22 and asked them to purchase items at the local store including juice, cheese, potato tots, and condiments. [NAME] #22 purchased the orange-flavored citrus punch. It was not a nutritional equivalent to orange juice, and they did not tell Registered Dietitian #5 the orange-flavored citrus punch was being substituted for orange juice. It was important to ensure the correct quantity of food items were on hand, so the residents were not missing items, and all menu substitutions were reviewed and approved by the registered dietitian to ensure they were nutritionally equivalent. They checked the meal trays for the lunch meal service on 9/10/2025 and heard after the meal items were missing. During an interview on 9/10/2025 at 5:41 PM, Registered Dietitian #5 stated the Food Service Director should alert them to any menu substitutions so they could ensure they were nutritionally equivalent. They were unaware an orange-flavored citrus punch was substituted for orange juice. They would not have approved that substitution as it was not a nutritional equivalent to orange juice. They were not aware the meal tickets and productions sheet documented assorted juices instead of specific juices. During a follow up interview on 9/11/2025 at 2:49 PM, Registered Dietitian #5 stated during their meal rounds they checked to ensure all items were on the residents' meal tickets. They were unaware the residents were not provided with two ounces of pineapple sauce or the alternate lunch entree on 9/10/2025. Residents should receive items on their tray to honor their food preferences. Resident #24 should have received their oral nutrition supplement as they had increased calorie and protein needs. During an interview on 9/12/2025 at 9:13 PM, the Administrator stated the Food Service Director was responsible for purchasing the food at the facility. At times the Food Service Director would ask to purchase items at a local store, but they thought the facility had enough food to serve the residents. They thought the recent holiday may affected the food purchasing and delivery schedule. During a follow up interview on 9/12/2025 at 9:19 AM, the Food Service Director stated the 9/10/2025 alternate lunch entree should have been served with two ounces of pineapple sauce. They thought it had been made and served. Oral nutritional supplements were put on the resident's meal trays by the food service department and they must have overlooked Resident #24's meal ticket. The residents should receive all items listed on their meal tickets. 10NYCRR 415.14(c)(1-3)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00346243/ iQIES 576143) surveys conducted 9/8/2025-9/12/2025, the facility did not ensure food was served at palatable and appetizing temperatures in accordance with professional standards for food service for 2 of 2 meals (9/9/2025 and 9/10/2025 lunch meals) reviewed. Specifically, the lunch meal test trays on 9/9/2025 and 9/10/2025 were not flavorful or served at palatable and appetizing temperatures. Additionally, seven (7) anonymous residents at the Resident Council Meeting stated the food was often cold and not flavorful Findings Include:The facility policy Food and Nutrition Services, revised 1/2025, documented each resident received meals that were nourishing and palatable. Food and nutrition staff would inspect food trays to ensure the food appeared palatable, attractive and was served at a safe and appetizing temperature. During a meal observation on 9/09/2025 at 12:37 PM, Resident #66's lunch tray was sampled in the presence of Certified Nurse Aide #19, and a replacement tray was ordered. The tray was tested for temperature and palatability with the following results: -assorted juice was 55 degrees Fahrenheit.-cheeseburger on bun was 104.5 degrees Fahrenheit and the center of the hamburger was red.-broccoli salad was 46.4 degrees Fahrenheit.-potato tots were 111 degrees Fahrenheit and cold.During a resident council meeting on 9/9/2025 at 2:00 PM, seven anonymous residents stated the hot food was usually cold and not palatable. During a meal observation on 9/10/2025 at 12:48 PM, Resident #1's lunch tray was sampled in the presence of Certified Nurse Aide #9, and a replacement tray was ordered. The tray was tested for temperature and palatability with the following results: -honey thick water was 58 degrees Fahrenheit and tasted sour.-honey thick Heath Shake (nutritional supplement) was 61 degrees Fahrenheit.-honey thick cranberry juice was 55 degrees Fahrenheit.-pureed roast pork sandwich with gravy was 105 degrees Fahrenheit and cold.-pureed carrots were 108 degrees Fahrenheit and cold.-mashed potatoes with gravy was 119 degrees Fahrenheit.During an interview on 9/10/2025 at 4:39 PM, Food Service Director #4 stated hot beef should be cooked to at least 145 degrees Fahrenheit and cooked pork should be cooked to 165 degrees Fahrenheit. They stated cold foods and beverages should be held at 36-41 degrees Fahrenheit. Hamburgers should be tan in the middle and not red. The cook took the first cooking temperature at the end of the cooking process and a second temperature when the food was loaded into the steamer. They stated it was important to cook and serve food at palatable temperatures to prevent bacterial growth and encourage intake. They stated they usually did test trays daily, changing meals and tray location.During an interview on 9/10/2025 at 5:41 PM, Registered Dietitian #5 stated they did meal tray observations during meals. If they noted any issues, they informed the Food Service Director or Administration. They stated they expected the food to be palatable and would rather the residents consume the food instead of supplements.During an interview on 9/11/2025 at 11:07 AM, Certified Nursing Aide #15 stated they had several food complaints from residents regarding food palatability and cold temperatures. They stated the kitchen staff were responsible for making sure all items served on the tray were hot and palatable.During an interview on 9/11/2025 at 1:34 PM, Licensed Practical Nurse #16 stated they had several resident complaints about food palatability, including lack of flavor and cold food temperatures. They stated the food did not appear appetizing.During an interview on 9/11/2025 at 3:14 PM, the Food Service Director stated after hot food was pureed, it was put in a metal hotel pan and reheated to at least 165 degrees Fahrenheit. The temperature was obtained with a stem thermometer. They purchased the honey thick milkshakes and sent them on the tray still in the carton. The nursing staff would open the carton and pour the milkshake into the glass. They stated they did test trays on pureed food at times by creating an extra tray and loading it on the meal cart, then testing the tray last, after all residents from that cart were served. They did not obtain a temperature of the honey thick milkshake prior to leaving the kitchen for the lunch meal on 9/10/2025. They stated they used a thermal base to keep plates hot at meals, however if a red divided plate was used, as was the case in the second test tray, the thermal base could not be used as it would melt the red plate. They stated that the red plate was used when therapy requested it. 10NYCRR 415.14(d)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for one (1) of one (1) main kitchen reviewed. Specifically, food was not discarded in a timely manner; one box of bananas was stored directly on the floor; [NAME] #21 scooped chopped eggs into a mixing bowl with ungloved hands; and dishes were not sanitized properly. Findings include: The facility policy Food Receiving and Storage, revised October 2024, documented all foods stored in the refrigerator and freezer would be covered and dated with a use by date. Food was kept at least 18 inches off the floor. The facility policy Sanitization, revised October 2024, documented all equipment, food contact surfaces, and utensils should be washed to remove or completely loosen soils by using manual or mechanical means necessary and sanitized using hot water and/ or chemical sanitizing solutions. Sanitizing would be performed with one of the following solutions: - 50-100 parts per million (ppm) chorine solution. -150-200 parts per million quaternary ammonium compound (QAC) or: - 12.5 part per million iodine solution. Sanitizing of utensils and removeable parts of equipment would be accomplished in of the following ways: -contact for at least 30 seconds with an iodine solution (at approved concentration). -contact with quaternary ammonium compound (at approved concentration) per manufacturer's instructions. -contact for at least 10 seconds with chlorine (at approved concentration) or; -Immersion for 30 seconds in hot (at least 171 degrees Fahrenheit (F)) water. The facility policy Food Preparation and Service, revised October 2024, documented food preparation staff would adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Bare hand contact with food was prohibited. Gloves were to be worn when directly handling food. Food Storage: During an observation in the main kitchen on 9/8/2025 at 6:18 PM, in the presence of [NAME] #21, the main walk-in cooler contained: - one undated metal half pan of home fries; - two plastic five-pound bags of coleslaw with a best used by of 8/25/25; - one plastic five-pound bag of mixed greens salad with a best used by date of 9/1/2025; - one undated plastic five-pound container of cottage cheese; - three pounds of undated corned beef wrapped in plastic wrap with Tuesday written on it; and - one eight-pound block of American cheese wrapped in plastic wrapped dated 9/3/2025. During an observation on 9/9/2025 at 11:55 AM, there was one cardboard box of bananas placed directly on the floor of the main kitchen. During an interview on 9/8/2025 at 6:51 PM, the Food Service Director stated all items in the walk-in cooler should be labeled and dated to ensure freshness and quality of food items and for food safety reasons. It was the responsibility of all food service staff to label and date items and check to ensure items were discarded when not dated or past their best used by date. If an item was taken out of its original container it was only good for three days. Dishware Sanitation: -During an observation on 9/9/2025 at 12:35 PM, [NAME] #21 was washing dishes in the 3-bay sink. There were no quaternary test strips observed. -During an observation on 9/9/2025 at 1:20 PM, [NAME] # 22 was washing dishes in the 3-bay sink. There were no quaternary test strips observed. During an interview on 9/9/2025 at 1:33 PM, [NAME] #22 stated they did not check the sanitizer solution in the 3-bay sink prior to washing dishes. There were no sanitizer testing strips to test the sanitizer solution. They did not let the Food Service Director know there were no sanitizer testing strips available. During an interview on 9/9/2025 at 1:34 PM, [NAME] #21 stated they filled the 3 -bay sink including the dish sanitizer bay of the sink. They did not test the sanitizer solution as there were no sanitizer testing strips. They were busy and did not tell anyone. The Pot and Pan Sink Sanitizing Log documented on 9/9/2025 at lunch the water temperature was 80 degrees Fahrenheit and 200 parts per million. Food Preparation: During an observation and interview on 9/9/2025 at 1:37 PM, [NAME] #21 used their ungloved hands to scoop chopped hard boiled eggs from the food processor into a metal mixing bowl. They added seasoning to the bowl and mixed the eggs with their bare hands. At 1:38 PM, [NAME] #21 stated they used their bare hands to scoop the chopped hard-boiled eggs from the food processor, and it was not sanitary. They discarded the chopped hard-boiled egg mixture. During an interview on 9/10/2025 at 4:39 PM, the Food Service Director stated they were unaware staff did not have the sanitizer test strips available to check the concentration of the sanitizer solution. They kept the extra supply of sanitizer testing strips in their desk and staff should let them know if they needed them. Dishes and utensils should be sanitized to ensure they were disinfected. All food service staff were educated on proper food preparation and should not use ungloved hands to scoop food from the food processor as there was a potential for foodborne illness. 10NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment for one (1) of two (2) resident units (West Unit). Specifically, the [NAME] Unit dining room had sticky floors with ants, there were flying insects throughout the unit, and resident room [ROOM NUMBER] had unclean walls.Findings include:The facility policy Quality of Life/Homelike Environment, revised 5/2025, documented residents were provided with a safe, clean, comfortable and homelike environment. The facility policy Inservice- Daily Cleaning, revised 7/12/2025, documented the housekeeper should clean and dust all windowsills, tables, chairs with disinfectant, and clean all spots, spills, scuff marks on vertical surfaces such as walls, doors, and over the bed table stands. The following observations were made of room [ROOM NUMBER]: -On 9/8/2025 at 6:29 PM, the wall to the right side of the window had a yellow-white liquid substance covering the wall. -On 9/9/2025 at 11:29 AM, there were white spots on the floor from the door to the head of the bed, the yellow-white splattered substance to the right of the window under the television remained on the wall. -On 9/9/2025 at 2:34 PM, a white thick substance was on the floor and baseboard to the right of the window, and the yellow-white substance remained on the wall under the television. During an interview on 9/9/2025 at 1:12 PM, Housekeeper #23 stated they cleaned the resident rooms every day. They were responsible for cleaning the resident walls but did not clean room [ROOM NUMBER] in a while and was due to be cleaned. The following observations were made on the [NAME] Unit: - On 9/8/2025 at 6:52 PM, the dining room had ants surrounding crumbs on the floor. - On 9/9/2025 at 11:20, there was a fruit fly in the hall outside of room [ROOM NUMBER]. - On 9/9/2025 at 2:14 PM, there was a fruit fly in the hall outside of room [ROOM NUMBER]. - On 9/10/2025 at 9:15 AM, there was a fruit fly in the hall outside of room [ROOM NUMBER]. - On 9/10/2025 at 12:01 PM, a fly landed on a tray table outside of room [ROOM NUMBER]. - On 9/11/2025 at 11:33 AM, a fruit fly was on the face of a resident in room [ROOM NUMBER]. During an interview on 9/11/2025 at 11:07 AM, Certified Nurse Aid #15 stated they saw fruit flies, ants and spiders in the facility. They had bug traps, but the fruit flies were a severe issue earlier in the year. It was not a homelike environment as food was left out, trash was not emptied, and food was not cleaned off the floor or nightstands in resident rooms. During an interview on 9/11/2025 at 1:34 PM, Licensed Practical Nurse #16 stated they saw fruit flies and ants, especially in the dining room when food was on the floor. They also had spiders. The floors were not cleaned properly at the facility leading to ants. During an interview on 9/12/2025 at 9:30 AM, the Director of Facilities stated housekeeping staff were responsible for cleaning the rooms every day. They had a checklist they followed to ensure the rooms were cleaned and included mopping the floor, sweeping, cleaning the sink, the toilet, dusting the bathroom and rooms and cleaning the walls. If they were soiled and were not able to be cleaned, they should put in a work order to ensure they order a product that cleaned the areas properly. They stated if any staff saw pests, they should let them know as soon as possible so they could contact pest control services. They were not aware of ants in the [NAME] Wing dining room, but the ant traps were due to be replaced that day. The housekeepers cleaned up all the food droppings in the dining room on Monday and Tuesday to prevent an ant problem. 10 NYCRR 415.29(j)(1)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure the comprehensive person-centered care plan was implemented to ensure a resident's nursing needs were met for one (1) of one (1) resident (Resident #46) reviewed. Specifically, Resident #46 was at risk for falls, and the care plan was not implemented or updated with individualized interventions for fall prevention. Findings include: The facility policy Care Planning, last reviewed 7/2025, documented the comprehensive care plan was based on the resident's comprehensive assessment and was developed by a Care Planning/Interdisciplinary Team. The resident and resident's family were encouraged to participate in the development and revisions of the resident's care plan. The policy did not document when to update a care plan.The facility policy Fall Policy and Procedure, last revised on 9/2024, documented when a resident had a fall, the charge nurse or designee would follow the accident and incident protocols and ensure the resident's comprehensive care plan was updated with interventions to reflect the event and ensure the event was documented on the 24-hour report.Resident #46 had diagnoses including dementia and anxiety. The 8/22/2025 Minimum Data Set assessment documented the resident had intact cognition, required partial to moderate assistance with most activities of daily living, and had two or more falls since their admission or prior assessment. The Comprehensive Care Plan initiated 2/20/2025 documented the resident was at risk for falls. Interventions included: on 3/13/2025 offer the resident assistance if they appear restless and attempt to get out of bed during rounds; on 4/2/2025 ensure the resident was toileted prior to lying down for a nap; on 5/6/2025 educate the resident on the use of the call bell and wait for staff to assist; and on 5/13/2025 have floor mats down when in bed.The 7/17/2025 at 3:55 PM incident report created by Registered Nurse #14, documented the resident had an unwitnessed fall in their room. Contributing factors included cardiac/respiratory disease. The resident was found in bed and stated they fell. The resident had a 5-centimeter abrasion and hematoma (pooled blood) on the top of the head, and a 2-centimeter bruise to the occipital (back of head) area. The medical provider and family were made aware. The incident report did not document if fall interventions were in place at the time of the incident. The 8/1/2025 at 11:18 AM incident report created by Registered Nurse #14 documented the resident had an unwitnessed fall in their room on 8/1/2025 at 11:12 AM. Contributing factors was checked none of the above. The resident was found on the floor and reported they fell when attempting to get out of bed. The resident was assessed and had two skin tears to the right elbow and posterior arm. The resident was assisted back to bed safely and reminded to use the call light for assistance. The medical provider and family were made aware. The incident report did not document if fall interventions were in place at the time of the incident. There was no documented evidence of root cause analysis of the fall and need for additional person-centered interventions for fall prevention. The 8/1/2025 Physician Assistant #13's progress note documented the resident was seen due to reported fall. The resident was found on their floor in the room and reported to nursing that they had fallen on their right elbow and posterior head. The resident had decreased safety awareness and was reminded to call for assistance prior to transferring and would continue with Physical and Occupational Therapy.The 9/7/2025 at 8:09 PM incident report created by Registered Nurse #11 documented the resident had an unwitnessed fall in their room. There were no contributing factors identified. The resident was found by nursing staff and reported they tripped over a pillow. The resident had reopened the previous skin tear on the left elbow. The medical provider and family were made aware. The incident report did not document if fall interventions were in place at the time of the incident. There was no documented evidence Resident #46's care plan was reviewed and updated to include the resident's recent falls on 7/17/2025, 8/1/2025 and 9/7/2025. The fall comprehensive care plan updated on 9/7/2025 documented to continue with current plan of care.During an observation on 9/8/2025 at 8:09 PM, Resident #46 was in bed. Their walker was on the other side of the room and there was a blanket and a pillow on the floor next to their bed. There were no fall mats on the floor or in the resident's room as planned. During an observation on 9/10/2025 at 8:58 AM, the resident was lying in bed with their walker on the other side of the room. There were no fall mats in the room. During an interview on 9/11/2025 at 12:01 PM, Registered Nurse Supervisor #11 stated after Resident #46 had a fall, the registered nurse was required to do a full observation and assessment. They should also look at the fall care plan and ensure all the fall prevention interventions were in place. On 9/7/2025, the resident was not independent with mobility and had their fall mats in place.During an interview on 9/11/2025 at 1:20 PM, the Assistant Director of Nursing stated care plans should be looked at with each fall. The situation of the fall should be reviewed, and they should add interventions that could prevent additional falls in the future. They stated when the resident tripped on the pillow on the floor, nursing should have added to the care plan to ensure the floors were clear and the room was clutter free. Resident #46 was alert and oriented. Nursing should be aware of all interventions placed on the care plan to prevent falls. If the resident was in bed, then nursing should place the fall mats on the floor until the resident got out of bed. They stated the resident's care plan was reviewed with each fall but there were no new interventions added. Staff should try new interventions to ensure the resident had fewer or no falls and to prevent injury. 10NYCRR 415.11(c)(2)(iii)

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025-9/12/2025, the facility did not ensure residents were provided the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living including functional communication systems for one (1) of one (1) resident (Resident #22) reviewed. Specifically, Resident #22's primary language was not English, and the resident was not consistently provided with translation services or alternate forms of communication. Findings include:The facility policy Residents Rights, last reviewed 1/2025, documented all residents would be treated with respect, kindness, and dignity; and had the right to communicate with and access people and services, both inside and outside the facility. The facility policy Translation and/or Interpretation of Facility Services, revised 1/2025, documented individuals with limited English proficiency had meaningful access to information and services provided by the facility. The Director of Social Work identified a language barrier and coordinated the language access plan. All persons were informed of their rights to obtain competent oral translation services free of charge. Family members and friends were not relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. Resident #22 had diagnoses including diabetes. The 7/17/2025 Minimum Data Set assessment documented the resident was cognitively intact, their preferred language was Spanish, and they needed or wanted an interpreter to communicate with a doctor or health care staff. The Comprehensive Care Plan initiated 5/25/2023 and revised 9/9/2025 documented the resident had a communication problem related to Spanish being their primary language. Interventions included a language line was to be used to communicate with the resident. The following observations were made of Resident #22: -On 9/08/2025 at 6:10 PM, were seated in their wheelchair in the doorway to their room. They were talking extensively to their roommate in Spanish. Their bed was covered with boxes of their belongings. No language or communication board was observed in the resident's room. -On 9/08/2025 at 7:46 PM, in their room with staff clearing off the bed and moving boxes. Staff spoke with the resident in English. The resident was crying and waving their arms in the air and trying to express themself in Spanish. They kept pointing at the boxes and speaking rapidly in Spanish. Nursing staff did not try to assess what the resident needed. No language or communication board was observed in the resident's room. -On 9/09/2025 at 12:50 PM, Resident #22 propelled themselves in their wheelchair between the hallway and their room. They were very talkative, but only spoke Spanish, not English. There was no language or communication boards observed in their room and the monthly activities calendar taped on the wall was in English. -On 9/09/2025 at 1:09 PM, Licensed Practical Nurse #10 approached Resident #22 and told them in English they needed to go to their room and followed the resident to their room to administer insulin. Licensed Practical Nurse #10 did not attempt to communicate with the resident in their preferred language or use an alternate form of communication.During an interview on 9/11/2025 at 1:50 PM, Certified Nursing Aide #9 stated Resident #22 had a communication board in their room. Certified Nursing Aide #9 entered the resident's room and pulled the communication board from under some towels. On 9/09/2025 at 1:27 PM, Resident #22 was interviewed using the Language Line (Spanish interpreter #425575). They stated the facility staff did not communicate with them in a way they could understand and did not tell them what meds they were taking or what they were doing when treating them. They stated they were frustrated when they did not know which procedures or medications they received but shrugged their shoulders and stated when staff called their name they would just follow and allow treatment. They stated they became very upset and started crying in the evening on 9/8/2025 because they thought staff were kicking them out of the facility, and it made them very angry because they had lived in the facility for so long.During an interview on 9/11/2025 at 1:50 PM, Certified Nursing Aide #9 stated they used a facility translator that was kept plugged in on the unit, however it was not available, and they did not know where it was. They stated staff often used their phones to translate and some residents had a communication board. They stated Resident #22 had a communication board. During an interview on 9/11/2025 at 2:00 PM, Licensed Practical Nurse #10 stated they used a language line to communicate with a resident if they did not understand English. They did not always use the language line if they were doing something they thought the resident understood. They sometimes used the language line with Resident #22, but not when they gave routine medications. They thought the resident knew what the medications were. During an interview on 9/12/2025 at 8:43 AM, Registered Nurse #11 stated they used the language line to communicate with residents who did not understand English. Residents also utilized communication boards, but they had not seen those in the facility. They stated the procedure to use the language line was posted on the unit and they knew it was being utilized if it was documented in the health record or through observation on rounds. They stated all residents had the right to know what medications they were taking and why, and that staff should use the language line for this purpose. During an interview on 9/12/2025 at 8:58 AM, the Director of Social Work stated they determined if a resident was unable to understand English from the admission hospital documentation. They added a communication problem to the care plan, with interventions, and sent an e-mail out to the departments to alert them. Staff should use the language line to communicate with the resident, and the interpreter helped determine how much the resident understood. During a telephone interview on 9/12/2025 at 10:10 AM, Physician's Assistant #13 stated they used a language line to communicate with residents who did not speak or understand English. Use of the language line depended on what they saw the resident for. They stated they utilized the language line if they needed information regarding the resident's symptoms or other subjective data. If they were addressing medicine reviews or laboratory findings, they did not access the language line. They stated they knew the resident understood them because they nodded their head. They stated residents all had the right to be spoken to in their own language. 10NYCRR 415.12(a)(3).

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025- 9/12/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (1) of three (3) residents (Resident #66) reviewed. Specifically, Resident #66 had brown debris underneath long, untrimmed fingernails; foul breath with white debris on their teeth; and uncombed hair.Findings include:The facility policy Activities of Daily Living (ADLs) Supporting, revised 3/2018, documented residents who were unable to carry out activities of daily living independently, would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services were provided for residents and in accordance with the plan of care including appropriate support with hygiene, bathing, dressing, grooming, oral care, toileting, meals, and mobility. Resident #66 had diagnoses including dementia, anxiety, and diabetes. The 6/17/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, did not reject care, and required partial/moderate assistance for most activities of daily living. The Comprehensive Care Plan initiated 7/31/2025, documented the resident had activity of daily living deficits and required assistance with activities of daily living and functional mobility. Interventions included set up for personal hygiene and assistance of one for bathing and dressing. The undated care instructions (Resident Care Profile) documented the resident required set up assistance with personal hygiene and assistance of one for bathing and dressing. During observations on 9/8/2025 at 6:59 PM, 9/9/2025 at 12:26 PM, 9/11/1015 at 8:53 AM, and 9/11/2025 at 11:33 AM, Resident #66 had long, untrimmed fingernails with a brown and black substance underneath their nails; uncombed hair; and noticeable bad breath with a white substance on their bottom front teeth. During an interview on 9/9/2025 at 12:26 PM, Resident #66 stated they were not sure what day they were scheduled for a shower. They never refused their shower but often did not receive a shower and wanted one because showers were weekly. They wanted their hair combed, their nails cleaned, cut, and painted, and their teeth brushed. The stated they did not believe they even had a toothbrush. The resident's drawers were opened with the resident present, and no toothbrush was observed. The shower schedule posted behind the nurse's station documented Resident #66's shower day was on Monday on the evening shift. During an interview on 9/11/2025 at 11:07 AM, Certified Nurse Aide #15 stated they were responsible for providing hygiene care for residents on shower days and as needed. Showers were provided weekly with hygiene care on shower days including washing the resident, washing hair, brushing teeth, and clipping nails. On their non shower days they were provided a bed bath washing under arms, under breasts, and the groin area, hair was combed, teeth brushed, and nail care was provided. Nails should be cut and cleaned even if it was not their shower day. Oral care should be completed twice a day to prevent heath issues and hair should be combed daily so it did not get matted. They did not notice Resident #66's nails that morning. Certified Nurse Aide #15 stated they did not provide oral care or nail care because they were busy. They did not give the resident a brush or comb because they thought the resident was going to do it themselves. During an interview on 9/11/2025 at 12:07 PM, Certified Nurse Aide #17 stated they worked the evening shift and often had showers assigned on their schedule. Resident #66 was on their assignment that week for a shower on 9/8/2025 and they worked that day. They did not give the resident a shower, provide nail care, or oral care because there were too many showers scheduled on the evening shift. If a resident did not get their shower they should tell the nurse. They did not tell the nurse Resident #66's shower was not completed, because the nurse was new. They normally also reported this to a supervisor but did not that evening. They did not clip Resident #66's nails because the resident could do it themselves, but they did not provide the resident with clippers or nail file. They did not provide oral care because the resident could do it themselves. They believed the resident's care plan documented the resident required set up assistance for hygiene which meant they should prepare the resident by giving them their toothbrush, toothpaste and hairbrush. During an interview on 9/11/2025 at 12:20 PM, Licensed Practical Nurse #18 stated they worked the evening shift on 9/8/2025 and was responsible for making sure certified nurse aides completed their assignment. They were not notified showers were not completed and should have been. They documented in a progress note when a resident did not get their shower or refused their shower. During an interview on 9/11/2025 at 1:34 PM, Licensed Practical Nurse #16 stated certified nurse aides provided hygiene care for the residents according to the care plan. When the care plan documented assistance of one, that meant one staff assisted the resident. Set up meant to set the resident up with the wash basin, tray, toothbrush and toothpaste. When a resident refused care the certified nurse aide notified them, and they documented it in the progress note. They were not notified of any resident that refused care this week. 10 NYCRR 415.12(a)(3)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00316447) surveys conducted 2/12/2024-2/16/2024 the facility did not ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for all 76 residents in the facility. Specifically, during a confidential resident group meeting residents stated their call bells were not answered timely, especially on the weekends, and there were not always enough certified nurse aides available to assist with activities of daily living such as transfers out of bed and dressing. Additionally, deficiencies related to staffing levels were identified in the areas of Comprehensive Resident Centered Care Plans, Activities of Daily Living, Pressure Ulcers, Respiratory Care, and Food Palatability. Finding include: The facility policy Emergency Staffing Plan revised 3/2023 documents in the event of an emergency, the Administrator or designee would make the decision to utilize emergency staffing strategies as necessary to provide for care and treatment of residents. In the event the facility had difficulty with staffing the facility would remove tasks from the nursing department that did not need to be completed by a certified nurse aide or a nurse. Agency staffing would be utilized if deemed necessary by the Administrator or designee. The Facility Assessment, last updated 1/16/2024, documented the facility was licensed for a total of 80 skilled nursing beds. Within the total beds, two units (east and west) accommodated long term care residents as well as a sub-acute rehabilitation residents. Most residents required assistance with mobility, bathing, dressing, toileting and transferring. The facility's staffing plan was based on resident population and their needs for care and support. They reviewed the residents' acuities and census to determine if they needed sufficient number of employees for each position to meet the needs of the residents at any given time. They used a daily staffing budget sheet as a guide for average total number needed. During the entrance conference on 2/12/2024 the Administrator stated the facility census was 76 residents. The facility provided documentation that as of 2/15/2024, there were 14 residents on the east unit, and 11 residents on the west unit that required a mechanical lift or extensive assistance of 2 staff for transfers. During a resident council meeting on 2/13/2024 at 10:18 AM, 8 anonymous residents stated that their call lights took a long time to be answered, weekends and night shift took the longest due to short staffing, staff was too busy to talk to, they could not get assistance out of bed at their preferred times, they had to wait for assistance to get dressed, and food was cold by the time they were served by unit staff. Actual facility staffing for 2/12/2024-2/15/2024 documented the following. -on 2/12/2024: 6:30 AM - 2:30 PM shift 1 registered nurse supervisor, 1 licensed practical nurse, 4 certified nurse aides: 2:30 PM - 10:30 PM shift 1 registered nurse supervisor, 2 licensed practical nurses, 5 certified nurse aides: 10:30 PM - 6:30 AM shift 1 registered nurse supervisor, 1 licensed practical nurse, 2 certified nurse aides: -on 2/13/2024: 6:30 AM - 2:30 PM shift 1 registered nurse supervisor, 1 licensed practical nurse, 7 certified nurse aides: 9:00 AM - 2:30 PM shift 1 licensed practical nurse: 2:00 PM - 6:00 PM shift 2 certified nurse aides: 2:30 PM - 10:30 PM shift 1 registered nurse supervisor, 2 licensed practical nurses, 5 certified nurse aides: 10:30 PM - 6:30 AM shift 1 registered nurse supervisor, 1 licensed practical nurse, 3 certified nurse aides: -on 2/14/2024: 6:30 AM - 2:30 PM shift 1 registered nurse supervisor, 2 licensed practical nurses, 6 certified nurse aides: 7:00 AM - 2:30 PM shift 1 certified nurse aide: 2:30 PM - 10:30 PM shift 1 registered nurse supervisor, 2 licensed practical nurses, 8 certified nurse aides: 10:30 PM - 6:30 AM shift 1 registered nurse supervisor, 1 licensed practical nurse, 2 certified nurse aides: -on 2/15/2024: 6:30 AM - 2:30 PM shift 1 registered nurse supervisor, 1 licensed practical nurse, 3 certified nurse aides: 2:30 PM - 10:30 PM shift 1 registered nurse supervisor, 2 licensed practical nurses, 6 certified nurse aides: 10:30 PM - 6:30 AM shift 1 registered nurse supervisor, 1 licensed practical nurse, 2 certified nurse aides: Care Plans Resident #17 was transferred using a mechanical lift with assistance of 1 and not 2 as care planned and Resident #22 was transferred and toileted with assistance of 1 and not 2 as care planned. During an interview on 2/15/2024 at 10:28 AM Resident #17 stated certified nurse aide #7 got them up without help on 2/14/2024 because they stated they were short staffed that day. During an interview on 2/15/2024 at 10:45 AM certified nurse aide #7 stated Resident #17 required two person assistance, but they got them up on their own because there were only two certified nurse aides for the entire floor. There was not enough staff to get Resident #22 changed more often or to use two for transfers. Activities of Daily Living Residents #17, #21 and #64 were not assisted with transfers out of bed, Resident #1 did not receive setup assistance with their meal tray, Resident #56 was not assisted with shaving or oral care, Residents #61 and #56 were not provided meal trays, Resident #22 was not provided timely checks for incontinence care, and Resident #12 did not receive assistance with a shower on their scheduled shower day. During an interview on 2/15/2024 at 2:08 PM, certified nurse aide #7 stated there was not always enough staff to get residents out of bed daily, especially if they needed a mechanical lift. Resident #64 had not been out of bed that week due to the facility being short staffed. They stated they did not have time to get all residents' activities of daily living completed. During an interview on 2/15/2024 at 12:00 PM, licensed practical nurse #27 stated they worked on 2/12/2024 until 4:00 PM and there were only 2 certified nurse aides and 1 nurse on the unit during the day shift. They did not have enough staff on 2/12/2024 and they had to assist with resident care, which they normally did not do. During an interview on 2/15/2024 at 12:14 PM, certified nurse aide #21 stated they worked the day shift on 2/12/2024 and it was difficult because they were short staffed. They made sure residents were washed up but not all showers were given. There was a certified nurse aide who was split between both units, and that certified nurse aide left the floor without notifying them. Pressure Ulcers Resident #55 did not have pressure relief for their heels as planned. During an interview on 2/16/2024 at 9:06 AM, certified nurse aide #21 stated they saw pressure relieving boots listed on Resident #55's care instructions that morning. They should have told therapy the boots were missing but they had been very busy that morning because there were only two certified nurse aides on the unit. Respiratory Care Resident #63's portable oxygen tank was empty and was not replaced. During an interview on 2/16/2024 at 10:04 AM certified nurse aide #21 stated on 2/12/2024 the unit was short staffed, and it made it difficult to provide all the care they needed to complete and check the resident's portable oxygen tank. Food Palatability Food was not served at appetizing temperatures during lunch meals on 2/13/2024 and 2/15/2024. On 2/15/2024 lunch trays were delivered to the unit at 12:41 PM and Resident #33 received their lunch tray at 1:27 PM. During an interview on 2/15/2024 at 1:30 PM, certified nurse aide #31 stated Resident #33 was served last because they needed to be fed. They stated there were 7-9 residents on the [NAME] Unit that needed encouragement, or full to partial assistance while eating and they only had 2 certified nurse aides, a licensed practical nurse, and one staff from therapy who had helped during the lunch service. They stated they did not have enough help with the lunch service to complete a safe and timely service and the service usually took about an hour to an hour and a half. During an interview on 2/15/2024 at 2:13 PM, licensed practical nurse #14 stated there were 11 residents on the [NAME] Unit that required assistance or supervision during meal service, but only 4 staff to complete the meal service. Therapy staff would often assist during meal service, but those staff were not available to assist during dinner service. They stated they did not have enough staff to complete a timely and safe meal service. They stated they were retired, but the facility called them and asked them to come back today because they were short staffed. General Staffing During an interview on 2/15/2024 at 10:40 AM, Director of Therapy #24 stated they were asked to help on the west unit by Administration due to short staffing and it was the worst short staffing they had seen. They stated they did not have an assignment, they provided care to 3 residents, and they had 2 other therapy staff members available to help. They stated having 1 certified nurse aide on the west unit and the facility being short staffed could impact the residents' quality of life. During an interview on 2/16/2024 at 9:14 AM, certified nurse aide #21 stated 2 certified nurse aides on the unit was not enough to get everything done in a timely manner. Call lights did not get answered timely, briefs did not get checked and changed, and some residents did not get turned and positioned every 2-3 hours. It was difficult to get their 20-resident assignment completed if they did not stay late. They stated it was normal to have 2 certified nurse aides on the unit a few days a week and on the weekends. They had brought their concerns to Administration, and they were told 2 certified nurse aides was sufficient staffing. During an interview on 2/16/2024 at 11:45 AM, the Infection Preventionist/Assistant Director of Nursing stated if a resident was care planned for 2 staff members to be transferred, then 2 staff members would need to assist due to safety issues for the staff and the resident. Residents should be dressed and out of bed daily. Lying in bed all the time could add to the risk of pressure ulcers or respiratory infections. They stated the residents care would suffer at times due to short staffing. They stated the facility was interviewing and trying to hire new staff. During an interview on 2/16/2024 at 12:53 PM, the Director of Nursing stated they were responsible for nurse staffing. Staffing was determined by state guidelines, census, and resident acuity. Staffing shortages were handled by calling staff to come in, asking per diem staff to work, and open shifts were posted for staff to sign up. They stated 2 certified nurse aides on a unit was not enough to meet resident needs, 3 certified nurse aides were not even enough due to residents needing to be checked and changed and turned and positioned every 2-3 hours. They would usually schedule 3 certified nurse aides per shift and hope other staff would pick up extra shifts. They stated the bare minimum on each unit would be 4 certified nurse aides and 2 licensed practical nurses and when that was not met it was hard to provide the care that was needed for all the residents. During an interview on 2/16/2024 at 1:22 PM, the Administrator stated they would meet with the interdisciplinary team monthly, they had a quality assurance and performance improvement manual they followed, and when they identified a problem or trend, they would discuss it at the meetings. They stated they were aware of staffing issues, and they had been discussing the issues with retaining staff and ways to recruit new staff members, including higher level staff. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews during the recertification and abbreviated surveys (NY00324905 and NY00316447) conducted 2/12/2024-2/16/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 8 of 9 residents (Residents #1, #12, #17, #21, #22, #56, #61, and #64) reviewed. Specifically, Residents #17, #21 and #64 were not assisted with transfers out of bed; Resident #1 did not receive setup assistance with their meal tray as planned; Resident #56 was not assisted with shaving or oral care; Residents #61 and #56 were not provided meal trays for one meal; Resident #22 was not provided timely checks for incontinence care; and Resident #12 did not receive assistance with a shower on their scheduled shower day. Findings include: The facility policy Activities of Daily Living, supporting revised 3/2023, documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services would be provided for residents who were unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plan of care, including appropriate care and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks). 1) Resident #64 had diagnoses including cerebrovascular disease, unspecified convulsions, and diabetes mellitus. The 12/29/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not exhibit behavioral symptoms, was dependent for bed mobility, transfers, and toileting, had one stage 3 pressure ulcer (full thickness tissue loss), and one deep tissue injury (pressure area with discolored intact skin). The comprehensive care plan initiated 6/21/2023 documented the resident required assistance with activities of daily living secondary to a cerebral vascular accident (stroke) and left sided hemiplegia(paralysis). Interventions included extensive assistance with bed mobility and a mechanical lift for transfers. The Resident Profile (care instructions) documented the resident was to be checked and changed every 2-3 hours (9/18/2023) , turned and positioned every 2-3 hours (9/18/2023) , preferred to get out of bed before breakfast (12/7/2023), back to bed after dinner (12/7/2023), was to eat in the day room, was to be in the day room around peers, bed mobility required extensive assistance with use of right lateral wedge when in bed, and transfers required total assistance with a mechanical lift. Physician orders dated 1/11/2024 documented the resident was to receive palliative care (optimize quality of life and provide relief from symptoms). Resident #64 was observed: - on 2/12/2024 at 11:10 AM, positioned in bed on their back wearing a gown. - on 2/12/2024 at 12:55 PM, in bed being assisted with lunch. - on 2/12/2024 at 1:18 PM, in bed on their back. The resident stated staff had not been in yet to assist them out of bed, remained on back with bed wedges on each side. - on 2/13/2024 at 8:59 AM, in bed on their back wearing a gown. - on 2/13/2024 at 10:35 AM, in bed on their back. They stated they would like to get up, but staff had not offered. - on 2/13/2024 at 12:51 PM in bed with the head of the bed elevated being assisted with lunch. - on 2/14/2024 at 9:23 AM in bed on their back wearing a gown and being assisted with breakfast. - on 2/14/2024 at 12:45 PM in bed with the head of the bed elevated for lunch. During an interview on 2/15/2024 at 11:24 AM, physical therapist #29 stated residents receiving comfort care (palliative care) should be out of bed and be a part of their surroundings. It would benefit a resident with pressure areas to get out of bed, encourage involvement with activity, and to relieve pressure. During an interview on 2/15/2024 at 12:15 PM, nurse practitioner #12 stated getting out of bed and interacting with others improved quality of life, breathing, and relieved pressure. During an interview on 2/15/2024 at 1:49 PM, certified nurse aide #25 stated resident care information was found in the computer resident profile. and contained information about resident's eating, transfers, likes, and dislikes, and any special equipment. It was important to get residents dressed and out of bed daily because it helped with repositioning, being with others, and overall mood. Comfort care did not mean residents did not get out of bed. During an interview on 2/15/2024 at 2:08 PM, certified nurse aide #7 stated all resident care information was in the computer. It included all activity of daily living information and assistance needed. There was not always enough staff to get residents out of bed daily, especially if they needed a mechanical lift. Resident #64 had not been out of bed that week due to the facility being short staffed. The resident was provided care while in bed, and it was easier to check and change in bed. During an interview on 2/15/2024 at 4:53 PM, registered nurse #26 stated a resident on comfort care should be out of bed unless they were actively dying, or it caused discomfort. Being out of bed helped by changing positioning and provided socialization. It also helped relieve pressure and prevented pneumonia. During an interview on 2/16/2024 at 9:46 AM, licensed practical nurse #5 Unit Manager stated comfort care did not mean do not get out of bed. The resident benefits of getting up included socialization, preventing pneumonia, and relieving pressure. Resident #64 already had pressure areas, so should be repositioned. During an interview on 2/16/2024 at 11:45 AM, the Assistant Director of Nursing stated residents should be dressed and out of bed daily. Comfort care did not mean they had to stay in bed. Resident #64 could benefit from getting out of bed for socialization. Lying in bed all the time could add to the risk for pressure ulcers, respiratory infections, or increased risk for deep vein thrombosis (blood clots). They stated resident care suffered at times because of staffing levels. 2) Resident #56 was admitted to the facility with diagnoses including neurocognitive disorder with Lewy bodies (a type of dementia), dysphagia (difficulty swallowing), and need for assistance with personal care. The 12/19/2023 Minimum Data Set assessment documented the resident had severely impaired cognition and was totally dependent for activities of daily living. The comprehensive care plan initiated 9/13/2023 and revised 2/12/2024 documented the resident had an activities of daily living deficit related to Lewy body dementia and interventions included total assistance of one for hygiene and extensive assistance of one for eating. During a continuous lunch meal observation on 2/12/2024 from 12:19 PM to 1:27 PM Resident #56 was lying flat in their bed with an empty bedside table. At 1:06 PM, Resident #56's untouched lunch tray was in the unit meal tray cart warmer. All lunch tray carts left the unit and were returned to the kitchen at 1:27 PM. Resident #56 did not receive a lunch tray. The point of care documentation completed by certified nurse aide #23 on 2/12/2024 at 2:17 PM documented the resident consumed 76-100% of their lunch meal with 1200 milliliters of fluids. During an observation and interview on 2/13/2024 at 3:06 PM, Resident #56's spouse shaved the resident's face and brushed their teeth. The spouse stated they shaved the resident's face and brushed their teeth every day because it was not done otherwise. They stated the resident never liked facial hair and was dependent on care, they did it because it was what the resident wanted. They did not feel they should have to perform these tasks but because they were not being done by staff, they did them for the resident's dignity. The point of care documentation completed by certified nurse aide #23 on 2/13/2024 at 2:26 PM documented extensive assistance of two with hygiene was provided. During an interview on 2/15/2024 at 11:16 AM certified nurse aide #7 stated Resident #56 needed help with meals and could not speak for themselves and could not verbalize their needs. The resident was a good eater and did not need encouragement to eat. It was important all residents received 3 meals a day to maintain their weight. Resident #56 also needed help with activities of daily living such as shaving or brushing their teeth. They stated they did not have time to get all residents' activities of daily living completed and Resident #56's wife came in daily and brushed their teeth and shaved their face. During an interview on 2/16/2024 at 9:23 AM licensed practical nurse Unit Manager #5 stated Resident #56 was dependent on staff for feeding. They expected staff to make sure all residents had a tray and ate. It was important for all residents to receive their meal trays for appropriate nutrition, hydration, prevention of unintended weight loss, and their livelihood. Each residents' consumption was documented on their meal ticket and then the certified nurse aides documented the intake. They stated Resident #56 should have received a lunch tray on 2/12/2024 and there should not be any documentation of consumption if the resident did not receive a lunch tray. They stated on 2/12/2024, there were only two certified nurse aides for the floor. They expected if something was documented in the Point of Care responses it was done. During an interview on 2/16/2024 at 9:40 AM the Assistant Director Nursing stated during mealtimes, staff ensured that all residents received a tray and had eaten. They expected dependent residents to be fed. They were not aware that Resident #56 did not receive a lunch tray on 2/12/2024 and this was not acceptable, all residents should receive three meals a day. The resident did not refuse feeding and was limited with communication. They expected care plans to be followed and residents received activity of daily living assistance as needed. It was not appropriate for anything to be documented as completed if it was not. 3) Resident #12 was admitted to the facility with diagnoses including traumatic brain injury, muscle weakness, and dementia. The 1/24/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, was independent with personal hygiene, and required supervision/touching assistance with bathing and showers. The comprehensive care plan revised on 2/12/2024 documented the resident required assistance with activities of daily living related to use of a prosthetic leg and weakness. Interventions included supervision with showers and shower day was during the day shift on Monday. The point of care documentation record for February 2024 documented Resident #12 did not receive a shower on 2/12/2023. During an observation and interview on 2/12/2024 at 11:27 AM, Resident #12 was in their room sitting in a wheelchair without their prosthetic leg, and a towel covering their lap. They stated the certified nurse aide woke them up at 6:30 AM to tell them their shower was at 11:30 AM. Resident #12 was observed sitting in their wheelchair in the hallway with a shirt covering their lap on 2/12/2024 at 11:40 AM, 11:58 AM, and 12:17 PM. During an observation an interview on 2/12/2024 at 2:48 PM, Resident #12 was seated in their wheelchair in the hallway. They stated they were on their way to therapy, and they did not receive a shower. During an observation and interview on 2/13/2024 at 8:43 AM, Resident #12 was in their room eating breakfast. They stated they never received their shower on 2/12/2024. During an interview on 2/15/2024 at 12:00 PM, licensed practical nurse #27 stated they worked on 2/12/2024 until 4:00 PM and there were only 2 certified nurse aides and 1 nurse on the unit during the day shift. They would oversee the certified nurse aides and they expected to be notified if a resident did not receive a shower. They stated Resident #12 would refuse care and showers at times. They stated they were not made aware that the resident did not receive a shower on 2/12/2024. If they were made aware they would have reapproached the resident. They did not have enough staff on 2/12/2024 and they had to assist with resident care, which they would not normally do. During an interview on 2/15/2024 at 2:12 PM, the Director of Nursing stated there was a shower list on each unit based on resident preferences. If Resident #12 refused care/shower the certified nurse aide should have told the nurse and the nurse should have reapproached the resident. If they refused, they should have documented the refusal and notified the Nurse Supervisor. If they documented the activity did not occur that meant it was not done. The shower/bath schedule could have been affected on 2/12/2024 because there were a lot of call-ins and only 2 certified nurse aides on each unit and 1 float. During an interview on 2/15/2024 at 4:54 PM, licensed practical nurse Unit Manager #5 stated there was a shower schedule on both units and the nurse did the skin checks on shower days. Showers should be attempted and completed on their scheduled day. If a resident refused a shower, it should be documented, and nurse notified. They were not notified of any missed showers for Resident #12. During an interview on 2/15/2024 at 12:14 PM, certified nurse aide #21 stated they worked the day shift on 2/12/2024 and it was difficult because they were short staffed. They made sure residents were washed up but not all showers were given. They had a certified nurse aide who was split between both units, and that certified nurse aide left the floor without notifying them. Resident #12 notified them at 12:05 PM they had not received a shower, but they were too busy with their assignment, and it was during lunch time. They stated they notified licensed practical nurse Unit Manager #5 Resident #12's shower was not completed. 10NYCRR 415.12(a)(3) 48675 49448

Based on observation, interview, and record review during the recertification survey conducted 2/12/2024-2/16/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 2 medication storage room (East and [NAME] medication storage rooms) reviewed. Specifically, the East and [NAME] Unit medication storage rooms were unclean and in disrepair. Finding include: The facility policy Daily/Weekly Cleaning revised 9/2023 documented the objective of a daily cleaning was to ensure cleanliness and safety. The nurse's station was to be cleaned and mopped daily. The policy did not address the cleaning of the medication storage rooms. The following observations were made: - on 2/12/2024 at 12:00 PM, the medication storage room on the [NAME] Unit was unclean. Medication packaging and debris was on the floor, there were dark dried on smudges on the floor, and the cove molding was in disrepair, hanging loose from the wall and laying across the floor. - on 2/12/2024 at 1:18 PM, the East Unit medication storage room had medication wrappers and debris on the floor; - on 2/15/2024 at 9:45 AM, with licensed practical nurse #14 present, the [NAME] Unit medication storage room was unclean. Medication packaging and debris was on the floor and the cove molding was in disrepair, hanging loose from the wall and laying across the floor; - on 2/15/2024 at 10:05 AM, with licensed practical nurse #5 present, the East Unit medication storage room was unclean with medication packaging and debris on the floor. During an interview on 2/15/2024 at 9:45 AM, licensed practical nurse #14 stated that all staff were responsible for keeping the medication storage rooms clean. Housekeeping swept the floor of the medication storage room and nursing staff was responsible for cleaning the rest of the room. They stated those areas should have been cleaned daily because it was important that everything was kept as clean as possible. During an interview on 2/15/2024 at 10:02 AM, housekeeper #34 stated that they did not clean the medication storage rooms and the nurses were responsible to keep those rooms clean. During an interview on 2/15/2024 at 10:05 AM, licensed practical nurse #5 stated they were not sure who was responsible for cleaning the medication storage rooms, or how often they were cleaned. They stated the medication room was not clean, and it should be to prevent infection and for infection control. During an interview on 2/16/2024 at 12:06 PM, the Maintenance Director stated they oversaw the housekeeping department. They stated the medication storage rooms were supposed to be cleaned daily by the housekeepers at least once or twice a week. The Maintenance Director stated it was important to keep those areas clean because that was where medications were kept. 10 NYCRR 415.29(j)(1)

48675 Based on observation, record review, and interview during the recertification survey conducted 2/12/2024- 2/16/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #9 and #56) reviewed. Specifically, staff were observed not wearing the required personal protective equipment in Resident #9's room while on transmission-based precautions for COVID-19, and staff fed Resident #56 a sandwich with ungloved hands and did not perform hand hygiene before assisting another resident. Findings include: The facility policy Initiating Transmission Based Precautions revised 2023, documented transmission-based precautions would be initiated when there was reason to believe that a resident had a communicable infectious disease. Precautions may include contact precautions, droplet precautions, or airborne precautions and should be used when the spread of infection cannot be reasonably prevented by less restrictive measures. Transmission based precautions should remain in effect until the attending physician or infection preventionist discontinued them. When transmission-based precautions were implemented, the infection preventionist or designee should ensure protective equipment was maintained near the resident's room so everyone entering the room had access to what they needed and to post the appropriate notice on the room entrance door so all personnel would be aware of the precautions. The facility policy Assistance with Meals reviewed 7/2023 documented all employees that provided resident assistance with meals were trained and demonstrated competency in the prevention of foodborne illness that included personal hygiene practices and safe food handling. The facility policy Meal Service/ Feeding/ Protocols revised 4/13/2015 documented New York State Law did not allow food to be handled without gloves and if a resident's food was touched, gloves had to be worn. 1) Resident #9 had diagnoses including COVID-19. The 12/16/2023 Minimum Data Set assessment documented the resident was cognitively intact. The comprehensive care plan initiated 2/11/2024 documented the resident tested positive for COVID-19. Interventions included maintaining appropriate droplet precautions, hand hygiene, social distancing, and mask usage. A 2/11/2024 physician order documented contact/droplet precautions related to COVID-19. Gowns, gloves, eye protection, and masks were required during all care. During an observation on 2/12/2024, at 11:32 AM, Resident #9 had a white droplet precaution sign, donning (putting on) sign, and doffing (taking off) sign on their door documenting staff must wash their hands before entering and exiting the room and pictures of all personal protective equipment needed to enter the room (gloves, gown, face shield, and mask). A plastic cart filled with personal protective equipment was outside the room next to a large garbage can with a lid that was labeled personal protective equipment. There was a white over the door caddy filled with gloves. Certified nurse aide #22 entered Resident #9's room wearing a blue surgical mask, did not perform hand hygiene, and did not put on gloves, a gown, or a face shield. At 11:33 AM, certified nurse aide #22 exited Resident #9's room, threw the blue surgical mask in the garbage can and completed hand hygiene. They did not have on gloves, gown, or a face shield. During an observation on 2/13/2024, at 11:50 AM, Resident #9 had a white droplet precaution sign, donning sign, and doffing sign on their door that documented staff must wash their hands before entering and exiting the room and had pictures of all personal protective equipment needed to enter the room (gloves, gown, face shield, mask). A plastic cart filled with personal protective equipment was outside the room next to a large garbage can with a lid that was labeled personal protective equipment. There was a white over the door caddy filled with gloves. Nurse practitioner #12 entered Resident #9's room without putting on any personal protective equipment. Resident #9 stated, I have COVID. Nurse practitioner #12 exited the room and put on gloves, gown, mask, and a face shield and re-entered Resident #9's room. During an observation on 2/14/2024, at 12:53 PM, Resident #9 had a white droplet precaution sign, donning sign, and doffing sign on their door that documented staff must wash their hands before entering and exiting the room and had pictures of all personal protective equipment needed to enter the room (gloves, gown, face shield, mask). A plastic cart filled with personal protective equipment was outside the room next to a large garbage can with a lid that was labeled personal protective equipment. There was a white over the door caddy filled with gloves. Certified nurse aide #22 entered Resident #9's room carrying a lunch tray and wearing a blue surgical mask. They did not perform hand hygiene, and did not put on gloves, gown, or a face shield. At 12:55 PM, certified nurse aide #22 exited Resident #9's room. They hand sanitized, removed the blue surgical mask holding it in their left hand before throwing it in a hallway trash can near room [ROOM NUMBER], and hand sanitized again. They did not have on gloves, gown, or a face shield. During an interview on 2/15/2024 at 12:49 PM, nurse practitioner #12 stated they should have looked at the door on Resident #9's room for isolation precautions, sometimes they did not see it, and they were reeducated about proper personal protective equipment for COVID-19 rooms. They stated it was important to wear proper personal protective equipment for the residents' and their own protection. During an interview on 2/15/2024 at 4:50 PM, licensed practical nurse #14 stated they were notified a resident was on transmission-based precautions in nurse-to-nurse report or by the signage on the resident's door. The signage should specify what kind of precautions and what personal protective equipment was needed to enter the room. They stated Resident #9 was on droplet precautions for COVID-19 and a gown, gloves, face shield, and mask were needed every time anyone entered the room. They received infection control training during orientation, annually, and if any changes were made to current procedures. They stated it was important to wear proper personal protective equipment to prevent the spread of infection and it could put all residents at risk. During an interview on 2/16/2024 at 9:29 AM, certified nurse aide #22 stated they would know a resident was on transmission-based precautions by the signage on the door and personal protective equipment would be outside the room. They had annual trainings on infection control and sometimes more frequently if they needed a refresher course. They stated Resident #9 was on droplet precautions for COVID-19 and they should have worn a mask, face shield, gown, and gloves every time they entered Resident #9's room. It was important to wear appropriate personal protective equipment into the room to keep themselves safe and prevent the spread of infection to other residents and staff. During an interview on 2/16/2024 at 10:30 AM, Infection Preventionist/Assistant Director of Nursing #4 stated when they found out a resident needed to go on transmission-based precautions they would place the appropriate signage on the resident's door, put the personal protective equipment outside the room, and notify the staff on the unit. They stated all staff members received infection control training when hired, every six months or annually, and as needed. All signage was specific to what kind of precautions and what personal protective equipment was needed to enter the residents room. Resident #9 was on droplet precautions, so it was not appropriate for any staff member to only wear a mask into the room and if any staff crossed the threshold, they needed to wear gloves, gown, face shield, and a mask. They stated it was important to wear appropriate personal protective equipment into Resident #9's room, so staff and residents were not put at risk for spreading Covid-19. 2) Resident #56 was admitted to the facility with diagnoses including Lewy body dementia and dysphagia (difficulty swallowing). The 12/19/2023 Minimum Data Set assessment documented the resident had severely impaired cognitive skills for daily decision making and was dependent on staff for eating. The comprehensive care plan initiated 9/13/2023 and revised 2/12/2024 documented the resident had an activities of daily living deficit related to Lewy body dementia and interventions included extensive assistance of one for eating. During a lunch meal observation on 2/14/2024 from 12:49 PM to 1:08 PM certified nurse aide #8 was assisting Resident #56 with feeding. The certified nurse aide was sitting on the right side of the resident and used their ungloved hands to pick up a fish sandwich and placed tartar sauce on the bun. They moved the sandwich to the resident's mouth, and the resident took a bite. Without performing hand hygiene certified nurse aide #8 assisted Resident #48 with their meal by holding a fork to the resident's lips to take a bite. Certified nursing assistant #8 continued to alternate feeding between Resident #56 and Resident #48 and touching the fish sandwich without a glove on. The meal service/ feeding/ protocols inservice documented certified nurse aide #8 signed the in-service log on 12/28/2023. During an interview on 2/15/2024 at 2:59 PM, certified nurse aide #9 stated gloves should be worn anytime a resident's sandwich was touched to prevent the spread of germs and bacteria. During an interview on 2/15/2024 at 3:04 PM, licensed practical nurse #6 stated they expected staff to wear gloves when feeding a resident a sandwich. Resident #56 could not feed themselves a sandwich and was dependent on staff to eat. During an interview on 2/16/2024 at 8:33 AM, certified nurse aide #8 stated they were supposed to wear gloves when they touched a resident's food. They stated they fed Resident #56 a fish sandwich for lunch on 2/14/2024 and did not wear gloves, and they should have. During an interview on 2/16/2024 at 9:23 AM, licensed practical nurse Unit Manager #5 stated if a resident needed assistance with feeding, staff were supposed to wear gloves anytime they touched the resident's food. During an interview on 2/16/2024 at 9:40 AM, the Infection Preventionist/Assistant Director of Nursing stated staff was supposed to wear gloves anytime they touched residents' food. 10NYCRR 415.19(b)(1) & 415.19(b)(4) 49448

Based on observation, interview, and record review during the recertification and abbreviated (NY00329249) surveys conducted 2/12/2024-2/16/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen walk-in cooler, walk-in freezer, storage rooms, and rest room had unclean and uncleanable surfaces. Findings include: The facility policy Cleaning Procedures for Dietary Equipment reviewed 1/20/2023 documented: - walk-in cooler - wipe spills immediately; every night, sweep under everything, and mop with hot water and floor cleaner. - freezer-check for ice buildup; scrape and sweep floor. - coat room-on a daily basis, sweep floor and mop with hot water and floor cleaner. - ovens-wipe the outside with degreaser daily. Observations in the kitchen: - on 2/12/2024 at 9:40 AM staff were wiping down counters and mopping the walk-in cooler which had dried-on spills under racks that were molded like the bottom of a milk crate. A sheet pan containing cartons of liquid eggs was sitting in an orange liquid. - on 2/12/2024 at 9:46 AM the floor of the walk-in freezer was soiled with food debris and ice trapped within the rubber mat on floor. - on 2/12/2024 at 9:48 AM the coat room opposite the walk-in cooler had a large quantity of debris on the floor including gloves, papers, hairnets, and soiled towels. - on 2/12/2024 at 9:49 AM the employee bathroom cove molding was in disrepair. An approximate 18-inch section had broken free from the wall and the broken tile pieces were on the floor. - on 2/12/2024 at 9:50 AM there were ketchup packets and dried red spills on the floor of the dry storage room/office beneath the racks of canned goods. - on 2/12/2024 at 9:54 AM the paper storage room located opposite the kitchen across the service hallway contained several boxes of dietary paper products stored directly on the floor. - on 2/12/2024 at 9:56 AM the emergency food and water storage room off the dining room had an approximately 30 square foot water damaged section of the ceiling. - on 2/13/2024 at 11:39 AM the floor of the walk-in freezer was soiled with food debris and ice trapped within the rubber mat on floor. - on 2/13/2024 at 11:41 AM the walk-in cooler had a spill in the shape of the milk crate, some other spills and debris present on the floor (small scrap of copper wire, plastic wrap, and food debris), and a sheet pan containing cartons of liquid eggs was sitting in an orange liquid. - on 2/13/2024 at 12:02 PM the inside of the microwave was soiled with food debris and splatters. - on 2/15/2024 at 12:34 PM the walk-in cooler door seal was ripped. A small 10-inch section by the handle was ripped and missing. Cold air was felt escaping through the section of the door that was missing the seal. - on 2/16/2024 at 11:20 AM the inside of the microwave was soiled with food debris and splatters. - on 2/16/2024 at 11:24 AM there were ketchup packets and dried red spills on the floor of the dry storage room/office beneath the racks of canned goods. During an interview on 2/12/2024 at 9:56 AM, the Director of Food Service stated the emergency food storage room ceiling had water damage the entire time they had worked at the facility which was about 6 months. They stated they did not report that to anyone and was unsure of the cause of the water damage. During an interview on 2/12/2024 at 11:03 AM, the Maintenance Director and Corporate Facilities Director each stated they did not know what the water damage was from in the emergency food storage room. The Corporate Facilities Director stated the roof to the facility was replaced within the last two years. During an interview on 2/16/2024 11:30 AM, the Director of Food Service stated the walk-in cooler and walk-in freezer were cleaned twice a week when stock came in on Tuesdays and Thursdays. If anything was spilled it should be cleaned. There should not be an impression of a milk crate on the floor from spilled food product. On Tuesdays and Thursdays, the rubber mat was removed from the walk-in freezer and the floor was swept. The coat room, and dry storage room were also cleaned on Tuesdays and Thursdays by the Director of Food Service. They stated the microwave should have been cleaned after it was used. They were not aware of the ripped section of the walk-in cooler door seal. The Director of Food Service stated the kitchen cleaning was not documented, but it was important to keep the kitchen and storage areas clean for the health of the residents. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the recertification and abbreviated (NY00329249, NY00324905, and NY00316447) surveys conducted 2/12/2024-2/16/2024, the facility did not ensure each resident received and the facility provided food and drink that was at appetizing temperatures for 2 of 2 meals reviewed (2/13/2024 and 2/15/2024 lunch meals). Specifically, food was not served at appetizing temperatures during lunch meals on 2/13/2024 and 2/15/2024. Findings include: The facility policy Food Preparation and Service revised 10/2017 did not include specific food service requirements regarding meal service temperatures. Lunch 2/13/2024 During an observation and interview on 2/13/2024 at 12:08 PM, the second meal cart left the kitchen and was delivered to the [NAME] Unit by the Assistant Director of Nursing. They stated they delivered carts because the kitchen only had 3 staff. During an observation on 2/13/2024 at 12:09 PM the meal cart was delivered to the [NAME] Unit. At 12:13 PM the Administrator was checking trays, adding cold drinks, and pouring coffee. At 12:19 PM staff began to pass the trays from the meal cart after the drinks were added. During an observation on 2/13/2024 at 12:27 PM, the Director of Social Services delivered Resident #34's tray which was selected as a test tray. The Director of Social Services obtained a replacement tray for the resident. The following food temperatures were measured with certified nurse aide #8, Spanish rice 146 degrees Fahrenheit (F), mixed vegetables 137 degrees F, coffee 137 degrees F, and strawberries 59 degrees F. The food items were tasted, and the strawberries were warm and at room temperature. During an interview on 2/13/2024 at 12:31 PM, the Director of Social Services stated they did not normally pass trays and they were only helping today. During an interview on 2/16/24 at 11:15 AM, the Director of Food Service stated the strawberries were a frozen product that was thawed for meal service and intended to be served cold. They stated 59 degrees F was an unacceptable service temperature for the strawberries. Lunch 2/15/2024 During an observation on 2/15/2024 at 12:14 PM, the following temperatures were measured on the service line in the kitchen: hot dogs 162 degrees F, broccoli 158 degrees F, liver, and onions 155 degrees F, and pureed hot dogs 144 degrees F. During an observation on 2/15/2024 at 12:39 PM, the final meal cart left the kitchen and was delivered to the [NAME] Unit at 12:41 PM. At 12:46 PM licensed practical nurse #14 started to pass trays and directed other staff where to go. During an observation on 2/15/2024 at 1:27 PM, certified nurse aide #31 delivered the last tray from lunch service (intended for Resident #33) and that tray was selected as a test tray and a replacement was requested. The following temperatures were measure with certified nurse aide #31 present, hot dog 113 degrees F, broccoli 109 degrees F, baked beans 100 degrees F, fortified nutritional shake 63 degrees F, and hot chocolate 143 degrees F. The fortified nutritional shake was warm and unpleasant to taste, and the baked beans were cold to taste. During an interview on 2/15/2024 at 1:30 PM, certified nurse aide #31 stated Resident #33 was served last because they needed to be fed. They stated there were 7-9 residents on the [NAME] Unit that needed encouragement, or full to partial assistance while eating. They only had 2 certified nurse aides, a licensed practical nurse, and one staff person from therapy who had helped during the lunch service. They stated they did not have enough help with the lunch service to complete a safe and timely service and the service usually took about an hour to an hour and a half. Certified nurse aide #31 stated the test tray selected came from the second cart that was delivered to the Unit and it was not timely for that to sit for over an hour before it was served. During an interview on 2/15/2024 at 1:59 PM, the Director of Food Service stated the facility did not complete test trays, but only monitored the temperatures of the food on the service line in the kitchen. At meal service the temperatures on the service line were supposed to be above 165 degrees F and at service hot foods should be above 120 degrees F. Cold foods should be at or below 36 degrees F. The hot dog, broccoli, and beans that were measured below 120 degrees F were not acceptable service temperatures. The fortified nutritional shake was supposed to be a cold product and should not have been served at 63 degrees F. Meal service was about an hour from the kitchen, but they could not speak for the service on the units because that was nursing's responsibility. The Director of Food Service stated Resident #33's tray was sent to the unit with the second cart, and they were not sure why that was the last tray served. During an interview on 2/15/2024 at 2:13 PM, licensed practical nurse #14 stated there were 11 residents on the [NAME] Unit that required assistance or supervision during meal service, but only 4 staff to complete the meal service. Therapy staff would often assist during the meal service like they did today, but those staff were not available to assist during dinner service. They stated they did not have enough staff to complete a timely and safe meal service but were making do with what they had available. Today's lunch service was too long, and the typical meal service was about 10 to 15 minutes until the trays were served. Licensed practical nurse #14 stated they were retired, but the facility called them and asked them to come back today because they were short staffed. 10NYCRR 415.14(d)(2)

Based on observation, record review, and interview during the recertification survey conducted 2/12/2024-2/16/2024, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included expiration dates when applicable for 1 of 2 medication carts (Southeast medication cart) reviewed. Specifically, the Southeast medication cart had resident specific insulin pens that were not labeled with open dates. Findings include: The facility policy Medication Administration revised 9/2021 documented the open date of insulin was recorded so expired medications were discarded. Insulin was discarded 28 days from the date opened. The licensed staff were to ensure all new medications were dated with the open date and dates were checked for expiration prior to medications being administered. The facility policy Medication Storage revised 3/2023 documented nursing staff was responsible that medication storage carts were maintained in a safe manner. The facility did not use outdated drugs or biologicals and outdated drugs were destroyed. During an observation of the Southeast medication cart on 2/13/2024 at 10:25 AM with licensed practical nurse #6, Resident # 8 had an opened Basaglar (a long-acting insulin) pen and Resident #69 had an opened Lispro (quick-acting insulin) pen that were not labeled with an open date. During an interview on 2/13/2024 at 10:36 AM licensed practical nurse #6 stated insulin pens should have open dates to know when they expired, and they were only good for a certain time frame. They would not know if the pen was expired without an open date. The unlabeled pens without an open date should be thrown away and a new pen should be obtained from the pharmacy. An expired medication was less effective and could cause an adverse reaction if outdated. Medications should not be administered if they could not be ensured as good. During an interview on 2/14/2024 at 11:30 AM licensed practical nurse Unit Manager #5 stated when insulin came from the pharmacy it went into the medication refrigerator until opened. Once the insulin pen was opened it should be dated and was good for 28 days. It was important that insulin pens were dated when opened so residents did not get injected with expired medications that could be less effective and would not control blood sugars appropriately. They expected open undated insulin pens to be thrown out and pharmacy notified to order a new one. During an interview on 2/15/2024 at 9:39 AM the Director of Nursing stated new insulin pens went into the medication refrigerator until opened and then they were labeled with an open date. There was a sticker to document the open date and if the sticker was not on the medication, the open date was documented directly on the insulin pen. Insulin pens were good for 28 days once open and without an open date, it was unknown if the medication was good. If there was an open pen without an open date, they expected the insulin pen to be thrown away and pharmacy was called for a new pen. Residents should not receive insulin that was not dated with an open date because there was no way of knowing how old the medication was, it could be not as effective, and the residents' blood sugars may not be appropriately controlled. 10NYCRR 415.18(d)

Based on observation, record review, and interview during the recertification survey conducted 2/12/2024 - 2/16/2024, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #63) reviewed. Specifically, Resident #63's portable oxygen tank was empty and was not replaced. Findings include: The facility policy Oxygen Administration revised 11/2023 documents verify the physician's order, review the resident's care plan to assess for any special needs of the resident, strap the portable oxygen tank to the stand, turn on the oxygen, start the flow of oxygen as ordered, and observe the resident upon setup and periodically thereafter to be sure oxygen was being tolerated. Resident #63 was admitted to the facility with diagnoses including dementia and chronic obstructive pulmonary disease (lung disease). The 12/20/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not reject care, and did not use oxygen. A 1/9/2024 nurse practitioner #12 progress note documented the resident was seen by the request of nursing to follow up for chronic obstructive pulmonary disease. The resident had a history of chronic obstructive pulmonary disease and recently had an exacerbation (flare up). The resident was examined at bedside with no signs or symptoms of respiratory distress. The resident's oxygen saturation (amount of oxygen in blood stream) level was 95% on room air. The plan was to discontinue DuoNeb (a combination medication used to treat chronic obstructive pulmonary disease) and continue to monitor the resident. A 1/28/2024 physician order documented the resident was to receive oxygen at 2-4 liters per minute via nasal cannula to maintain oxygen saturation levels of 92% or greater. The 1/2024 and 2/2024 Medication Administration Records did not document oxygen administration as ordered. The 2/5/2024 comprehensive care plan documented the resident required oxygen at 2 liters per minute via nasal cannula. Interventions included provide supplemental oxygen per physician orders, monitor for signs and symptoms of respiratory distress and report to medical, check oxygen saturation levels as needed, and report abnormal findings to medical. The resident profile (care instructions) did not document the resident's use of oxygen. Resident #63 was observed: - on 2/12/24 at 10:00 AM, sitting in the dining room. The gauge on the resident's portable oxygen tank was almost at the red, indicating the tank was almost empty. At 11:08 AM, the portable oxygen tank gauge was in the red, indicating the tank was empty. At 11:42 AM, the resident was observed self-propelling their manual wheelchair down the hallway towards the lobby and the portable oxygen tank gauge remained in the red. At 11:57 AM, an unidentified staff member brought the resident back to the unit and asked if they were ok and brought the resident to licensed practical nurse #27. At 12:03 PM, licensed practical nurse #27 changed the resident's portable oxygen tank. At 3:37 PM, the resident was observed seated in the dining room and their portable oxygen tank gauge was in the red, indicating the tank was empty. - on 2/13/2024 at 11:25 AM, in a resident meeting sleeping and their portable oxygen tank gauge was in the red, indicating the tank was empty. There were no signs of respiratory distress. The vitals report dated 2/1/2024-2/15/2024 documented the resident's oxygen saturation had been measured once on 2/15/2024 at 2:10 PM. During a telephone interview on 2/15/2024 at 12:12 PM licensed practical nurse #27 stated on 2/12/2024 the unit was short staffed, only they and 2 certified nurse aides were scheduled. Resident #63 was the only resident on the west wing that wore continuous oxygen. They stated certified nurse aide should check the resident's portable oxygen tank throughout the shift to ensure the resident was receiving their ordered oxygen. The licensed practical nurse checked the portable tanks to ensure the correct rate of oxygen was provided. They were not made aware the resident's portable tank was empty until the resident was brought to them during the lunch meal. It was important for residents to receive their oxygen as order to prevent respiratory distress. They thought the lack of staffing on 2/12/2024 could impact the resident's quality of care. During an interview on 12/15/2024 at 12:57 PM nurse practitioner #12 stated they expected residents to receive their supplemental oxygen as ordered to prevent low oxygen levels. During an interview on 2/15/2024 at 2:08 PM the Director of Nursing stated the certified nurse aides should check the portable oxygen tanks throughout their shift and notify a nurse when the tank needed to be replaced. It was important for residents to receive their supplemental oxygen as ordered to prevent low oxygen levels. During an interview on 2/15/2024 at 4:50 PM licensed practical nurse Unit Manager #5 stated all nursing staff should check the resident's portable oxygen tanks throughout the shift. If a certified nurse aide observed the tank needed to be changed, they should tell a nurse who would change the portable tank. It was important for the residents to receive their supplemental oxygen as ordered to prevent low oxygen levels. During an interview on 2/16/2024 at 10:04 AM certified nurse aide #21 stated they should check the resident's portable oxygen tank every 2 hours and let the nurse know if the tank needed to be replaced. They stated the resident's family member often came in and complained the resident's portable oxygen tank was empty and needed to be replaced. They stated on 2/12/2024 the unit was short staffed, and it made it difficult to provide all the care they needed to complete and check the resident's portable oxygen tank. If a resident used supplemental oxygen, it was not listed on the certified nurse aide care instructions and there was nowhere for them to document they checked the portable oxygen tanks during their shift. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00314609) conducted 2/12/2024-2/16/2024, the facility did not ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 5 residents (Resident #55 and #64) reviewed. Specifically, Resident #55 did not have pressure relief for their heels as planned and Resident #64 had positioning devices for pressure relief ordered that were not being used correctly. Findings include: The facility policy Prevention of Pressure Ulcers/Injuries revised 7/2023 documented reposition residents at least every 2 hours if they were dependent on staff for repositioning. Reposition more frequently as needed, based on the condition of the skin and resident's comfort. Provide support devices and assistance as needed. 1) Resident #55 had diagnoses including pressure-induced deep tissue damage of unspecified heel (purple or blue discoloration to intact skin) and fracture of the left femur (thigh bone). The 12/27/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, required partial/moderate assistance for bed mobility, was at risk for developing pressure ulcers, and had pressure reducing devices for chair and bed. A 2/6/2024 at 2:40 PM Director of Nursing progress note documented they were notified by the licensed practical nurse the resident had a black area on their heel. The area measured 3 centimeters x 4 centimeters and was a deep tissue injury (damage to underlying soft tissue from pressure) to the left heel. Skin prep was applied. Pressure relieving boots were to be worn when in bed. The comprehensive care plan revised 2/6/2024 documented the resident had a pressure injury to the left heel related to impaired mobility. Interventions included air mattress on the bed, pressure reduction cushion in the wheelchair, turn and position per the plan of care, and application of pressure relieving boots when in bed. The resident profile (care instructions) revised 2/6/2024 documented turn and position every 2 hours, elevate/encourage elevation of heels while in bed, apply pressure relieving boots when in bed, and a pressure reduction cushion to the chair. Resident #55 was observed at the following times: - on 2/13/2024 at 12:47 PM, lying in bed on their right side and was not wearing pressure relieving boots. - on 2/14/2024 at 10:30 AM, lying in bed on their back. The resident was wearing nonskid socks, their heels were resting directly on the air mattress, and they were not wearing pressure relieving boots. - on 2/15/2024 at 2:38 PM, lying in bed on their back. The resident was wearing nonskid socks, their heels were resting directly on the air mattress, and they were not wearing pressure relieving boots. During an interview on 2/15/2024 at 1:27 PM, licensed practical nurse #14 stated the residents care plan listed instructions on how to properly care for the resident. They stated it was important to use pressure relieving devices as ordered to prevent pressure ulcers from getting worse and if they were not used new areas could develop. During an interview on 2/16/2024 at 9:06 AM, certified nurse aide #21 stated Resident #55 should wear foot booties to protect their heels, they used to wear them, but they had not seen them recently. They stated they saw pressure relieving boots listed on the resident's care instructions that morning. They should have told therapy the boots were missing but they had been very busy that morning because there were only two certified nurse aides on the unit. They stated it was important to follow the care plan and use pressure relieving boot to prevent Resident #55 from developing new pressure ulcers and pressure ulcers from getting worse. During an interview on 2/16/2024 at 10:30 AM, Infection Preventionist/Assistant Director of Nursing stated if Resident #55 was care planned to use offloading heel boots while in bed, they expected the direct care staff on the unit to make sure it was being done. They stated the Unit Manager or nurses should monitor to ensure the boots were being implemented. They expected staff to notify management or therapy if they were unable to locate the pressure relieving devices. They stated if Resident #55 was not wearing the heel booties as ordered it put them at risk for further skin breakdown. 2) Resident #64 had diagnoses of cerebrovascular disease, unspecified convulsions, and diabetes. The 12/29/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not exhibit behaviors, did not reject care, required was dependent for bed mobility, transfers and toileting, had one Stage 3 pressure ulcer (full thickness tissue loss), one deep tissue injury (a form of pressure injury with localized tissue damage), and had a pressure reducing device for the bed and the chair. The comprehensive care plan initiated 6/21/2023 documented the resident required assistance with activities of daily living secondary to cerebral vascular accident and left sided hemiplegia (weakness or paralysis). Interventions included extensive assistance with bed mobility, use of a right lateral wedge in bed, a mechanical lift for transfers, and a wheelchair for locomotion. The resident profile dated 1/1/2024 documented bed mobility was extensive assistance of 1 and a right lateral wedge when in bed. A 1/5/2024 nurse practitioner #12 progress note documented the resident had a pressure ulcer on the left buttocks measuring 2 centimeters x 2.5 centimeters x 0.1 centimeters, serous (watery) drainage, and was 100% slough (moist, dead tissue). A physician order dated 1/8/2024 documented lateral wedge on right side of the bed to promote proper positioning and pressure relief. A 1/10/2024 Wound Evaluation and Management Summary documented the resident had a Stage 3 right sacral pressure ulcer. Recommendations included off-load wound, reposition per facility policy, and turn side to side in bed every 1-2 hours if able. Resident #64 was observed at the following times: - on 2/12/2024 at 11:10 AM, positioned in bed on their back with a bed wedge on both the left and right sides. - on 2/12/2024 at 12:55 PM in bed being assisted with lunch with a bed wedge on both the left and right sides. - on 2/12/2024 at 1:18 PM the resident stated staff had not been in yet to assist them out of bed. The bed wedges were present on both the left and right sides. - on 2/13/2024 at 8:59 AM in bed on their back in a gown with a bed wedge on both the left and right sides. - on 2/13/2024 at 10:35 AM in bed on their back with a bed wedge on both the left and right sides. The resident stated they would like to get up, but staff had not offered. - on 2/13/2024 at 12:51 PM repositioned in bed with the head of the bed elevated for the lunch meal. The bed wedges were present on both the left and right sides. - on 2/14/2024 at 9:23 AM in bed lying on their back with bed wedges present on both the left and right sides. - on 2/14/2024 at 12:45 PM resident in bed with head of bed elevated. The bed wedges were present on both the left and right sides. - on 2/15/2024 at 3:02 PM in bed on their back with the bed wedge positioned under their left side. During an interview on 2/15/2024 at 11:24 AM, physical therapist #29 stated wedges, rolls, and pillows could be used for bed positioning to prevent pressure and contractures. A back wedge should be partially under the back to rotate off pressure points, and then follow down the body to make sure pressure was not placed somewhere else. An order was required for bed wedges, they should not be used without orders and must be used as ordered. Residents with pressure areas should get out of bed to relieve pressure. During an interview on 2/15/2024 at 11:48 AM, certified nurse aide #25 stated resident care information was found on the Kiosk in the computer and included adaptive equipment for pressure reduction. They were not sure if the bed wedges for resident # 64 were in the orders. The wedges were on the resident's bed on both sides when they got the resident up that morning. The certified nurse aide stated they put them back as they found them when they put the resident back to bed. The certified nurse aide did not check the care plan and thought the wedges were used to keep the resident from falling out of bed. Shifting position was important to for comfort and pressure relief. During an interview on 2/15/2024 at 12:15 PM, nurse practitioner #12 stated orders should always be followed. That would include any pressure relieving devices. Getting out of bed and changing positions improved breathing, and relieved pressure. During an interview on 2/15/2024 at 2:15 PM, certified nurse aide #7 stated bed wedges were used to reposition, and for safety to keep residents from falling out of bed. They were not sure if resident #64 was to have 2 wedges. They had not checked the care profile for information. During an interview on 2/15//2024 at 5:05 PM, licensed practical nurse #6 stated Resident #64 was to have a wedge on their right side for positioning and pressure relief. There had been 2 wedges present this week, and it was not ordered that way. Orders should be followed. During an interview on 2/16/2024 at 9:46 AM, licensed practical nurse #5 stated they did not realize resident #64 was supposed to have only one bed wedge. Two bed wedges could prevent the resident from being able to reposition for comfort. Resident #64 had pressure areas and should be able to reposition if they were uncomfortable. During an interview on 2/16/2024 at 11:45 AM, the Assistant Director of Nursing stated positioning devices, and turning and positioning were used to help pressure ulcers. Resident #64 had an order for a bed wedge on the right side for positioning and pressure relief. The use of 2 bed wedges could lead to the resident not being able to reposition themselves for comfort or pressure reduction. During an interview on 2/16/2024 at 12:53 PM, the Director of Nursing stated Resident #64 had orders for a right lateral wedge for positioning and pressure relief. Using 2 bed wedges could limit the resident's ability to relieve pressure or get comfortable. They should not have 2 bed wedges in place. 10NYCRR 415.12(c)(1)

Based on observation, record review, and interview during the recertification and abbreviated (NY00313895) surveys conducted 2/12/2024- 2/16/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs for 3 of 3 residents (Resident's #17, #22, and #329) reviewed. Specifically, Resident #17 was transferred using a mechanical lift with assistance of 1 and not 2 as care planned; Resident #22 was transferred and toileted with assistance of 1 and not 2 as care planned; and Resident #329 did not have a motion detector outside of their room as care planned. Findings include: The facility policy Care Plan, Comprehensive Person- Centered revised 3/2023 documented a comprehensive, person- centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs would be developed and implemented for each resident. The care plan identified problem areas and their cause and include interventions that were targeted and meaningful to the resident were developed. Care plan interventions were chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. The facility policy Activities of Daily Living, supporting last revised 3/2023, documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services would be provided in accordance with the plan of care. The facility policy Lifting Machine, Using a Mechanical reviewed 2023 documented at least two nursing assistants are needed to safely move a resident with a mechanical lift. 1) Resident #17 was admitted to the facility with diagnoses including benign neoplasm (non-cancerous tumor) of the central nervous system, quadriplegia (paralysis of both arms and legs) and post laminectomy (removal of a vertebrae) syndrome. The 1/8/2024 Minimum Data Set assessment documented the resident was cognitively intact, dependent on staff for bed to chair transfer, and utilized a mechanical lift for transfers from bed to electric wheelchair. The comprehensive care plan initiated 1/13/2023 and revised 2/12/2024 documented the resident required assistance with activities of daily living, was totally dependent on two with a mechanical lift for transfers and was at risk for falls. Interventions included verbal reminders not to transfer without assistance. During an observation on 2/14/2024 at 10:17 AM, certified nurse aide #7 transferred Resident #17 from the bed to their electric wheelchair with a mechanical lift by themself without additional staff present. There was no documentation Resident #17 was transferred during the day shift on 2/14/2024 in the Point of Care Response History. During an interview on 2/15/2024 at 10:28 Resident #17 stated two staff members were supposed to get them up with a mechanical lift. Certified nurse aide #7 got them up without help on 2/14/2024 because they stated they were short staffed that day. During an interview on 2/15/2024 at 10:45 AM certified nurse aide #7 stated a resident's level of assistance was followed as indicated on their care plan. Resident #17 required two person assistance, but they got them up on their own because there were only two certified nurse aides for the entire floor. It was a safety measure to have assistance of two for transfers so the resident would not fall. During an interview on 2/15/2024 at 3:04 PM licensed practical nurse #6 stated the level of assistance needed was in the care plan which was checked by certified nurse aides at the beginning of each shift. If a resident required assistance of two, they should not have been transferred with one and the care plan was not followed. Not following the care plan could result in a fall or it could be rough on the resident because they could be pushed or pulled too hard, and it could cause injury. Resident #17 required assistance of two and a mechanical lift and should never be transferred by one person. During an interview on 2/16/2024 at 9:23 AM licensed practical nurse Unit Manager #5 stated certified nurse aides were supposed to look at the care plan at the beginning of each shift and were expected to follow the level of assistance indicated for the safety of both the residents and the staff. If the care plan was not followed, residents could get hurt either from a fall or they could get a bruise from being pushed or pulled with too much pressure and staff could injure their back. Resident #17 required a mechanical lift and should always be transferred by two staff. During an interview on 2/16/2024 at 9:40 AM the Assistant Director of Nursing stated they expected certified nurse aides to know the level of assistance required by referencing the care plan and they expected the care plan to be followed for resident and staff safety. One staff member assisting a mechanical lift resident was never appropriate and could lead to falls or injuries. 2) Resident #22 had diagnoses including chronic obstructive pulmonary disease (lung disease), dementia, and hypertension (high blood pressure). The 1/16/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, and was dependent on staff assistance for toileting and transfers. The comprehensive care plan initiated 10/17/2018 documented the resident required assistance with activities of daily living due to decreased mobility and impaired cognition. Interventions edited on 2/6/2024 included toileting care at bed level with extensive assistance of 2 staff and check and change every 2 -3 hours. The resident required extensive assistance of 2 for transfers prior to 2/15/2024. The resident profile (care instructions) documented on 2/2/2024 toileting care at bed level with extensive assistance of 2, and check and change every 2 -3 hours. On 2/14/2024 transfer with total assistance of 2 using a mechanical lift. During an observation on 2/14/2024 at 1:37 PM, certified nurse aide # 7 assisted Resident #22 to their room. and transferred the resident back to bed without a second person present. They provided toileting care without a second person present. During an interview on 2/14/2024 at 1:50 PM, certified nurse aide #7 stated the resident was supposed to have 2 staff for transfers and incontinence care. When there were more certified nurse aides, they were able to provide more frequent care. They were aware the care plan documented 2 staff for transfers and care, but they felt safe transferring the resident alone There was not enough staff to get the resident changed more often or to use two for transfers. During an interview on 2/16/2024 at 12:53 PM, the Director of Nursing stated care information was found in the resident profile on the computer. All resident transfers had to follow the care plan for both staff and resident safety. It was not acceptable to use staffing as a reason for not following the care plan. Staff should come and ask for assistance from supervisors, the Assistant Director of Nursing, or themselves. If the care plan documented 2 staff for transfers, 2 staff should be used for resident and staff safety. During an interview on 2/16/2024 at 11:45 AM, the Assistant Director of Nursing stated resident care information was found in the computer under the resident profile. The plan of care included assistance level, diet preferences, transfers, and shower dates. A resident should not be transferred with less staff than what was care planned. It would be a safety issue for both the resident and staff. 3) Resident #329 had diagnoses including traumatic brain injury, mood disorder, and inappropriate sexual behavior. The 1/10/2024 Minimum Data Set Assessment documented the resident had mildly impaired cognition, did not wander, did not exhibit behavioral symptoms, used a manual wheelchair, was able to independently wheel 50 feet and make two turns once seated in wheelchair, wheel 150 feet independently once seated in wheelchair in a corridor or similar space and did not use any restraints or alarms, including motion sensor alarms. The comprehensive care plan initiated 7/3/2019 documented the resident had behavioral symptoms. The resident was non-complaint with respecting other's space and belongings, was sarcastic, and used sexually inappropriate language and gestures towards female staff and residents. The resident had attempted to kiss other residents. Interventions included approach the resident in a calm consistent manner, make eye contact, explain purpose on approach, psychological consult and follow up as ordered and as necessary. Provide the resident with the opportunity to express feelings through 1:1 and group visits. Staff were to encourage the resident to participate in group activities, monitor for any changes in mood, and report to medical. The resident was placed on 15-minute checks. On 1/24/2023 interventions were updated to include the resident was re-educated about inappropriateness with female residents and redirected, and call family member so they could speak to the resident about their behavior. On 2/14/2023, interventions were updated to include a medical consult to review medications. On 2/20/2023, interventions were updated to include to keep the resident in highly visible area when out of their room. On 2/28/2023, interventions were updated to include pharmacy consultant medication review and a motion detector was to be placed outside room. The resident profile (care instructions) documented a motion sensor was to be placed outside of the room on 2/28/2023. A 4/1/2023 Incident report documented on the evening of 4/1/2023, a female resident entered Resident #329's room. The facility's video footage showed Resident #329 talking and standing behind the female resident while they were seated in their wheelchair. Resident #329 wheeled the female resident into their room. Staff separated the residents. Resident #326 was placed on 1:1 and had a room change to the west wing of the facility. On 4/2/2023, former Director of Nursing #11 documented the behavior care plan interventions were updated to include a motion sensor placed outside of the resident's room and the resident was placed on 15-minute checks. On 2/13/2024, social worker #18 documented the resident had a room change due to a reported incident with a female resident on 2/9/2024. The resident's room was observed without a motion detector outside of their room on: - On 2/12/24 at 2:11 PM. - On 2/13/24 at 8:39 AM. - On 2/14/24 at 11:12 AM. During an interview on 2/14/2024 at 11:12 AM certified nurse aide #7 stated any resident safety interventions, such as alarms, were documented on the resident's profile card. They typically worked on the unit and did not know of any residents that had a motion detector outside of their rooms. During an interview on 2/14/2024 at 12:57 PM, licensed practical nurse #17 stated they were unaware of any residents with a motion detector outside of their room. Recently Resident #329 was moved to the east wing due to inappropriate behaviors. They had never observed a motion sensor outside of the resident's room prior to the move and never heard any noise when they had entered or exited the resident's room while the resident was on the west wing. During an interview on 2/14/2024 at 1:37 PM certified nurse aide #23 stated they were currently assigned to Resident #329. They knew how to provide care for the resident by reviewing the resident profile and the profile also included any safety interventions the resident required. They stated the resident had a history of being inappropriate with females and was recently moved to the east wing after an incident. They had not observed any motion detector on the resident's doorway and never heard any alarm while entering or exiting the room. During an interview on 2/14/2024 at 1:49 PM licensed practical nurse #6 stated they usually worked on the east unit and Resident #329 was recently moved to the unit due to behaviors. They were unaware if the resident had a motion detector on their doorway. During an interview on 2/14/2024 at 2:26 PM certified nurse aide #22 stated Resident #329 was recently moved from the west wing to the east wing due to their behaviors. They thought Resident #329 used to have a motion detector on their doorway, but that was in the past. During an interview on 2/14/2024 at 2:33 PM certified nurse aide #21 stated Resident #329 used to be on the west wing on their side of hall, but they were recently moved to the east wing. They had never observed a motion detector outside of the resident's room. During a telephone interview on 2/14/2024 at 3:59 PM certified nurse aide #20 stated Resident #329 was recently moved from the west wing to the east wing due to their behaviors. They stated the resident had a motion detector on their door in the past, but it had not worked in a while. They let a nurse on the unit along with the former Director of Nursing #11 know the motion detector was not working. They stated there was nowhere for them to document if it was working or in place. During an interview on 2/15/2024 at 1:15 PM social worker #18 stated Resident #329 was recently moved to the east wing for their behaviors. Usually, maintenance staff moved the resident's items including dressers, floor mats, and personal belongings to their new room. They were unsure if any residents at the facility had a motion detector outside of their room and had never heard Resident #329 was care planned to have one. They thought the behavior care plan would be updated by the nursing staff. It was important for the resident's care plan to be followed to ensure the safety of the resident and other residents. During an interview on 2/15/2024 at 1:40 PM the Director of Nursing stated when the interdisciplinary team discussed the care plan, they also reviewed the interventions in place to determine if they remained appropriate. They stated Resident #329 had inappropriate behaviors and recently had a room change. The resident's care plan included 15-minute checks and to keep in highly visible areas when out of their room. They had never observed a motion detector outside of the resident's room. They stated if the resident was care planned to have a motion detector, they should have it and at this time it had been discontinued from the care plan. It was important for staff to follow the care plan to ensure the residents were cared for properly and for safety reasons. If staff observed the motion detector not working, it should have reported to the nursing supervisor and maintenance should have also been made aware. During an interview on 2/15/2024 at 2:35 PM the Maintenance Director stated they recently moved Resident #329's belongings to the east wing. They did not observe a motion detector outside of the resident's previous room and they were not made aware a motion detector was not working. If they were made aware they would have fixed it. They did not put up a motion detector outside of the resident's new room on the east wing. 10NYCRR 415.11(c)(1) 44838 49448

Based on record review and interview during the recertification and abbreviated (NY00314008) surveys conducted 2/12/2024-2/16/2024, the facility did not ensure allegations of abuse, neglect, or mistreatment were thoroughly investigated for 1of 2 residents (Resident #22) reviewed. Specifically, Resident #22 had skin alterations that were not thoroughly investigated to rule out abuse, neglect, or mistreatment. Findings included: The facility policy Abuse and Neglect Policy reviewed by the facility 1/9/2023 documents injuries of unknown origin would be investigated to rule out abuse, neglect, or mistreatment. The facility policy Accidents and Incidents- Investigating and Reporting revised 10/2023 documents all accidents or incidents involving residents, employees, visitors, vendors, etc. occurring on facility premises shall be investigated and reported to the administrator. Resident #22 had diagnoses including chronic obstructive pulmonary disease (lung disease), dementia, and hypertension (high blood pressure). The 7/24/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, did not wander, was incontinent of bladder and bowel, had no falls since admission/entry or reentry or the prior assessment, did not receive an anticoagulant (blood thinning medication), and had no unhealed pressure ulcers. The 2/21/2023 comprehensive care plan documented the resident was at risk for purpuric lesions (breaking of blood vessels under the skin), petechiae (tiny, round spots due to bleeding under the skin), ecchymosis (bruise), or hematoma (a pool of clotted blood), they were at times combative with care, had poor spatial awareness and when self-propelling wheelchair would bump their legs or arms. Approaches were to inspect the resident's skin daily and document location and characteristics of lesions. The 6/1/2021 comprehensive care plan documented the resident had behaviors including liking male attention and would exhibit unwanted affection seeking behaviors towards male residents, was combative with care. Approaches included address resident by name and explain purpose upon approach. Nursing progress notes documented: - on 6/7/2023 by registered nurse #10, called to the unit to assess the resident's left forearm. There was a large area of purpura approximately 6 centimeters by 2 centimeters in size and non-blanchable (area of redness that does not disappear when pressed). Flush to the skin. No signs of infection. No pain on palpation. No signs of distress. Resident known to have these marks. No interventions necessary. - on 7/3/2023 by former Director of Nursing #11, the resident was noted with large area of purpura to the right upper forearm measuring 11.5 centimeters x 4 centimeters, raised and hard, no redness or pain was noted, and the area was irregular in shape. The resident had a long history of these chronic areas. The purpura was purplish to black in color due to aging skin where blood vessels break under the skin. There was no blanching when pressure was applied, and the area remained deep purplish black in color. Nurse practitioner #12 progress notes documented: - on 7/6/2023 the resident was seen at the request of nursing for a right forearm discoloration. For their purpura, the resident had an area to their arm that was dark purple in color. The area did appear as if it was a bruise but was actually purpura. Purpura was hemorrhagic areas under the skin that were due to aging and the skin being thinner. - on 12/26/2023 the resident was seen for their increased agitation especially during care. There was concern with the resident hurting themself or causing bruising due to their fighting during care. There was no documented evidence of investigations for the discolored areas noted on 6/7/2023 and 7/3/2023. During an interview on 2/15/2024 at 11:48 AM, certified nurse aide #25 stated they were supposed to report any changes in skin conditions or bruising. They stated that Resident #22 could be resistive with care and had seen purple areas on their skin in the past. During an interview on 2/15/2024 at 12:05 PM, nurse practitioner #12 stated an assessment for a dark purple discolored area would include asking about any falls or injuries. They would expect nursing to have ruled out injury. If they were told there was no injury, they felt the area was purpura. It would be important to rule out injury first, especially in this population. They did not remember specifics regarding Resident #22's skin discolorations. They were not sure if there had been labs to support purpura diagnosis. During an interview on 2/15/2024 at 3:25 PM licensed practical nurse #6 stated if any alteration in skin was noted, they would notify a supervisor. For bruises or skin tears staff statements were obtained to try to make sure abuse or neglect did not take place. They tried to find out what happened to prevent it from happening again. Resident #22 could be difficult and combative with care. During an interview on 2/15/2024 at 4:46 PM, registered nurse Supervisor #26 stated they expected staff to report any alteration in skin for a registered nurse to assess. Any skin area that was discolored or purple should have an investigation to make sure there was no abuse, and to prevent reoccurrence. They remembered Resident #22 having purple skin areas and was not sure if there had been investigations into the cause. During an interview on 2/16/2024 at 9:54 AM licensed practical nurse #5 stated any change in skin condition required a registered nurse assessment. A bruise required assessment and investigation to rule out abuse. They stated they were not sure about Resident #22's history of skin discolorations. During an interview on 2/16/2024 at 11:45, the Assistant Director of Nursing stated if a resident had any changes in skin a registered nurse should be notified to complete an assessment. Investigations needed to be completed for all bruises to rule out abuse. They were not sure how to tell the difference between purpura and bruising, but it should always be investigated. All staff were educated regarding abuse and neglect. They stated this population was especially vulnerable. During an interview on 2/16/2024 at 12:53 PM, the Director of Nursing stated alterations in skin integrity should be reported to a registered nurse for an assessment. Any discolored areas needed to be investigated to rule out abuse. Interventions should be in place to prevent recurrence. A purple skin area could not be called purpura without an investigation. 10NYCRR 415.4(b)

Based on observation and interview during the recertification survey conducted 2/12/2024-2/16/2024, the facility did post on a daily basis 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 place readily accessible to residents and visitors for 5 of 5 days reviewed. Specifically, the current daily resident census and nurse staffing schedules were in the dental office off the main hallway that was not readily accessible to visitors or residents. Findings include: The daily resident census and nurse staffing information was not observed in an area that was readily accessible to residents and visitors: - on 2/12/2024 at 4:23 PM. - on 2/13/2024 at 8:05 AM. - on 2/14/2024 at 8:07 AM. During an interview on 2/15/23 at 3:17 PM, receptionist #2 stated the daily staffing or census was not posted in the front lobby. The staffing schedule could be posted in one of the rooms off the main hallway near the time clock. During observations on 2/15/2024 at 4:53 PM and 2/16/2024 at 9:52 AM, the daily resident census and nurse staffing information was posted in the dental office off the main hallway and was not readily accessible to residents or visitors. During an interview on 2/16/2024 at 11:10 AM, the Director of Nursing stated they did not have a staff scheduler and they were responsible for the staffing schedule, keeping it updated, and making sure it was posted. They stated they were aware daily staffing should be posted in an area visible to all visitors upon entrance. They stated it must have been moved when construction started in the main lobby. 10 NYCRR 415.13

Based on record review and interview during the abbreviated survey (NY00303060), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 was assessed on readmission from the hospital to the facility to have excoriated (reddened, superficial abrasion) areas to the buttocks and coccyx (end of spine) and a treatment was not ordered or administered for 18 days. Subsequently, Resident #1's pressure ulcer to the coccyx worsened to a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) that became infected. The resident became septic (widespread infection) and expired related to septic shock. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The facility policy Ulcers/Skin Breakdown- Clinical Protocol, revised ,d+[DATE], documented the nursing staff and practitioner will assess and document an individual's risk factors for developing pressure ulcers, such as immobility, weight loss, and prior pressure ulcers. The staff and practitioner will examine the skin of newly admitted residents for pressure ulcers or other skin conditions. The physician will order wound treatments, dressings, and application of topical agents. The physician will guide the care plan as appropriate especially when wounds were not healing as anticipated or new wounds develop despite existing interventions. Resident #1 was readmitted to the facility with diagnoses including sepsis (system wide infection) from a urinary tract infection (UTI), dementia, and a pressure ulcer to the left heel. The [DATE] Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, did not reject care, required extensive assistance of 2 for bed mobility and extensive assistance of 1 for most other activities of daily living (ADL), was always incontinent of urine and bowel, currently had one Stage 3 (full thickness tissue loss) pressure ulcer present upon admission to the facility (readmission from the hospital), had moisture associated skin damage (MASD), had pressure reducing devices for the chair and the bed, and received pressure ulcer/injury care. The comprehensive care plan (CCP) updated on [DATE], documented the resident had potential for pressure ulcer development. Interventions included to assess skin upon admission, certified nurse aides (CNA) were to monitor skin daily and report alterations in skin integrity to the Nurse Manager/ Supervisor, and complete documentation for any wounds identified at admission within 24 hours, or anytime a wound was identified. The [DATE] at 9:21 PM, licensed practical nurse (LPN) #12's progress note documented the resident was sent to the hospital due to lethargy, dehydration, and blood in the brief from an unknown cause. The [DATE] hospital discharge orders documented the resident had a pressure ulcer to the coccyx (bone at the base of the spinal cord) that was unstageable (full thickness tissue loss with the wound bed covered with dead tissue). Treatment orders for the coccyx pressure ulcer included cleanse with wound cleanser, apply anti-microbial dressing over open areas, cover with foam absorbent dressing, and change every other day. The [DATE] at 2:09 PM admission progress note by registered nurse (RN) Manager #9 documented the resident was readmitted to the facility from the hospital. The resident was incontinent of a large amount of stool and urine and had excoriated areas to the buttock and coccyx area. The resident's wound to the coccyx measured 1.5 centimeters (cm) x 1 cm x 0.2 cm with the wound bed having granulation tissue (new tissue). The progress note did not document if RN Manager #9 contacted a medical provider for a treatment order. The [DATE] readmission attending physician #7's orders did not include a treatment for the coccyx wound. The CCP, updated [DATE] by RN Manager #9, did not include skin impairment to the coccyx or interventions for the wound. A [DATE] at 2:30 PM progress note by RN Manager #9 documented the resident was seen on wound rounds and see physician dictation. The coccyx was seen by the physician and stated it was a Stage 2 (partial thickness tissue loss) and there was no need to follow the resident and continue the same treatment. The area measured 1.4 cm x 1.0 cm x 0.2 cm. There was no documented evidence a treatment was ordered at the time for the coccyx wound. The [DATE] Wound Evaluation and Management Summary completed by wound physician #6 did not include a wound assessment for the coccyx. There was no documented evidence the ,d+[DATE] Treatment Administration Record (TAR) included a treatment to the resident's Stage 2 coccyx wound from [DATE] to [DATE]. The [DATE] RN Manager #8's progress notes at 10:24 AM documented the resident was seen by the wound physician and wound physician #6 was not following the Stage 2 on the coccyx. There was no documentation whether RN Manager #8 applied a treatment to the coccyx pressure ulcer and no documentation a medical provider was contacted for a treatment order. The [DATE] Wound Evaluation and Management Summary completed by wound physician #6 did not include a wound assessment for the coccyx. There was no documented evidence the ,d+[DATE] TAR included a treatment to the resident's Stage 2 coccyx wound from [DATE] through [DATE]. The ,d+[DATE] TAR contained no documentation a treatment was ordered or rendered to the coccyx pressure ulcer on [DATE] or [DATE]. The [DATE] at 9:55 PM, LPN #12's progress note documented staff noted a wound on the resident's coccyx. LPN #12 and the RN Supervisor (RNS, identify not specified) observed the wound. The wound measured 2 cm x 2 cm x 2 cm, was round and equal in depth, and appeared to have exposed bone. A foam border dressing was applied for comfort and the plan was to monitor. There was no documentation a medical provider was contacted for a treatment order for the pressure ulcer on [DATE] The ,d+[DATE] TAR did not include an order for the foam dressing applied to the resident's coccyx pressure ulcer on [DATE] by LPN #12. The [DATE] Wound Evaluation and Management Summary by wound physician #6's documented they were asked by attending physician #7 to see the resident for a Stage 4 pressure ulcer to the coccyx which measured 3 cm x 1.9 cm x 1.2 cm, had light serous exudate (clear to yellow drainage), and 100% thick adherent devitalized necrotic (dead) tissue. The recommended treatment plan was to apply sodium hypochlorite gel (antiseptic), cover with a gauze sponge, and ABD (large soft gauze) pad daily and as needed. The [DATE] nurse practitioner (NP) #13's orders documented to the coccyx pressure ulcer: cleanse with wound spray, pack with antiseptic soaked gauze, and cover with a foam dressing. The ,d+[DATE] TAR documented on [DATE], a new order for the coccyx pressure ulcer: cleanse with wound spray, pack with antiseptic soaked gauze, and cover with foam dressing once a day. The TAR documented the treatment was completed as ordered from [DATE] through [DATE]. A [DATE] NP #13 order documented for the coccyx wound, cleanse with wound spray, pack with antiseptic soaked gauze, cover with foam dressing twice daily. There was no corresponding medical or nursing note indicating why the ordered was changed to twice per day. The ,d+[DATE] TAR documented, on [DATE], for the coccyx pressure ulcer: cleanse with wound spray, pack with antiseptic soaked gauze, and cover with foam dressing, twice a day. The [DATE] Wound Evaluation and Management Summary by wound physician #6 documented the coccyx pressure ulcer was a Stage 4 with moderate serous exudate and measured 2.7 cm x 2 cm x 2.5 cm, with undermining (tunneling) at 2 o'clock and 6 o'clock. There was 50% thick adherent necrotic tissue and 50%, granulation tissue and the wound had improved. The recommendation was to continue the current treatment order. The ,d+[DATE] TAR documented on [DATE] at 9:29 PM by LPN #10, on [DATE] at 3:23 PM by LPN #11, and on [DATE] at 10:10 PM by LPN #10, the coccyx pressure ulcer treatment was not completed and the resident refused. The [DATE] at 3:23 PM, LPN #11's progress note documented the resident refused the coccyx treatment and the resident claimed they were in pain. There was no documentation the RN Manager #8 or a medical provider were notified the coccyx treatment was not completed as ordered due to pain. The [DATE] Wound Evaluation and Management Summary by wound physician #6 documented the coccyx Stage 4 pressure ulcer measured 5 cm x 3 cm x 3 cm, had undermining at 2 o'clock, had moderate serous drainage, 100% granulation tissue, had been debrided (dead tissue removed), and had deteriorated. There was no recommendation for a change in treatment. The [DATE], NP #13's order documented to change the coccyx pressure ulcer treatment to cleanse with wound spray, pack with antiseptic soaked gauze, packing deeper at 2 o'clock and 8 o'clock where the wound was undermining and cover with a foam dressing. The ,d+[DATE] TAR documented the treatment order was changed and completed as ordered. The [DATE] Wound Evaluation and Management Summary by wound physician #6 the coccyx Stage 4 pressure ulcer measured 7.5 cm x 3.0 cm x 5.5 cm, undermining at 2 o'clock, moderate serous drainage, and the wound had deteriorated. No changes were recommended to the treatment order. The [DATE] at 10:46 AM, RN Manager #8's progress note documented the resident was showing signs of decline, not eating/drinking, and lethargic, and was transferred to the hospital. The hospital records documented on [DATE], the resident was admitted with altered mental status due to septic shock. Hospital admission plans included a general surgery consult for wound debridement (removal of dead tissue) of the coccyx pressure ulcer. On [DATE], extensive necrotic tissue was debrided from the wound down to the level of the fascia (a thin casing of connective tissue), muscle, and bone. On [DATE], the resident expired. The New_York State Department of Health (NYS DOH) Certificate of Death documented the resident expired on [DATE] and the immediate cause of death was acute respiratory failure due to septic shock as a consequence of polymicrobial bacteremia (bacteria in the blood) and infected pressure ulcer. During an interview on [DATE] at 9:40 AM, LPN #11 stated the resident's wound care was difficult to do because the resident screamed the entire time even if they were medicated prior. LPN #11 stated the coccyx wound was terrible and wound care was time consuming. It was a big wound and got larger and there was an odor at times. The facility had a wound care physician who recommended treatments, but they were not sure if the wound care physician saw the resident's coccyx pressure ulcer. If the resident refused a treatment, they were to notify the Director of Nursing (DON) or attending physician, and document in a progress note. When the resident refused their treatment on [DATE], they would have notified the DON, but stated they may not have documented. They did not recall if they notified a medical provider when the resident refused the treatment and stated the DON typically called the medical provider. During an interview on [DATE] at 10:11 AM, LPN #15 stated the resident's coccyx pressure ulcer was very deep and needed to be packed well. The resident would allow them to do the treatment. The wound got worse, and they thought the resident was becoming septic. They stated they documented concerns in the nursing notes so that other shifts and nurses would be aware of those concerns. If they documented the resident's treatment was not done, it was related to the resident being moved to the other unit, and the nurse on the other unit would have been responsible to document and complete the treatment. They were not able to recall if wound physician #6 saw the resident in ,d+[DATE]. They stated the wound was deep and wide, smelled bad, and had a lot of drainage. They stated it was impossible not get fecal matter in the wound when the resident was incontinent. If the resident refused the treatment, they would try to talk the resident into it doing it. If they were unable to complete the treatment, they would report to the next shift. During a telephone interview on [DATE] at 1:50 PM, LPN #10 stated they should have written a progress note about the worsening of the resident's wounds when the resident was at the facility. They stated the resident had a large coccyx pressure ulcer and the dressing did not always get completed because they did not have time, it took ,d+[DATE] minutes to complete. During a telephone interview on [DATE] at 1:53 PM, RN Manager #8 stated the resident developed a coccyx pressure ulcer that was not present on their initial admission to the facility. RN Manager #8 followed wound physician #6 on weekly wound rounds and entered the treatment orders recommended by wound physician #6. When the resident was readmitted in ,d+[DATE], the hospital after-visit summary was available in the medical record and the admitting RN should have inputted the wound treatment orders at that time. If a resident refused a treatment, the LPN should document the refusal and tell the RN so they could figure out the best way to reapproach the resident and get the treatment done. If a resident had a Stage 2 pressure ulcer or greater, they should have a wound treatment ordered. During a telephone interview on [DATE] at 11:09 AM, attending physician #7 stated they relied heavily on nursing to complete skin checks and notify them of any concerns. They also relied on wound physician #6's orders and assessments. A resident admitted with a Stage 2 pressure ulcer should not have it progress to a Stage 4 pressure ulcer if treatments were administered. When the resident was readmitted from the hospital in ,d+[DATE], the hospital discharge orders should have been implemented at the facility for pressure ulcer treatment. Normally on admission, the RN or DON notified a medical provider of any skin issues, and they were not aware the resident had a wound on their coccyx, and they never observed the resident's pressure ulcer. During a telephone interview on [DATE] at 11:40 AM, NP #13 stated they did not assess the resident on readmission on [DATE]. The RN would assess and review the hospital discharge orders over the phone with a medical provider. They stated the resident's treatments ordered in ,d+[DATE] should have been based on the hospital discharge paperwork. They stated if a resident was admitted from the hospital with orders for wound care, the nursing staff should enter the orders from the hospital. During a telephone interview on [DATE] at 12:20 PM, wound physician #6 stated on [DATE] they saw the resident for a Stage 4 coccyx pressure ulcer and that was the first time they were asked to see the resident for the coccyx wound. During a telephone interview on [DATE] at 9:55 AM, the Director of Nursing (DON) stated on admission or readmission, a head to toe skin assessment should be done and if skin issues were identified, the RN was to notify the medical provider for a treatment order. A resident with a Stage 2 pressure ulcer or greater was followed by the wound team weekly and during wound rounds, the nurse present should be looking at the resident's entire body to assess for new areas of concern. Hospital discharge orders should be reviewed by the admitting nurse with the NP and treatment orders should be implemented. When the resident returned from the hospital in ,d+[DATE], the orders for the Stage 2 coccyx pressure ulcer were not implemented and should have been. On [DATE], RN Manager #8 was doing weekly skin checks with LPN #12, noted the open area on the resident's coccyx and reported it. The wound physician saw the resident the next day and the resident had a Stage 4 pressure ulcer to their coccyx. Pressure ulcer treatments should be completed as ordered. If there was a treatment in place at the time of readmission, the pressure ulcer may not have progressed to a Stage 4. If the resident refused to have their treatment done, this should be documented on 24-hour report and followed up with on the next shift until the dressing was changed. During an interview with the DON on [DATE] at 1:49 PM, they stated sometime during the resident's admission the resident changed units, but they did not know the date. They stated when the unit change occurred, all treatments ordered on the prior unit should have been reported to the new Unit Manager and if they were not already completed that day, they should have been done on the new unit. If the treatment was refused, this should be communicated to and completed by the evening shift. They were not aware of this resident refusing any treatments. They stated refusal should also have been reported to the RN Manager and to the DON and documented om the 24-hour report. They did not recall this being documented on the 24 hour report. 10 NYCRR 415.12(c)(2)

Based on observation, record review, and interview conducted during the standard and the abbreviated survey #NY 633, it was determined for 3 of 13 sampled residents (Residents #1, 2, and 7), the facility did not provide an environment free of accident hazards or adequate supervision to prevent accidents. Specifically, for Resident #1, there was no preventative maintenance program for mechanical lifts, and during a transfer the mechanical lift malfunctioned resulting in a fall with injury; Resident # 2, was turned and positioned in bed, during wound care, by one staff instead of two as planned; for Resident #7, after multiple falls, and a fall with a hip fracture, there was no documented evidence the comprehensive care plan (CCP) was evaluated for effectiveness. This resulted in actual harm for Resident #1, a hematoma on the head, and no actual harm with potential for more than minimal harm, that is not immediate jeopardy, for Residents #2 and 7. Findings include: 1) Resident #1 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 6/26/2014 documented the resident was at risk for falls due to advanced dementia and immobility. The goal was for the resident to remain free of injuries. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively severely impaired, and required extensive assistance with all activities of daily living (ADL). The MDS recorded the resident had impairments of both legs and one arm. The undated Plan of Care (care instructions, used by the caregivers) documented the resident required the use of a mechanical lift, with the assistance of two, for transferring. The registered nurse (RN) supervisor progress note dated 9/7/2014 at 10 PM, documented the resident was found lying on her back on the floor of her room. The metal bracket of the mechanical lift was across the resident's chest. The RN supervisor recorded the certified nurse aides (CNA) stated the bolt holding the metal bracket came out, and the resident fell from a high position onto her back, hitting her head. The resident was transferred to the hospital for evaluation. The hospital emergency department discharge paperwork dated 9/7/2014 documented the resident was diagnosed with [REDACTED]. The Incident Report dated 9/7/2014 documented the resident was being transferred via the mechanical lift, when the lift was in a high position, the bolt to the lift came out, and the resident fell on her back and struck the back of the head. The incident report documented routine maintenance on equipment would have prevented the fall from happening. The registered nurse note 9/8/2014 at 4 AM, documented the resident returned to the facility, from the hospital, with a golf ball sized hematoma on the back of the head. The physician's interval note dated 9/8/2014 documented the resident fell the previous evening while being transferred via a mechanical lift which malfunctioned. She documented the resident had hit the back of her head sustaining a hematoma measuring approximately four centimeters. During an interview with Maintenance Director on 9/17/2014 at 2:45 PM, he stated he was not aware of any preventative maintenance program for mechanical lifts prior to the resident's fall due to equipment malfunction on 9/9/2014. He stated he started at the facility around two months ago. During an interview on 9/17/2014 at 2:55 PM maintenance staff #1 stated he worked in the facility before the current Maintenance Director was hired. He stated he was not aware of a preventative maintenance program for mechanical lifts. He stated he inspected the lift after the incident, and the bolt projecting upward through the spreader bar had fallen out. The surveyor observed the lift involved in the incident on 9/17/2014 at 3 PM and 3:52 PM, in the West Unit corridor. On 9/18/2014 at 9 AM, corporate maintenance staff, stated to the surveyor, the manufacturer was contacted, the specific lift involved in the incident was taken out of service on 9/18/2014, and a representative was being sent by the manufacturer to check the lift. The undated Operating Instructions from the lift manufacturer documented there was a 7 cm long bolt in the center of the spreader bar, projecting up into the U joint at the center of the spreader bar. The instructions documented the lifts should be inspected monthly to checks bolts and hooks for wear and/or damage. The current undated Preventative Maintenance Program policy did not address mechanical lifts. 2) Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 4/22/2014, documented the resident was cognitively intact, required limited to extensive assistance with activities of daily living (ADL), used a wheelchair and was independent in locomotion on and of the unit. The MDS recorded the resident had recent falls with injury. A nursing note, dated 4/19/2014 at 4:15 PM, documented the resident dropped an item on the floor, bent to pick it up and slipped out of the wheelchair. The note recorded the resident was not injured. A nursing note dated 4/20/2014 at 11:30 AM, documented the resident dropped her Ipod, slipped out of the wheelchair, and hit her head. The resident displayed signs of right sided weakness and was sent to the hospital for evaluation. The physical therapy (PT) note dated 4/21/2014, documented the resident had Dycem (a slip resistant surface) and a cushion in the wheelchair. The PT recorded the cushion was moved to the resident's recliner and a new piece of Dycem was added to the seat of the recliner. A nursing note, dated 6/30/2014 at 11 AM, documented the resident slipped out of the recliner and was found on the floor. There was no documented evidence the CCP was followed, or evaluated for effectiveness as the facility could not provide former/inactive CCPs documenting interventions implemented at the time of the resident's falls. A nursing note, dated 8/9/2014 at 9:45 PM, documented the resident slipped out of the wheelchair after being wheeled from bathroom. The note recorded the resident was not injured. Review of the incident report dated 8/9/2014 documented the resident slipped out of the wheelchair while being wheeled to bed. The report documented the resident's CCP was followed, and recommended the resident be assisted to bed earlier. A nursing note, dated 8/10/2014 at 9:30 AM, the resident complained of left hip pain. The resident was sent to hospital, and was diagnosed with [REDACTED]. The fall risk assessment, dated 8/12/2014, documented the resident was at low risk. The CCP dated 8/14/2014 documented the resident was at risk for falls and would remain free from injury. Interventions included to keep the call light within reach, encourage the resident to use it, bed and chair alarms, verbal reminders to not transfer or ambulate independently, and the assistance of two for transferring and bed mobility. The CCP did not document the use of Dycem in the wheelchair or recliner. The current, undated, Plan of Care documented the resident was propelled by staff when in the wheelchair. The care instructions did not document the use of Dycem in the resident's recliner or wheelchair. During an interview, on 9/16/2014 at 10 AM, the resident stated she had recent falls, and fractured her hip. The resident stated that she used her call bell all the time but the staff were too busy helping other residents. During an observation, on 9/16/2014 at 2:45 PM, the resident was seated in a wheelchair, at the foot of the bed, with a table in front of her, coloring. She attempted to pick a crayon up from the floor without success. She sat back up in a misaligned position, and requested help with repositioning. The resident stated to the surveyor she was not able to reach her call bell to ask for assistance. The cord of the call bell was at the head of the bed underneath the blanket. During an interview with the MDS coordinator, on 9/18/2014 at 10 AM, she stated the resident's CCPs were purged from the medical record when new CCPs were developed on 8/14/2014. She stated they could not locate the old CCP for review, was unsure what happened to them, or what interventions were in place when the resident fell on [DATE], 4/20/2014 and 6/30/2014. During an interview with PT assistant #18, on 9/18/2014 at 3:30 PM, she stated she did not see any physical therapy referrals for the resident after 4/21/2014. 3) Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. The resident required extensive assistance of two for bed mobility, transferring, toileting, and bathing. The MDS documented the resident had one "Stage 3" pressure ulcer and impairments of both arms and legs. The CCP, dated 9/11/2014, documented the resident was at risk for falling and the goal was for the resident to remain injury free. Interventions included repositioning per the Plan of Care (care instructions used by the caregiver) certified nurse aide (CNA). The resident's undated care instructions documented the resident required total assistance of two or more for bed mobility, turning, and repositioning. The care instructions documented the resident was at risk for falls, had weakness/paralysis of both arms and legs, and contractures of both arms and hands. Physician orders [REDACTED]. During a pressure ulcer dressing change observation on 9/18/2014 at 10:25 AM the licensed practical nurse (LPN): - raised the resident's bed to the highest position; - turned and positioned the resident on the right side approximately 3 inches from the edge of the bed; - held the resident's hip with her left hand and provided the treatment as ordered; and - pulled the resident's brief up, then turned and positioned her on her back. The LPN was interviewed immediately after the pressure ulcer dressing change, and stated the resident required one staff member for repositioning in bed. She stated she did not feel it was unsafe to position the resident on her side that close to the edge of the bed without assistance from another staff member. The LPN stated she reviewed the care instructions and did not require assistance with turning and positioning the resident in bed. When interviewed on 9/19/2014 at 11 AM, the LPN Unit Manager stated the resident was to be repositioned with the assistance of two staff. She stated it was unsafe for one staff to turn the resident onto her side and provide pressure ulcer care. The Unit Manager stated another staff should have been on the opposite side of the bed to prevent the resident from rolling. 10NYCRR 415.12(h)

Based on interview and record review conducted during the standard survey and abbreviated survey #NY 633, it was determined for 5 of 5 mechanical lifts (2 sit to stand and 3 for non weight bearing residents) the facility did not ensure patient care equipment was in safe operating condition. Specifically, after a mechanical lift malfunctioned, resulting in a fall with injury to Resident #1, the facility did not document a preventative maintenance program for mechanical lifts, or the steps taken to ensure that specific lift did not malfunction again. This resulted in actual harm, to Resident #1 who was injured when the lift malfunctioned, that is not immediate jeopardy. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The undated Plan of Care (care instructions used by the caregivers) documented the resident required the use of a mechanical lift and two staff members for transferring. The nursing progress note dated 9/7/2014 at 10 PM, documented the resident was found lying on her back on the floor of her room with the metal bracket of the mechanical lift across her chest. The note recorded the certified nurse aides (CNA) reported the bolt holding the metal bracket came out causing the resident to fall from a high position onto her back hitting her head. The resident was transferred to the hospital for evaluation. The emergency department discharge report dated 9/7/2014 documented the resident had a hematoma (a swollen area filled with blood) on her head. During an interview with Maintenance Director on 9/17/2014 at 2:45 PM, he stated: - there were currently 5 mechanical lifts in the building; - each unit had a sit to stand lift; - east unit had a lift for residents unable to bear weight; - west unit had 2 lifts for residents unable to bear weight; - all of the lifts in use were Brand A; - he was not aware of any preventative maintenance program for mechanical lifts prior to the incident on 9/7/2014; - there currently was a preventative maintenance program for the lifts, which began after the resident's fall; and - one lift was checked each week, resulting in each lift being checked once every 5 weeks. Maintenance staff #1 was interviewed on 9/17/2014 at 2:55 PM, and stated he worked in the facility before the current Maintenance Director was hired. He stated he was not aware of a preventative maintenance program for mechanical lifts before a lift malfunctioned on 9/7/2014. He said he checked the Brand B lift that failed on 9/7/2014, and that the bolt projecting upward through the spreader bar had fallen out. Observations made on 9/17/2014 at 3 PM and 3:52 PM showed the Brand B lift involved in the incident was in the West Unit corridor. There was an upfacing bolt in the center of the spreader bar of the lift. On 9/18/2014, corporate maintenance staff stated the manufacturer of the Brand B lift was contacted, and the specific lift involved in the incident was taken out of service today. A representative was being sent by the manufacturer to check the lift. The undated Operating Instructions from the Brand B lift manufacturer documented there was a 7 cm long bolt in the center of the spreader bar, projecting up into the U joint (at the center of the spreader bar) and the Jib (arm holding the person being lifted away from the upright part of the lift). Brand B lifts should have been inspected monthly to checks bolts and hooks for wear and/or damage. The undated Owners Operator and Maintenance Manual for the Brand A lift documented the lift was to be inspected monthly, including inspection of the bolt in the center of the spreader bar. The facility's current, undated Preventative Maintenance Program policy did not address mechanical lifts. The undated form titled "Hoyer Lift - Sit to Stand Maint Sched." listed the 5 lifts in use at the facility, the rest of the form was blank. There was no documented evidence the facility implemented the manufacturer's recommendations for preventative maintenance of the mechanical lifts. 10NYCRR 415.29(b)