Every finding on record at The Grand Rehabilitation and Nursing at Mohawk

Based on observations, record review, and interviews during the abbreviated (IQIES 2600078) survey, the facility failed to ensure a resident received adequate supervision and assistance devices for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 required supervision at meals due to hyperphagia (insatiable hunger) and dysphagia (difficulty swallowing) and was on aspiration precautions (inhaling food into the lungs). Specifically, the resident was left unattended in the dining room on 08/23/2025 with access to inappropriate food consistency and the Resident began choking, showed signs of distress, and staff did not intervene to assist the resident. The resident was discovered unresponsive approximately 90 minutes later and was pronounced deceased after cardiopulmonary resuscitation was attempted. This resulted in Immediate Jeopardy to Resident #1 and placed 29 residents requiring supervision at meals at risk for the likelihood of serious harm, serious impairment, serious injury, or death.Findings include: The facility policy Aspiration Precautions, revised 03/2025 documented a dietitian, speech language pathologist or licensed nurse would be present during meals and consumption of intake to monitor for signs of choking or aspiration. Resident #1 was admitted to the facility on [DATE] and had diagnoses including aspiration pneumonia, progressive hyperphagia, and dysphagia. The Minimum Data Set assessment had not yet been completed. The 08/20/2025 physician admission orders documented Full Code (perform cardiopulmonary resuscitation) and a diet of regular ground texture, honey consistency liquids with aspiration precautions. The 08/21/2025 at 08:21 AM Speech Language Pathologist #4 screening documented the resident had loss of liquids/solids from mouth, was holding food in their mouth/cheeks and had pain with swallowing. The current diet order was ground, honey thick liquids with aspiration precautions. The 08/21/2025 Speech Language Pathologist #4 progress note documented aspiration precautions, maroon spoon (adaptive utensil), 1:1 supervision to implement strategies, out of bed for all meals, maintain upright position for 30 minutes after meals, encourage small bites/sips, reduce rate, alternate liquids/solids, double swallow, lingual sweep, and throat clear with swallow. The 08/21/2025 Diet Technician #18 dietary progress note documented the resident perseverated (to recur or repeat continually) about food. Speech Therapy recommended aspiration precautions, maroon spoon for pacing along with feeding techniques. The Comprehensive Care Plan initiated on 08/21/2025 documented the resident required a mechanically altered diet and perseverated on, food/eating/feeling hungry. Interventions included to provide diet as ordered and maroon spoons for pacing. The Comprehensive Care Plan did not include documentation related to aspiration precautions or specialized feeding techniques. The undated Kardex (care instructions) documented a ground diet with honey thick liquids, and aspiration precautions. The resident's assistance with feeding was not included in the Kardex. The 08/21/2025 Nurse Practitioner #19 progress note documented the resident was dependent on a feeding tube but tolerated a modified diet with supervised oral intake.The 08/25/2025 Investigative Summary completed by the Director of Nursing documented that on 08/23/2025 at 3:15 PM, Resident #1 was found in the dining room unresponsive with no signs of life. A Code Blue (emergency response) was called, the resident was taken to their room and cardiopulmonary resuscitation was initiated. Emergency Medical Services arrived, immediately called the hospital and received an order to cease cardiopulmonary resuscitation, and the resident was pronounced deceased . The conclusion of the investigation documented the meal consistency served to the resident during lunch was accurate. Review of the camera footage showed the resident waving their arm and pounding on their chest, which went unnoticed by Dietary Aide #11 and Housekeeper #5 who were present in the dining room at the time. The investigation documented, it was not seen and could not be determined on video footage the resident consumed anything prior to the event, and it was the facility's belief the resident regurgitated and choked on their vomit.The 08/23/2025 lunch meal tickets documented: -Resident #1 received a ground diet with honey thick liquids, required two maroon spoons, and was on aspiration precautions. The resident received mashed potatoes, ground cauliflower, yogurt, and ground mixed fruit.-Resident #4, who was seated next to Resident #1 during the meal was given a regular diet of Swedish meatballs, brown gravy, noodles, cauliflower and mixed fruit. The facility's 08/23/2025 surveillance videos from the second-floor dining room from 12:00 PM through 3:30 PM and the Nursing Station from 2:40 PM to 2:50 PM was reviewed. The following was observed:-From 12:10 PM to 1:23 PM, Resident #1 was in the dining room seated to the right of Resident #4 and across from Resident #3. Certified Nurse Aides #7, #8, and #9 served residents' lunch. There were no licensed nurses in the dining room. At 12:41 PM, Resident #1 was served their food and was not assisted with eating.-From 1:24 PM to 1:32 PM, Resident #1 remained in the dining room. Residents #3 and #4 left and their plates remained on the table. Licensed Practical Nurses #2 and #6 entered the dining room and were observed talking to Resident #1 and Certified Nurse Aide #9. At 1:32 PM, both licensed practical nurses left the dining room and Certified Nurse Aides #8 and #9 remained in the dining room feeding other residents.-At 1:34 PM and 1:37 PM, Resident #1 was observed reaching over and taking food from Resident #4's plate with their fork. -At 1:37 PM, Certified Nurse Aide #9 wheeled another resident out of the dining room, Resident #1 reached over and pulled Resident #4's plate toward them and was observed removing something from the plate. The remaining staff member in the dining room was Dietary Aide #11.-From 1:38 PM - 1:41 PM, Resident #1 was waving their arms around and banging on their chest. Dietary Aide #11 looked in the direction of the resident several times, did not intervene, and continued to clear dishes from a table. The resident's head then slumped to the left side with slight movements of the head.-At 1:42 PM, Resident #1 ceased any further movement.-At 1:43 PM, Licensed Practical Nurse #2 entered the dining room and looked at Resident #1 as they passed by, did not appear to say anything, and several seconds later walked back past the resident and out of the dining room.-At 1:46 PM, Housekeeper #5 swept and mopped the floor around Resident #1's table and did not appear to look at the resident.-From 1:56 PM - 2:00 PM, Dietary Aide #11 cleared the dishes from Resident #1's table.-From 2:00 PM - 3:14 PM, Resident #1 remained in the dining room while several staff members entered and exited the dining room. No one was observed approaching the resident. -From 3:15:56 PM - 3:16:15 PM, Certified Nurse Aide #14 entered the dining room toward Resident #1. They looked at the resident, bent over to look closer and walked out of the dining room toward the nursing station.-At 3:16:36 PM, Certified Nurse Aide #14 returned with Licensed Practical Nurse #13, who appeared to look closely at Resident #1. At 3:16:57 PM, Licensed Practical Nurse #13 left the dining room walked toward the nursing station and returned to the resident at 3:17:58 PM. They pushed the table away from the resident and along with Certified Nurse Aide #14 bent over the resident. Certified Nurse Aide #8 and Licensed Practical Nurse #17 entered the dining room. Licensed Practical Nurse #17 was on a cellphone. At 3:18: 34 PM, they wheeled the resident out of the dining room.The 08/23/2025, Change in Condition Evaluation documented Resident #1 was found unresponsive in the dining room, cardiopulmonary resuscitation and code blue were initiated. Emergency Medical Services was called at 3:19 PM and arrived at 3:25 PM. Resident #1 was pronounced deceased at 3:29 PM after Emergency Medical Services called the hospital. The 08/29/2025, Police Report documented upon review of the Death Certificate the cause of death was asphyxia (lack of oxygen) due to obstruction of the airway with a meatball.During an interview on 08/28/2025 at 12:48 PM, Certified Nurse Aide #1 stated they knew a resident was on aspiration precautions as it was on their meal ticket. Aspiration precautions meant you had to stay with the resident while they ate and not leave them alone with their food. During an interview on 08/28/2025 at 1:45 PM, Licensed Practical Nurse #2 stated during meals they were responsible for meal tickets and staying in the dining room while the residents ate. If a resident was on aspiration risk, it was documented on their meal ticket and on the Medication Administration Record. They would make sure the resident had the correct food and liquid consistency. On 08/23/2025, they were assigned to supervise lunch in the dining room but were doing a treatment with another resident. Their orientee, Licensed Practical Nurse #6, stayed in the dining room and told them they supervised the dining room before. When they went into the dining room during lunch, Licensed Practical Nurse #6 was there, and Certified Nurse Aide #9 was feeding another resident. At that time, they spoke to Resident #1, who was upset about not getting any milk and wanted more food. They explained to the resident dietary was done serving lunch. They left the dining room to restock their medication cart. Around 1:30 PM, they went back into the dining room to refill their water pitcher and Resident #1 was just sitting at the table. They told the resident they would let someone know to come get them, as residents were not supposed to be left in the dining room after they ate. At that time the resident was awake and breathing but did not respond to them. They went back to their medication cart and told the certified nurse aides at the desk to make sure everyone was out of the dining room. During an interview on 08/29/2025 at 8:30 AM, Speech Language Pathologist #4 stated Resident #1 was admitted late on 08/20/2025. They were told the resident was on aspiration precautions, and 1:1 supervision with feeding, which meant a nurse should be with resident while feeding. On 08/21/2025, they reviewed the resident's record from the previous facility and noted they required 1:1 for swallowing cues, small bites and sips, alternating solids and liquids. They met with the resident who was alert and oriented. They did an initial screen on the resident and scheduled the full swallow evaluation for Monday. From the record, they were aware the resident pocketed food. They also observed during the screen the resident had an issue with saliva, which was also documented in the previous facility's record. They went to find a staff member to educate on the feeding strategies. There was only one certified nurse aide available, so they verbally told them about the resident's feeding strategies. Speech Language Pathologist #4 stated they were not able to put the strategies in the Eating Task so it would show up on the Kardex, as nursing staff did not initiate the task when the resident was admitted . They were previously told they were not able to initiate that task themselves. They put the resident's risks and feeding strategies in a progress note then clicked the button that would allow the note to be seen by all shifts. The Speech Language Pathologist stated they spoke to nursing about what the resident required, and expressed concerns about being able to provide the complex care the resident required. They indicated Resident #1 was not an appropriate admission for the facility based on the fact the resident required a licensed nurse for 1:1 with eating. During the 08/21/2025 shift, the Speech Language Pathologist verbally educated all the certified nurse aides about the resident's feeding strategies. They stated the resident was impulsive and should have 1:1 feeding and not be left in the dining room while there was food accessible to them. During an interview on 08/29/2025 at 9:50 AM, Housekeeper #5 stated they were in the dining room on 08/23/2025 between 1:30 PM - 2:00 PM. Resident #1 was in the dining room, and they did not see any nurses or certified nurse aides. There was vomit on the floor next to Resident #1 and they cleaned the floor around them but did not really look at the resident. The resident was making soft, gurgling sounds, but they did not think anything of it because a lot of residents made noises. They did not see the resident wave their arms around at any time. During an interview on 08/29/2025 at 10:40 AM, Licensed Practical Nurse #6 stated they worked on 08/23/2025 and were orienting with Licensed Practical Nurse #2. They were in the dining room for a short period of time and Licensed Practical Nurse #2 talked to Resident #1, who was upset about not getting milk. Licensed Practical Nurse #2 told the resident they could not change their diet and would notify dietary, which calmed the resident down. Licensed Practical Nurse #6 stated they did not stay in the dining room after that and was not told by anyone they were responsible to stay in the dining room to monitor the residents while they ate. There were certified nurse aides in the dining room. During an interview on 8/29/2025 at 11:00 AM, Certified Nurse Aide #7 stated on 08/23/2025 during the day shift there were four (4) certified nurse aides, and they split the two (2) hallways, two (2) assigned to the North side and two (2) to the South side. They were assigned the North side with Certified Nurse Aide #9, and they were both assigned to Resident #1. Resident #1 would say all day I want food. They toileted Resident #1 around 11:00 AM when they had slipped out of their wheelchair, but did not provide any care prior to that. Certified Nurse Aide #7 stated they were in the dining room for lunch, setting up trays and checking meal tickets. There were no nursing staff in the dining room for the lunch meal and very rarely did a nurse come in during meals. Resident #1 was able to feed themselves. During lunch the resident was upset about not being given milk and wanted more food. They gave the resident chopped meatballs and chopped noodles. The last time they saw the resident was at 1:45 PM, playing on their phone and they did not believe the resident had any food left in front of them. They did not provide the resident any care after lunch and took over doing a 1:1 for another resident at 2:00 PM. During an interview on 08/29/2025 at 11:20 AM, Certified Nurse Aide #8 stated they were in the dining room for lunch on 08/23/2025. They assisted with passing trays. They did not pass a tray to Resident #1, but knew the resident was able to feed themselves and was not assisted with eating. There were no nurses in the dining room. No one provided 1:1 supervision to the resident during meals. Nurses were rarely in the dining room during meals as they had to pass medications. Earlier that day they assisted with cleaning the resident's chair pad, after they had slid out of the wheelchair, as it was soaked in urine. The resident had been in a gown all day and did not know why no one got them dressed as they did have clothes. During an interview on 8/29/2025 at 11:35 AM, Certified Nurse Aide #9 stated they brought Resident #1 into the dining room on 08/23/2025 for lunch but food had not been served yet. When Resident #1 got their meal, they did not like what they had, and they were given chopped meatballs and noodles. They did not assist the resident with eating their meal. Aspiration precautions were on meal tickets, and they were not aware of any special instructions for feeding Resident #1. The licensed nurses were in and out of the dining room that day. Licensed Practical Nurse #2 did come in at one point to explain to Resident #1 why they could not have milk. After that, they were in the dining room for another 30 minutes feeding another resident. They left the dining room around 1:20 PM to do afternoon care on other residents and Resident #1 was still eating. They were helping other aides and did not provide any afternoon care to Resident #1. They usually checked and changed the resident but the last time they changed Resident #1 was around 11:45 AM. They left their shift at 2:15 PM. During an interview on 08/29/2025 at 11:55 AM, the Director of Nursing stated a resident with aspiration precautions needed to be out of bed for meals and supervised in the dining room. Before the incident with Resident #1, a licensed nurse was not required to be in the dining room, it could be a certified nurse aide. Aspiration precautions were written on their meal ticket. The specialized feeding instructions for Resident #1 were not communicated as Speech Language Pathologist #4 did not initiate the task so the instructions did not show up on the Kardex. They watched the 08/23/2025 lunch video and staff did feed the resident their meal. There were multiple staff in and out of the dining room and the resident remained in the dining room until Certified Nurse Aide #14 found the resident at 3:15 PM. Dietary Aide #11 admitted to them they knew Resident #1 was in distress as per the video they looked right at the resident, and they did not report it. Housekeeper #5 cleaned up vomit around the resident and did not report it. Both staff were suspended. During an interview on 08/29/2025 at 1:00 PM, Dietary Aide #11 stated on 08/23/2025, they were in the dining room picking up dishes after lunch. Resident #1 remained in the dining room, and they thought the resident was sleeping. They did not notify anyone the resident was still in the dining room. There was a certified nurse aide in the dining room who saw the resident too. They did see Resident #1 waving their hands around. They assumed the resident was just waving their hands around. They did not speak to the resident. They picked up some drinks in front of the resident at around 1:00 PM or 2:00 PM but could not remember if there was food or plates. During an interview on 08/29/2025 at 1:20 PM, the Medical Director stated they were informed on 08/25/2025 about Resident #1's passing and was told they did not eat anything prior to the incident. They were not aware of all the details, or that the resident was on aspiration precautions. If a resident was on aspiration precautions, they were usually followed by the speech language pathologist, and they would follow their recommendations. All staff should be aware of aspiration precautions and follow appropriate orders. They were unsure of the facility policy for the presence of licensed nursing staff in the dining room during meals. They stated without knowing all the facts of the incident they could make no further comments.During an interview on 08/29/2025 at 4:00 PM, the Administrator stated they were notified on the evening of 08/23/2025 of what happened to Resident #1. There was a procedural breakdown with communicating a resident's needs for eating. Before the incident, the registered nurse or licensed practical nurse would only be in the dining room for meal set up and were not required to be present while residents were eating. They had not shared the investigation with the Medical Director yet but did let them know what happened. They did not know the resident's cause of death but speculated Resident #1 vomited and had silent aspiration, given the resident's previous history of vomiting. They met with Resident #1 and their family member upon admission. The family member expressed concerns related to the resident falling so they put the resident on a 1:1 to see how they acclimated to the facility. After two (2) days they discontinued the 1:1 because the resident seemed to be doing well, and the resident was not sneaking food. Sneaking food was not an identified concern mentioned by the family member, just that the resident had a history of getting up in the night. During an interview on 09/03/2025 at 5:10 PM, Licensed Practical Nurse #17 stated Resident #1 was admitted to the facility on a 1:1 always, as they would go after everyone's food. After a couple of days, the 1:1 was discontinued. The resident was independently mobile in their wheelchair and required more supervision than the facility could provide. The resident was up the night before constantly asking for food. -------------------------------------------------------------------------------------------------------------------------------Immediate Jeopardy was identified, and the Administrator was notified on 08/29/2025 at 5:00 PM. Prior to survey exit the Administrator was notified on 08/30/2025 at 12:30 PM the Immediate Jeopardy was lifted based on the following corrective action plans:-All staff were educated on Aspiration Precautions, Dining Supervision, and Notification of Change in Condition. The facility attestation documented 87% of staff were educated with a plan to educate the remaining staff prior to the beginning of their next work assignment. The educational presentation was reviewed by New York State Surveyors and determined to be complete and an acceptable plan.-Staff interviews conducted on 08/30/2025 verified understanding and retention of education provided.10 NYCRR 415.12(h)(2)

Based on observations, record review, and interviews during the abbreviated (IQIES 2600078) survey, the facility did not ensure provision of emergency basic life support immediately when needed, for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 was found in the dining room unresponsive and without a pulse and staff did not initiate cardiopulmonary resuscitation (chest compressions and rescue breathing) immediately and moved the resident to their room to start cardiopulmonary resuscitation.Findings include: The facility policy Cardiopulmonary Resuscitation. revised 02/2024, documented the facility would ensure personnel completed training on the initiation of cardiopulmonary resuscitation and basic life support, including defibrillation, for victims of sudden cardiac arrest. If a resident was found unresponsive and not breathing a licensed staff member who was cardiopulmonary resuscitation certified shall initiate cardiopulmonary resuscitation unless there is a do not resuscitate order and there are obvious signs of irreversible death.Resident #1 was admitted to the facility on [DATE] and had diagnoses including aspiration pneumonia, progressive hyperphagia (excessive hunger) and dysphagia (difficulty swallowing). The [DATE] physician admission orders documented Full Code (perform cardiopulmonary resuscitation). The [DATE] facility surveillance videos from the second floor dining room from 12:00 PM through 3:30 PM was reviewed. The following was observed:-From 3:15:56 PM - 3:16:15 PM, Certified Nurse Aide #14 entered the dining room toward Resident #1. They looked at the resident, bent over to look closer and walked out of the dining room toward the nursing station.-At 3:16:36 PM Certified Nurse Aide #14 returned with Licensed Practical Nurse #13, who appeared to examine Resident #1. At 3:16:57 PM, Licensed Practical Nurse #13 left the dining room walked toward the nursing station and returned to the resident at 3:17:58. They pushed the table away from the resident and along with Certified Nurse Aide #14 bent over the resident. Certified Nurse Aide #8 and Licensed Practical Nurse #17 entered the dining room. Licensed Practical Nurse #17 talked on a cellphone. At 3:18: 34, they wheeled the resident out of the dining room. The [DATE], Change in Condition Evaluation documented Resident #1 was found unresponsive in the dining room, cardiopulmonary resuscitation and code blue were initiated. Emergency Medical Services was called at 3:19 PM and arrived at 3:25 PM. Resident #1 was pronounced deceased at 3:29 PM after Emergency Medical Services called the hospital. During an interview on [DATE] at 2:45 PM Registered Nurse #3 stated on [DATE] they arrived at the facility at 2:45 PM. They received a text from Licensed Practical Nurse #17 to call them, they called back at 3:21 PM and the call was not answered. They headed to the resident's floor and received a call back the resident was unresponsive. When they arrived, the resident was on their bed on a backboard and Licensed Practical Nurse #13 was doing chest compressions. Registered Nurse Unit Manager #15 was present in the room. Certified Nurse Aide #14 was getting the crash cart and Licensed Practical Nurse #17 called Emergency Medical Services at about 3:19 PM. Emergency Medical Services arrived at approximately 3:25 PM. When they arrived, they inspected the resident's legs and stated the resident was cold to the touch, called the hospital, and the physician in the Emergency Department called time of death at 3:29 PM.During an interview with the Director of Nursing #10 on [DATE] at 11:55 AM they stated staff should have done cardiopulmonary resuscitation right there in the dining room, but they did not. During an interview with Licensed Practical Nurse #13 on [DATE] at 2:15 PM they stated when they started their shift on [DATE] at 2:15 PM they were given report. Around 3:00 PM Certified Nurse Aide #14 told them Resident #1 was in the dining room and was not responding. They entered the dining room and the resident's head was to the side. The resident did not have a pulse. The left the dining room to look at the resident's Medical Orders for Life-Sustaining Treatment Form, but the resident did not have one, but they knew the resident was a Full Code as they checked their orders the night before and again checked at the time. They returned to the dining room and was going to put the resident on the floor but there were residents coming in and out of the dining room, so they decided to take the resident to their room. The resident's legs were cold, but their upper body was warm. Licensed Practical Nurse #17 was instructed to call the supervisor, call 911 and get the crash cart. Once they got the resident in the bed, they put the board behind the resident and started chest compression. Emergency Medical Services arrived shortly after that, and said the resident had been dead a long time. Emergency Medical Services went to make a call to the hospital and got an order to stop cardiopulmonary resuscitation and they called the time of death. Licensed Practical Nurse #13 did not believe moving the resident to their room to do cardiopulmonary resuscitation caused a delay in emergency response. During an interview on [DATE] at 1:20 PM the Medical Director stated cardiopulmonary resuscitation should be started immediately at the point of care. 10NYCRR 415.3(e)2)iii

Based on observations, record review, and interviews during the abbreviated (IQIES #2600078) survey the facility did not implement a comprehensive person-centered to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for one (1) of three (3) residents (Resident #1) reviewed. Specifically, Resident #1 was left in the dining room after the lunch meal ended, and staff did not assist with toileting as planned. Findings include: The facility policy Care Plans, Comprehensive Person-Centered, reviewed 1/2025, documented the comprehensive care plan would describe the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and reflect currently recognized standards of practice for problem areas and conditions. The facility policy Resident Care with Activities of Daily Living, reviewed 1/2025, documented residents on a toileting program will be offered assistance every 2-4 hours and as needed. Staff would document resident toilet use in the certified nurse aide accountability record. Preparation included to review the resident's care plan to assess for any special needs. Resident #1 had diagnosis including aspiration pneumonia (inhaling matter into the lungs), progressive hyperphagia (insatiable hunger) and dysphagia (difficulty swallowing). The Minimum Data Set assessment had not been completed.The 8/20/2025 admission Evaluation completed by Registered Nurse #20 documented the resident had intact cognition, was incontinent of bladder related to acute condition, and required substantial/maximal assistance with toileting.The 08/23/2025 at 11:10 AM Incident Report documented Resident #1 was witnessed sliding out of their wheelchair and landing on the floor. The resident did not strike their head. The resident was assessed by Registered Nurse #15 to have no injuries. The resident was soaked in urine and incontinence care was provided at the time. Interventions to prevent reoccurrence included to check and change every two hours, report any refusals, document the resident was checked every two hours and whether the resident was wet or dry. A 08/23/2025 at 12:00 PM verbal order documented check and change the resident every two hours to maintain skin integrity. The 8/23/2025 Comprehensive Care Plan documented to check and change every two hours and as needed, document if resident was wet/dry and any refusals for incontinence care.The Kardex (care instructions) as of 8/28/2025 documented check and change every two hours and as needed, document if resident is wet/dry and any refusal for incontinence care. The Certified Nurse Aide Activities of Daily Living Report documented on 08/23/2025 Resident #1 was provided bathing and personal hygiene activities at 9:45 AM and toileting at 11:36 AM, by Certified Nurse Aide #9.The Treatment Administration Record documented beginning on 08/23/2025 at 12:00 PM to check and change the resident every two hours. At 12:00 and 2:00 PM, Licensed Practical Nurse #2 documented the resident was checked and wet.The facility's 08/23/2025 surveillance videos from the second-floor dining room from 12:00 PM through 3:30 PM was reviewed. The following was observed:-From 12:10 PM - 3:15 PM, Resident #1 was seated in the dining room. No staff checked or provided care to the resident. At 3:15 PM, Certified Nurse Aide #14 entered the dining room and found the resident unresponsive. There was no documented evidence the resident was toileted every two hours as planned from 12:10 PM-3:15 PM. During an interview on 08/28/2025 at 1:45 PM Licensed Practical Nurse #2 stated on 8/23/2025 at around 1:30 PM, they went into the dining room to refill their water pitcher and Resident #1 was still sitting at the table. They told the resident they would let someone know to come get them, as residents were not supposed to be left in the dining room after they ate. They went back to their medication cart and told the certified nurse aides at the desk to make sure everyone was out of the dining room. During an interview on 8/29/2025 at 11:00 AM Certified Nurse Aide #7 stated on 8/23/2025 during the day shift there were four certified nurse aides, and they split the two hallways, two assigned to the Northside and two to the Southside. The were assigned the Northside with Certified Nurse Aide #9 and they were both assigned to Resident #1. They toileted Resident #1 around 11:00 AM when the resident slipped out of their wheelchair but did not provide any care prior to that. The last time they saw the resident was at 1:45 PM. They did not provide the resident any care after lunch and took over doing a one to one for another resident at 2:00 PM. During an interview on 8/29/2025 at 11:20 AM Certified Nurse Aide #8 stated earlier in the day on 8/23/2025 they assisted with cleaning the resident's chair pad after they slid out of their wheelchair, as it was soaked in urine. During an interview on 8/29/2025 at 11:35 AM Certified Nurse Aide #9 stated on 8/23/2025 they left the dining room around 1:20 PM to do afternoon care on other residents and Resident #1 was still eating. They did not provide any afternoon care to Resident #1 as they were helping other aides. They usually checked and changed the resident but the last time they changed Resident #1 on 8/23/2025 was around 11:45 AM. They left their shift at 2:15 PM. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00340946 and NY00374215) surveys conducted 6/23/2025-6/30/2025, 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 five (5) of eight (8) residents (Residents #7, #23, #55, #57, and #75) reviewed. Specifically, Residents #23 was not provided with shaving and showers as planned; Resident #75 did not receive assistance at meals as planned; Residents #57 and #7 had unclean fingernails; and Resident #55 was not offered a lunch meal. Findings include: The facility policy Assistance with Meals, last reviewed 1/2025, documented residents would receive assistance with meals in a manner that met the individual needs of the resident. Facility staff would serve residents meal trays and help residents who required assistance with eating. The facility policy Shower/Tub Bath, last reviewed 1/2025 documented the date and time the shower was performed, the name and title of the individual who assisted the resident would be recorded on the resident's activities of daily living record. If the resident refused the shower the reason why and interventions taken would be recorded. The facility policy Care of Fingernails/Toenails, reviewed 1/2025 documented nail care included daily cleaning and regular trimming. 1) Resident #23 had diagnoses including fracture of the left hand and wrist. The 6/4/2025 Minimum Data Set assessment documented the resident was cognitively intact, required substantial/maximal assistance for showering/bathing, supervision or touching assistance with personal hygiene, and did not reject care. The Comprehensive Care Plan initiated 2/26/2025 documented the resident was at risk for functional decline in mobility and self-care related to a fractured left wrist. Interventions included substantial/maximal assistance with showering/bathing, and partial/moderate assistance with personal hygiene. The Unit 2 shower schedule documented Resident #23 was to receive a shower on Tuesdays during the day shift. During an observation and interview on 6/23/2025 at 1:11 PM, Resident #23 was lying in their bed with thick, long white hair covering their chin. The resident stated they would like to have their facial hair trimmed or shaved. Staff did not often help them, they did not receive weekly showers, and they were unsure when they last received a shower. The June 2025 activities of daily living record documented: - the resident did not receive a shower on Tuesday during the day shift on 6/3/2025, 6/10/2025, and 6/17/2025. - the resident received supervision or touching assistance with personal hygiene during the day shift on 6/11/2025 by Certified Nurse Aide #44, 6/16/2025 by Certified Nurse Aide #45, and 6/26/2025 by Certified Nurse Aide #46. There was no provision of care documented 6/1/2025-6/10/2025, 6/12/2025-6/15/2025, and 6/18/2025-6/25/2025. During an interview on 6/27/2025 at 11:58 AM, Certified Nurse Aide #15 stated certified nurse aides were responsible for completing personal hygiene care in the morning and at night. Personal hygiene consisted of oral care, dressing, hair care, shaving, and a bed bath since showers were usually completed weekly. At the end of the day, they documented in the computer all care that was provided throughout their shift and if a resident refused any care, they documented the refusal. If the care documentation was left blank it could mean it was not completed. They cared for Resident #23 on 6/24/2025 during the day shift. They noticed how long and thick the resident's facial hair was and the resident told them they had not been shaved or received a shower in a while. During an interview on 6/27/2025 at 11:50 AM, Registered Nurse Unit Manager #5 stated showers were completed weekly on the resident's shower day and personal hygiene was completed by certified nurse aide's multiple times throughout the day. When staff signed off that personal hygiene was completed it meant they provided oral care, shaving, dressing, grooming, and they washed the resident. If a resident refused any care during the shift the certified nurse aide should document the refusal and let the nurse know so they could follow up with the resident. If care documentation was left blank there was no way to prove it was completed. They were not made aware of Resident #23 not receiving showers, refusing any care, and they did not notice their long facial hair. It was important for all residents to receive showers and personal hygiene care to maintain their dignity. During an interview on 6/27/2025 at 1:19 PM, Licensed Practical Nurse #22 stated certified nurse aides provided personal hygiene care multiple times throughout the day, but it was always done in the morning and at night. Showers were done weekly, and the certified nurse aides were expected to complete resident showers on their scheduled shower day. If a resident refused a shower or personal hygiene care they should be notified so they could approach the resident. The certified nurse aides were expected to document all refusals if care was not completed. They were not made aware of Resident #23 refusing personal care or showers. It was important for Resident #23 to receive their scheduled showers for infection control reasons and to be shaved for their dignity. 2) Resident #57 had diagnoses including congestive heart failure, anxiety, and depression. The 4/11/2025 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, and required supervision/ touching assistance with personal hygiene. The Comprehensive Care Plan initiated 10/2/2023 documented the resident required assistance with self-care related to limited mobility. Interventions included supervision/ touching assistance with personal hygiene. The current care instructions documented the resident required supervision/ touching assistance with personal hygiene and with bathing. The resident was to receive a shower/ bath on Mondays during the 2:00 PM-10:00 PM shift. The June 2025 activities of daily living log documented the resident received supervision or touching assistance with personal hygiene during the day shift: - on 6/23/2025 at 1:59 PM, by Certified Nurse Aide #41. - on 6/24/2025 at 10:47 AM, by Certified Nurse Aide #42. - on 6/25/2025 at 1:59 PM, by Certified Nurse Aide #43. - on 6/26/2025 at 11:14 AM, by Certified Nurse Aide #33. Resident #57 was observed with a dark substance under their fingernails: - on 6/23/2025 at 10:39 AM. - on 6/24/2025 at 2:10 PM. - on 6/25/2025 9:27 AM, 11:53 AM, and at 12:58 PM while eating a hot dog. - on 6/26/25 at 11:00 AM, and 12:37 PM in the main dining room eating a hamburger. During an interview on 6/26/2025 at 1:04 PM, Certified Nurse Aide #33 stated each resident had care instructions detailing the level of assistance they required. They were supposed to look at the resident's nails each day to ensure they were clean and not sharp. If the resident's nails were unclean, they should clean them and cut and file them if needed. They were assigned to Resident #57 at 11 AM today after the unit assignments were reassigned. They did not observe the resident's nails and did not provide any hand hygiene to the resident as they weren't assigned to the at the start of their shift. They were supposed to complete hand hygiene and look at the resident's nails to ensure they were clean and not sharp daily. It was important for the resident's nails to be clean for hygiene purposes. During an interview on 6/27/2025 at 1:03 PM, Registered Nurse Unit Manager #7 stated nail care should be completed weekly on shower days and as needed. It was important for the residents to have clean nails as it was an infection control, safety, and a dignity issue. 3) Resident #75 had diagnoses including dementia and failure to thrive (overall decline in health). The 6/9/2025 Minimum Data Set assessment documented the resident had severely impaired cognition and required maximum assistance with eating. The 2/25/2025 Comprehensive Care Plan documented the resident was at risk for functional decline in self-care and had potential nutritional problems related to progression of dementia. Interventions included full assistance at meals; out of bed for meals; ensure upright position during intake; aspiration precautions, encourage modification of bolus size; and alternate between solids and liquids during meals. Resident #75 was observed at the following times: - on 6/23/2025 at 12:46 PM at the dining room table. The resident had a meal tray placed in front of them but could not access the tray due to positioning at the table. The resident received no assistance with eating. - on 6/24/2025 at 12:42 PM seated at the table approximately 5 feet from their plate. The resident attempted to reach their food but was not able to reposition themselves effectively. The resident dragged their plate to the edge of the table using their finger to catch the lip of the adapted plate. The resident began eating their meal with the plate in their lap and used their fingers as a scoop. The resident attempted to reach their three drinks near the middle of the table but was unable. There were no staff assisting residents at the table during the meal. Certified Nurse Aide #27 removed the resident from the table without asking if they were done. Three full drinks were left untouched. During an interview and observation on 6/30/2025 at 12:20 PM License Practical Nurse #16 stated they were not aware of any specific instructions regarding mealtime assistance for the resident. The resident was poorly positioned and eating their mashed potatoes with a butterknife. License Practical Nurse stated that was unacceptable and the resident was not assigned to the table for the residents who required help. License Practical Nurse stated the resident did not usually require any queuing despite their cognitive impairment. During an interview and observation 6/30/2025 at 12:40 PM Registered Nurse # 5 stated staff should follow the resident's care plan which documented they required full assistance with meals. During an interview on 6/30/2025 at 1:04 PM Certified Nurse Aide #27 stated the resident usually fed themselves and they often ate with their plate in their hand. They stated all they needed was a spoon and they could feed themself. They would have helped them if they noticed they needed assistance. They stated they did not refer to the care plan as a guide as they just knew the resident. 10NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification survey conducted from 6/23/2025-6/30/2025, 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 three (3) of seven (7) residents (Residents #24, #32 and #51) reviewed. Specifically, Licensed Practical Nurse #6 administered medications through Resident #51's gastrostomy tube (a tube placed into the stomach to provide nutrition) without wearing required personal protective equipment; Resident #32 had a gastrostomy tube and staff did not utilize required personal protective equipment while providing a shower; and Resident #24 received hemodialysis (medical procedure to filter the kidneys) through a catheter and was not placed on enhanced barrier precautions. Findings include: The facility policy Enhanced Barrier Precautions, revised 1/2025, documented enhanced barrier precautions expanded the use of personal protective equipment and designated the use of gown and gloves during high-contact resident care activities that posed opportunities for the transfer of multidrug-resistant organisms. High contact resident care activities include, but not limited to dressing, bathing/showering, transferring residents that required extensive hands on assistance, changing linens, changing briefs or assisting with toileting that requires extensive hands on assistance, device care or use, and wound care (chronic wounds rather than skin tears and abrasions). Signage would be placed on the outside of the resident room with an isolation cart on the outside of the resident room. Residents were allowed to participate in group activities. The Enhanced Barrier Precautions were intended to be in place for the duration of the wound or discontinuation of the indwelling medical device that placed them at higher risk. 1) Resident #51 had diagnoses including gastrostomy tube and a tracheostomy. The 5/8/2025 Minimum Data Set assessment documented the resident had significantly cognitive impairment, was dependent with activities of daily living, and had a gastrostomy tube. The 6/27/2025 resident care instructions documented to implement isolation precautions when indicated, and enhanced barrier precautions every shift. The 1/23/2025 Physician Order documented to maintain enhanced barrier precautions every shift for tracheostomy and gastrostomy tubes. During an observation and interview on 6/26/2025 at 9:01 AM, Licensed Practical Nurse #6 administrated medications to Resident #51 through their feeding tube wearing gloves. Licensed Practical Nurse #6 did not wear a gown. Licensed Practical Nurse #6 stated the only time a gown was worn was if there was an open wound. They stated they were unclear of the parameters of enhanced barrier precautions. 2) Resident #32 had diagnoses including disorder of the esophagus, dementia, and malnutrition. The 4/4/2025 Minimum Data Set assessment documented the resident was cognitively intact, required supervision/touching assistance with showers, and had a gastrostomy tube. The Comprehensive Care Plan, initiated 9/17/2024, documented the resident was at risk for infection related to the gastrostomy tube site. Interventions included implement isolation precautions if indicated. The resident care instructions documented the resident required supervision or touching assistance for showering/bathing. During an observation on 6/23/2025 at 10:45 AM, Certified Nurse Aides #27 and #31 were in Resident #32's room and were not wearing personal protective equipment. At 10:47 AM, Certified Nurse Aides #27 and #31 entered the shower room with Resident #32 and closed the door without wearing personal protective equipment. At 10:48 AM, the door to the shower room opened, the water in the shower was running, and Certified Nurse Aides #27 and #31 were not wearing personal protective equipment while showering the resident. During an observation on 6/23/2025 at 10:49 AM, there was an orange sign outside of Resident #32's room, that documented enhanced barrier precautions, providers and staff must wear gloves and gowns for high-contact resident care activities, such as bathing/showering and dressing. During an interview on 6/27/2025 at 2:08 PM, Registered Nurse Manager #7 stated personal protective equipment was not necessary while showering a resident on enhanced barrier precautions but would be required when dressing a resident. Registered Nurse Manager #7 stated enhanced barrier precautions were important for the prevention of the spread of bacteria and infection. During an interview on 6/27/2025 at 2:10 PM, Certified Nurse Aide #31 stated Resident #32 only required supervision in the shower, so they did not think they had to wear personal protective equipment. 3) Resident #24 had diagnoses including kidney failure and hepatitis C (viral infection of the liver). The 3/24/2025 Minimum Data Set assessment documented the resident was cognitively intact and was dependent with most activities of daily living. A 5/5/2025 hospital consult documented the resident had a totally implantable venous access device (used to supply long-term venous access) and the device was ready for use. The 5/6/2025 at 3:20 PM Licensed Practical Nurse Unit Manager #17 progress note documented the resident was seen for a port insertion, progress note states (does not indicate what progress note) implantable venous access device ready for use. The Comprehensive Care Plan did not include enhanced barrier precautions. The physician orders did not include enhanced barrier precautions. During an observation on 6/23/2025 at 11:30 AM there was no enhanced barrier precautions signage or personal protective equipment bin near the resident's room. During an interview on 6/30/2025 at 12:45 PM, Registered Nurse Unit Manager #5 stated all staff were educated on infection control. Staff should wear personal protective equipment when showering a resident on any type of precaution. The signs on the resident's door described exactly what should have been done in every situation. During an interview on 6/30/2025 at 1:36 PM, Infection Control Registered Nurse #8 stated they tracked all residents that were on precautions along with any new infections that occurred. They ensured signage was placed and proper personal protective equipment was available for all direct care staff. Staff were educated yearly and as needed on infection control and knew how to identify a resident on precautions and what personal protective equipment was necessary. Personal protective equipment should be worn during any direct care of residents on precautions. 10 NYCRR 415.19(a)(b)

Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of three (3) resident floors (Floor 4) reviewed. Specifically, Floor 4, a locked dementia care unit had an unlocked treatment cart accessible to residents, containing medicated creams and other potentially hazardous items. Findings include: The facility policy Storage of Medications, revised 6/2025, documented the facility would store all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments, including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes, containing drugs and biologicals were to be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. During an observation on 6/26/2025 at 9:41 AM, the Floor 4 treatment cart outside the dining room was unlocked and unattended with residents in the immediate area. The first drawer in the treatment card contained Silvsorb gel (antimicrobial used for wounds), antifungal ointment and powder, zinc oxide 20% cream (medicated skin cream), alcohol prep pads, antimicrobial skin wound gel, and clotrimazole-betamethasone cream (topical antifungal cream). The second drawer contained povidone-iodine swabs (antiseptic), gauze pads, lemon glycerin sticks, medicated shampoos, calcitriol ointment (used to treat psoriasis), wound gel, antifungal topical powder, and iodoform packing strips (wound dressing). The third drawer contained blue foam dressings, abdominal pads, gauze squares, and hydrogel saturated gauze. The fourth drawer contained surgical tape, gauze sponges, xeroform petrolatum dressing, superabsorbent dressings, and calcium alginate dressings. The fifth drawer contained wound cleanser spray, a bag of Epsom salt (contains magnesium sulfate), Medi grip tube bandages, wound drapes, and opticell chitosan based gelling fiber (wound dressing). During an observation and interview on 6/26/2025 at 9:42 AM, Licensed Practical Nurse #12 approached the unlocked treatment cart and stated it was supposed to be locked. They stated another nurse was assisting with treatments that morning and they must have left the cart unlocked. During a follow up interview on 6/27/2025 at 3:02 PM, Licensed Practical Nurse #12 stated the treatment cart should be locked when not in use and attended by a nurse. The cart needed to be locked so no one, including residents, was able to get into it. There was the potential for an accident or hazard with the treatment cart being left unlocked as residents could get into it. During an interview on 6/30/2025 at 11:53 AM, Registered Nurse Interventional Care Nurse #32 stated the treatment cart should be locked when not in use. There were residents on the unit who opened cabinets and drawers and took things causing the potential for an accident hazard. During an interview on 6/30/2025 at 1:58 PM the Assistant Director of Nursing stated that treatment carts should never be left unlocked. The fourth floor was a specialized locked unit, and it was important for the treatment carts to be locked for safety. 10 NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025 to 6/30/2025, the facility did not ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing of pressure ulcers for one (1) of three (3) residents (Residents #35) reviewed. Specifically, Licensed Practical Nurse #12 did not adhere to the physician orders for Resident #35's pressure ulcer treatment and applied a different dressing than what was ordered. Additionally, Resident #35's pressure relieving devices for their heels were not consistently implemented as planned. Findings include: The facility policy Wound Care, revised 1/2025, documented the licensed staff were to verify the order for wound care, gather the required materials, and perform wound care and dressing as ordered. Resident #35 had diagnoses including left side weakness and paralysis. The 5/9/2025 Minimum Data Set assessment documented the resident's cognition was severely impaired, had no behaviors, and required maximum assist for most activities of daily living including bed mobility. The resident was at risk for pressure ulcers, had a Stage 3 pressure ulcer (full-thickness skin loss extending into fatty tissue), received pressure ulcer care, and had a pressure relieving device for their bed and wheelchair. The 4/23/2024 comprehensive care plan, revised 6/5/2025, documented the resident had an alteration in skin integrity related to impaired mobility with a Stage 3 pressure ulcer on the left lateral heel. Interventions included weekly wound assessments, diabetic socks, offloading shoe to the left foot while out of bed and both feet raised with heel floats while in bed. The undated resident's Kardex (care card) documented to apply heel float boots and heel protector boots while the resident was in bed to help off load heels and to wear DARCO boots to bilateral feet as an adaptive device. The 6/18/2025 Wound Evaluation by Wound Physician #3 documented the resident had a Stage 3 pressure ulcer on the left lateral heel. Approaches included offloading the heel. The pressure ulcer measured 0.9 centimeters by 0.3 centimeters by 0.1 centimeters with an overall surface area of 0.27 centimeters. There were no signs of infection, and the treatment plan was changed to apply honey hydrogel (wound treatment), apply skin prep to the peri-wound area and cover with border gauze island dressing daily. The 6/19/2025 physician order documented wound care to the left lateral heel: cleanse with wound cleanser, apply honey hydrogel to the wound bed, and cover with border gauze every dayshift. The 6/25/2025 Wound Evaluation by Wound Physician #3 documented the resident had a Stage 3 pressure ulcer on the left lateral heel. Approaches included offloading the heel. The pressure ulcer measured 0.9 centimeters by 0.7 centimeters by 0.1 centimeters with an overall surface area of 0.63 centimeters. There were no signs of infection, and the treatment plan was changed to apply alginate calcium with silver, apply skin prep to the peri-wound area and cover with an abdominal absorbent pad and wrap with 3.4-inch gauze roll daily. During an observation on 6/25/2025 at 1:26 PM, 1:40 PM, and 4:56 PM, the resident was lying in bed with their heels directly on the bed with no floating boots or a pillow for pressure relief. During an observation on 6/26/2025 at 9:25 AM and 9:57 AM, the resident was lying in bed with their feet directly on their mattress without their heels being elevated or wearing heel float boots. During an observation and interview on 6/26/2025 at 11:02 AM with Licensed Practical Nurse #12, Resident #35 was lying in bed with their heels directly on the bed without heel floats. Licensed Practical Nurse #12 entered the room and prepared for the resident's dressing change to the left lateral heel. They placed a towel under the resident's heels on the bed and prepared to remove the dressing currently in place. Licensed Practical Nurse #12 stated the treatment order in the electronic medical record was border gauze but the dressing on the resident's heel was an abdominal pad and kerlix gauze dressing. They stated the wound team must have changed the treatment recommendations and they would have to go get an abdominal pad and kerlix gauze dressing from the supply room, as they only brought in the supplies that were documented in the current physician order. Licensed Practical Nurse #12 left the room to retrieve the abdominal pad and kerlix gauze and when they returned they cleansed the wound, placed honey hydrogel on the wound, placed the abdominal pad over the wound and wrapped it with Kerlix gauze. Licensed Practical Nurse #12 placed resident's heels directly on the bed prior to exiting the room. The 6/26/2025 at 11:53 PM physician order documented to discontinue the treatment of honey hydrogel to the wound, and cover with border gauze every dayshift. The treatment order was changed, with a start date of 6/27/2025 to cleanse the left lateral heel with wound cleanser, apply alginate calcium with silver, apply skin prep to the peri-wound area and cover with an abdominal absorbent pad and wrap with 3.4-inch gauze roll daily. During an observation on 6/27/2025 at 10:33 AM the resident was lying in bed with their heels directly resting on the mattress, without heel floats on. At 10:52 AM, and 11:54 AM the resident was again observed without heel floats and heels lying directly on the mattress. During a phone interview on 6/27/2025 at 3:02 PM, Licensed Practical Nurse #12 stated a resident's wound care orders were listed in the resident's Treatment Administration Record. The resident's wound care order should be followed as written. They should have utilized the dressing that was ordered as opposed to the dressing they saw when they completed Resident #35's wound care. They stated if a resident required skin prep to the peri-wound area it would be in the order. If a resident was care planned to have offloading boots in bed, they should be applied if available. They believed Resident #35's boots were in the wash due to drainage from the wound but was unsure when they went to laundry. During an interview on 6/27/2025 at 10:37 AM, Certified Nurse Aide #15 stated they knew how to care for a resident by their Kardex. If a resident was supposed to have their heels floated or to wear offloading boots, it would be on a resident's Kardex. Resident #35 had put themselves back to bed after they had been gotten up for breakfast. Certified Nurse Aide #15 stated they had gone in after the resident had put themself back to bed to change the resident and get them back up for lunch. The resident did not have offloading boots in their room. The resident was also supposed to have special shoes when they're out of bed, but they did not see them in the resident's room either. They stated since the resident's boots were not in their room, they put slipper socks on the resident and would ask therapy when they came to the floor about the missing boots. During an interview on 6/27/2025 at 11:57 AM, Licensed Practical Nurse #16 stated they knew what treatment to provide a resident's wound by the order in their Treatment Administration Record in the electronic medical record. Wound care orders were supposed to be followed as the order was written. They stated if they went to do a resident's wound care and noticed the dressing done by the wound team the day before was different than the order, they would call the supervisor for clarification on the order. If a resident was to have skin prep to their peri-wound area, there was supposed to be an order. Residents who were supposed to have their heels offloaded or having offloading boots would have it on their Kardex, and they should be applied as planned. Resident #35 did not have an order for offloading boots, but they should have them as they had a heel wound. They stated they knew the resident did not have boots on this morning when they did their wound care. If the resident did not have the offloading boots in their room, the certified nurse aides were to check the stock room or call laundry. During an interview on 6/27/2025 at 1:20 PM, Assistant Director of Nursing/Registered Nurse stated it was her responsibility to put the new wound treatment orders in the electronic medical record and would try to get the order in before the next treatment was due. If the orders were not updated by the next wound care, they expected the nurse to follow the wound care in the computer. They stated if a nurse noticed the dressing done by the wound team was different than they order, the nurse was expected to follow the current order. Resident #35's wound care order was not updated until after the resident's wound care was completed on 6/26/2025 so the nurse should have followed the order that was in the electronic medical record. The nursing staff should be applying offloading boots if that was care planned for the resident If the resident did not have the offloading boots, the certified nurse aides were to contact the team lead or supervisor so they can be gotten from the stock room or clean utility. 10NYCRR 415.12(c)(1)

Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) of one (1) resident (Resident #24) reviewed. Specifically, Resident #24 required dialysis (used to filter waste products from the blood) at a community based dialysis center, did not have orders for on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site, and their comprehensive care plan did not reflect the resident received dialysis. Additionally, the resident did not have a rolled washcloth in their hand as planned and their nails were long with a dark substance underneath. Findings include: The facility policy End Stage Renal Disease Coordination of Care, revised 1/2020 documented the interdisciplinary team, and the end stage renal disease facility would coordinate, develop, and implement an individualized care plan based on the patient's assessment. Both the nursing home staff and end stage renal disease facility staff were responsible for monitoring and addressing any medical or non-medical needs identified. The facility policy Care of Fingernails/ Toenails, last reviewed 1/2025, documented proper nail care included daily cleaning and regular trimming. If a resident refused nail care a supervisor was to be made aware. Resident #24 had diagnoses including chronic kidney disease stage 3 (the kidneys have mild to moderate damage) and dependence on renal dialysis. The 3/24/2025 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, had no functional limitation to the upper extremities, required partial/ moderate assistance with personal hygiene, substantial/ maximum assistance with upper body dressing, and did not receive hemodialysis. Dialysis: The 6/19/2025 Comprehensive Care Plan documented the resident had a potential for nutritional related problems. The resident had end stage renal disease and recently started routine hemodialysis treatments. Interventions included to provide diet as ordered and monitor food and fluid intakes. The care plan did not include nursing interventions for monitoring. The 4/30/2025 at 3:00 PM, Licensed Practical Nurse #17 progress note documented the resident was seen by nephrology (kidney specialist), had severe chronic kidney disease, needed to start dialysis, and had an appointment scheduled for the placement of a tunneled hemodialysis catheter (for dialysis access). The 5/6/2025 at 9:42 AM, Licensed Practical Nurse #17 progress note documented the resident was seen for a port insertion and their implanted venous access device (a device used to carry medications into the bloodstream, also known as a port or central line) was ready for use. The 5/8/2025 Dialysis Communication Form documented it was the resident's first day receiving dialysis. The dialysis center documented the resident tolerated the treatment. There were no documented facility pre/ post dialysis evaluation/ assessments of the resident's condition and monitoring for complications. The 5/9/2025 Nurse Practitioner #24 late entry progress note documented the resident went to dialysis as scheduled, but did not receive their morning medication prior to leaving. Their chart was reviewed, and they advised the nurse to obtain vital signs upon return from dialysis and to notify the provider if their blood pressure or heart rate was elevated. Dialysis Communication forms included: - on 5/10/2025 the form was completed by the facility, there was no documented pre or post dialysis evaluation/ assessments. - on 5/13/2025 the form was blank and not completed by the facility with no documented communication from the dialysis center and no pre- dialysis evaluation/ assessment. - on 5/15/2025 there was no documented pre-dialysis evaluation/ assessment. - on 5/17/2025 there was no form. - on 5/22/2025, 5/24/2025, 5/27/2024, 5/29/2025, and 5/31/2025 there was no documented pre or post dialysis evaluation/ assessments. On 6/3/2025 at 12:05 PM, Licensed Practical Nurse #16 completed a post dialysis evaluation/ assessment. There was no Dialysis Communication Form completed by the facility. There was no documented pre- dialysis evaluation/ assessment. On 6/5/2025, there was no Dialysis Communication Form completed by the facility. The 6/6/2025 Physician orders documented the resident went to dialysis 3 times a week on Monday, Wednesday, and Friday. Additionally, there was no orders for staff to monitor their dialysis access cite. Dialysis Communication forms included: - on 6/7/2025, there was no form completed by the facility. - on 6/10/2025, 6/12/2025, and 6/14/2025, there were no documented pre or post dialysis evaluation/ assessments. - on 6/17/2025, 6/19/2025, and 6/21/2025 there were no documented pre or post dialysis evaluation/ assessments. HANDS/NAILS: The 4/3/2025 Comprehensive Care Plan documented the resident was at risk for functional decline in mobility and self-care related to decreased activity tolerance and strength. Interventions included partial/ moderate assistance with personal hygiene The 4/17/2025 Occupational Therapy Discharge Summary completed by Assistant Director of Therapy/ Occupational Therapist #4 documented staff should assist with activities of daily living, mobility, and transfers. Staff was educated on placing a small cloth for the resident's right hand to decrease risk of developing pressure sores. The undated care instructions documented to place a rolled washcloth in the resident's right hand due to 4th/ 5th fingers being in a fixed position; the washcloth should be in place at all times except during bathing/ hygiene tasks; and the resident required partial/ moderate assistance with personal hygiene. The following observations of the resident were made: - on 6/23/2025 at 11:30 AM, seated in their wheelchair. Their right hand was contracted (shortening of muscles) and their nails had a brown substance underneath them. They did not have any devices in their hand. At 12:35 PM, in the dining room eating their lunch without a device in their hand. - on 6/24/2025 at 2:14 PM, 6/25/2025 at 12:36 PM, and 6/26/2025 at 11:43 PM, their right hand was contracted without any device in place. - on 06/27/2025 at 11:11 AM, seated in their wheelchair in their room. Their right hand was contracted, their nails were long, with a dark substance underneath, and their nails were touching their palm. There was a dark area on their palm where the nails were touching their skin. The resident could not open their hand fully and stated it hurt when they attempted to do so. The June 2025 activities of daily living record documented a rolled washcloth was placed in the resident's right hand due to their 4th/5th finger being in a fixed position: - on 6/23/2025 at 1:59 PM, by Certified Nurse Aide #27. - on 6/25/2025 at 11:45 AM, by Certified Nurse Aide #28. During an interview on 6/27/25 at 11:31 AM, Certified Nurse Aide #31 stated the resident's care instructions documented the level of assistance they required with care. Certified nurse aides cleaned and cut resident's nails as needed and on shower days. Resident #24 did not like to have the rolled washcloth in their hand and sometimes removed it after staff put it in their hands. The resident refused to have the rolled washcloth placed in their hand today and they did not alert the nurse the resident refused. The resident's right hand was difficult to open which made it difficult to cut and clean their nails. They did not look at the resident's nails today and never saw them pressing into the palm of their hand. During an interview on 6/27/25 at 12:12 PM, Licensed Practical Nurse #17 stated Resident #24 received dialysis on Tuesdays, Thursdays, and Saturdays at 6:15 AM. The nurse who worked the 10:00 PM - 6:00 AM shift should obtain the resident's vital signs, complete the pre-dialysis evaluation/ assessment, and fill out the dialysis communication form. When the resident came back from dialysis the nurse should take the resident's vital signs, complete the post-dialysis evaluation/ assessment, and review the dialysis center's communication. The resident's dialysis access site should be monitored to ensure there were no issues. A registered nurse needed to start the care plans, and the licensed practical nurse could update the care plans after they were created. Resident #24's fingers on their right hand were in a fixed position and they should have a rolled washcloth in their hand. If the resident refused, the certified nurse aide should tell the nurse so they could approach the resident to attempt placement again. They were not aware the resident refused the rolled washcloth. The nurse aides should clean and cut the resident's nails as needed. They should be made aware if Resident #24 refused nail care because their fingers were in a fixed position and if their nails were long it could lead to skin breakdown. During an interview on 6/27/2025 at 1:03 PM, Registered Nurse Unit Manager #7 stated care plans were started by a registered nurse and should be resident specific. If a resident was on dialysis, they should have a care plan, so staff knew what to monitor and how to care for the resident. Staff should monitor the resident's dialysis site to ensure it was working and there were no issues. Nursing staff should complete the pre/post dialysis evaluation/ assessments, pre-dialysis communication forms, and review the post dialysis communication forms after each dialysis session. They were unaware the resident did not have a dialysis care plan, and nursing staff were not consistently completing the pre/post dialysis evaluations/ assessments, and pre-dialysis communication. The resident's nails should be checked daily to ensure they were clean and the certified nurse aides should cut the resident's nails at least weekly. If the resident refused, they should let a nurse know. They should also let the nurse know if the resident refused their rolled washcloth as it aided to prevent skin breakdown in their hand. On 6/27/2025 at 2:43 PM, during an interview the Assistant Director of Therapy stated Resident #24 was last seen by therapy in April 2025. They recommended a rolled washcloth be placed in the resident's right hand to decrease the risk of pressure ulcers. The resident tolerated the rolled washcloth and they educated staff on how to apply the washcloth and the importance of its use. If the resident was refusing staff should let therapy know so they could re-evaluate the resident. Resident #24 had long nails, and it was important for staff to clean and cut their nails as tolerated to prevent skin breakdown. On 6/30/2025 at 1:07 PM, the Assistant Director of Nursing stated nail care should be completed on shower days and as needed. Staff should follow the care plans and apply any devices recommended by therapy. If a resident refused, they should alert the nurse so they could re-approach the resident. Nursing staff should check the resident's dialysis access site daily to ensure there were no issues. Additionally, staff should have been completing the dialysis communication form and pre/ post evaluations. Any registered nurse could have started a dialysis care plan, and each care plan should be resident specific and include refusal of care and any specific treatments they received including dialysis. 10NYCRR 415.12

Based on record review and interview during the recertification survey conducted 6/23/2025 to 6/30/2025, the facility failed to ensure each resident who experienced a significant change in status was comprehensively assessed using the Centers for Medicare and Medicaid Services specified Resident Assessment Instrument for one (1) of two (2) residents (Resident #55) reviewed. Specifically, a Significant Change Minimum Data Set assessment was not completed as required for Resident #55 following enrollment in a hospice program. Additionally, the resident did not have an individualized care plan including the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Findings include: The undated facility policy Agreement for Hospice Care for Skilled Nursing Facility Residents and Respite Care Services documented the responsibility of the skilled nursing facility was to participate in ongoing interdisciplinary comprehensive assessments. The facility policy Care Plans, Comprehensive Person-Centered, revised 1/2025, documented care plans were revised as information about the resident and the resident's condition changed; described the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and reflected the resident's wishes regarding care and treatment goals. The facility policy Comprehensive Minimum Data Set Policy, reviewed 6/13/2025, documented the Minimum Data Set would be completed upon admission, quarterly, with a significant change, and annually. Resident #55 had diagnoses including adult failure to thrive and malignant neoplasm (cancer) of the right kidney. The 5/7/2025 Minimum Data Set assessment documented severely impaired cognition and dependence for most activities of daily living. There was no documentation related to the resident receiving hospice services. The hospice consultant plan of care documented the resident was enrolled in hospice services on 4/29/2025. The 4/29/2025 Social Worker #19's progress note documented hospice did an initial intake for Resident #55 and the family accepted hospice services. There was no documented evidence a Significant Change Minimum Data Set assessment was initiated or completed when the resident was enrolled in hospice services. The facility's Comprehensive Care Plan for Resident #55 did not include enrollment in hospice services and collaboration with the hospice plan of care. Hospice recorded progress notes in Resident #55's medical record on 4/28/2025, 5/8/2025, 5/12/2025, 6/16/2025, and 6/26/2025. During an interview on 6/27/2025 at 11:08 AM, the Minimum Data Set Registered Nurse #14 stated significant changes were discussed during morning report. It was a team collaboration with all departments in determining who qualified. Resident #55 was not scheduled for a significant change assessment. There was confusion with the daughter as to whether the resident was going to go on hospice. They stated they were not always notified when hospice services were initiated for a resident and if a resident was newly placed on hospice a significant change Minimum Data Set should be completed. During an interview on 6/27/2025 at 1:03PM, Registered Nurse Unit Manager #7 stated registered nurses created the care plans and licensed practical nurses updated them. Resident #55 was on hospice. Hospice should be included in their care plan, so staff knew how to provide care. They were not aware the resident did not have a hospice care plan. During an interview on 6/30/2025 at 1:17 PM, the Assistant Director of Nursing stated the comprehensive care plan should have reflected end of life interventions, including hospice recommendations. 415.11(a)(3)(ii)

Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025, the facility did not provide ongoing programs to support each resident in their choice of activities for one (1) of one (1) resident (Resident #37) reviewed. Specifically, Resident #37 was not offered meaningful activities that included their interests and preferences. Findings include: The facility policy Activities Attendance, last reviewed 1/2025, documented the activity department was to record the activity attendance and participation for all residents. The attendance records were reviewed on a regular basis, at least quarterly, to determine any changes in resident participation that may indicate a change in condition and lead to reassessment and care plan review. A resident's attendance record was used when completing a resident's progress notes to determine their participation as it related to their activity plan. Resident #36 had diagnoses including dementia with other behavioral disturbance, bipolar II disorder, and major depressive disorder. The 4/13/2025 Minimum Data Set documented the resident had severe cognitive impairment, did not isolate themselves from others, had physical and behavioral symptoms that disrupted or impacted their participation in social activities and care or the living environment 1 to 3 days, and wandered. It was important for the resident to listen to music they liked, and somewhat important to do things with groups of people and do their favorite activities. The resident's Comprehensive Care Plan documented: - 5/27/2025, the resident would be monitored by social services and be offered emotional support as needed. Interventions included to provide support and reassurance, encourage participation in activities offered, and encourage the resident to remain social with staff and peers. - 5/28/2025, the resident was a readmission and had limited involvement in group activities due to their behaviors and short attention span. Interventions included to assist the resident in finding programs of interest and encourage resident suggestions regarding program choices. The resident liked music and to walk on the unit. Staff should encourage individual activities, invite /escort the resident to activities, special events, and parties of choice/interest, and provide appropriate cognitive/sensory activities. - 6/6/2025 and revised 6/23/2025, the resident exhibited behavior symptoms such as being socially inappropriate, wandering behavior, cognitive impairment, and had poor safety awareness. The resident preferred lying on the floor on floor mats. Interventions included to distract the resident with activities of interest and distract from wandering by offering pleasant diversions. The 4/15/2025 Recreation Assessment by the Activities Director documented the resident's interests were crafts and music. The resident's preferred activity setting was self-directed/independent and small groups. The resident needed reminders and escort assistance to activities and assistance with group activities. The resident's response to group activities was positive, the resident was alert but confused and enjoyed music and doing crafts with assistance. The 5/28/2025 Recreation Assessment by the Activities Director documented the resident's interests were music, movies, and television/radio. The resident participated in small group situations and self-directed/independent pursuits. The resident preferred their own room for an activity setting. It was important the resident could do their favorite activities. The resident was alert with confusion, had a very short attention span, and could have behaviors daily. The staff were to attempt activities with the resident. The resident liked music, and the staff were to encourage group activity as tolerated. A daily activity calendar was provided and the resident's right to refuse was respected. The resident needed to be told of the time of an activity and required close supervision. The resident's activity log dated 6/20/2025-6/27/2025 documented the resident had a personal visit every day, except 6/20/2025 when they did an independent activity and 6/25/2025 when they attended the music activity. The June 2025 facility Activities calendar documented: - on Monday 6/23/2025 morning visits at 8:00 AM, 10:00 AM Patio Put Put, 1:30 PM Mail delivery, 2:00 PM discussion ball, and 3:30 PM personal visits. - on Tuesday 6/24/2025 morning visits at 8:00 AM, 10:00 AM Bingo, 1:30 PM Mail delivery, 2:00 PM bowlers practice, and 3:30 PM personal visits. - on Wednesday 6/25/2025 morning visits at 8:00 AM, 10:30 AM Live Music, 1:30 PM Mail delivery, 2:00 PM movie/popcorn or outside, and 3:30 PM personal visits. - on Thursday 6/26/2025 morning visits at 8:00 AM, 10:00 AM Music Group, 12:00 PM Birthday Luncheon, 1:30 PM Mail delivery, 2:00 PM Pokeno, and 3:30 PM personal visits. The resident was observed on: - 6/24/2025 at 1:02 PM walking down the hallway and was redirected down the hallway by a staff member. At 1:10 PM, they tried to open a door on the unit, shaking it vigorously four times before continuing to wander down the hallway. At 1:13 PM, they were redirected out of another resident's room, wandered down to the nurses' station and played with the computer mouse at the nurses' station, then was attempting to get into the trashcan at the nurses' cart. The resident was provided with a pudding by Certified Nurse Aide #35. From 1:23 PM to 2:08 PM, the resident wandered up and down both North and South hallways and was only redirected to keep walking the hallway if they went into another resident's room. At 1:46 PM Activities Aide #39 came up to get three residents for bingo, signed them out and took them off the unit. - 6/25/2025 at 9:37 AM, Assistant Activities Director #36 documented they attempted to talk to the resident but walked away when the resident did not respond. At 10:17 AM, there was a live music entertainer, the resident was not invited to the music activity. From 10:50 AM to 11:20 AM, the resident continuously walked up and down the North and South hallway without redirection or offered distraction. At 11:22 AM, they walked into the dining room with the music entertainer, sat down, and then left again. - 6/26/2025 at 10:24 AM, the resident was not invited to the music activity Activities Aide #39 was playing in the dining room. At 1:35 PM, the resident was wandering up and down both North and South hallway. At 3:35 PM, the resident attempted to enter another resident's room and was redirected by Certified Nurse Aide #37. During an interview on 6/27/2025 at 12:10 PM, Activities Aide #39 stated they tried to visit with residents every day, but some resident one-to-ones were a few times a week as opposed to daily. They stated they visited with the resident if they were having a good day. A one-to-one visit consisted of talking to the resident, hand massages, lotion, and interaction with them about their life/family. Resident #36 liked to walk up and down the hallways so they would do that with the resident and try to have a conversation. The resident did not always answer the questions. The resident came to music as the fourth floor was very much a music floor. Everyone was invited to music activities, and everyone had the right to refuse. Refusals were documented on the activities log. It was important for residents to have activities to keep them active, keep them up to date on what was going on, and engaged. During an interview on 6/30/2025 at 12:38 PM, Assistant Activities Director #36 stated most of the dementia unit activities revolved around music because music is a part of everyone's life. Resident #36 got a mixture of one-to-one visits and personal visits. They stated the resident liked music activities, like on 6/25/2025 the resident came and went from the music activity. The resident had a short attention span and on a bad day if you tried to engage the resident, they walked away. They stated the activity staff attempted to bring the resident into an activity, and if they did not want to stay, they walked out. The resident liked to do crafts but sometimes needed assistance with finishing them. One-to-one visits were based on personal preferences. They stated they walked up and down the hallway with the resident and talked to them. During an interview on 6/30/2025 at 12:38 PM, the Activities Director stated when a personal visit was marked on a resident's activity log, that meant checking in with the resident, seeing if they needed anything and offering independent leisure activities. A one-on-one was 15 minutes or more and was different from a personal visit. Resident #36 was happiest when they were walking and could just be with a person. The resident should always be invited to music activities even if they sometimes walked in and out. 10NYCRR 415.5(f)(1)

Based on record review and interviews during the recertification survey conducted 6/23/2025 to 6/30/2025, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for two (2) of three (3) residents (Residents #89 and #271) reviewed. Specifically, Resident #89 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) when Medicare Part A coverage was ending and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A as required; and Resident #89 had a planned discharge from the facility and was not provided with a timely Notice of Medicare Non-Coverage. Findings include: The facility policy Cut Notices, last reviewed 5/2025, documented Minimum Data Set employees would issue or inform the resident and/or their family and follow the rules for a resident's right to appeal for Managed Medicare and Medicare A residents. The rehabilitation department would issue for Medicare and Managed Medicare part B residents. All notices were to be uploaded to the electronic medical record for the resident. Medicare cut notices were to be issued timely. If a resident could not sign their own notice, the Health Care Proxy or designated representative was to be contacted. The notice could be given verbally with a witness present on the call. The witness and the person signing the cut letter were to sign the cut letter. The person who the letter was issued to, the acceptance of the notice, and the date and time of the notice given. The notice should then be mailed to the proxy. The Center for Medicare and Medicaid Services form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055, expiration date 1/31/26, documented a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (form 10055) must be issued by providers to beneficiaries in situations where Medicare payment was expected to be denied. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage must be delivered far enough in advance that the beneficiary or representative had time to consider the options and make an informed choice prior to services ending. 1) Resident #89 had diagnoses including dementia, anxiety, and muscle weakness. The 5/29/2025 Minimum Data Set assessment documented it was a Skilled Nursing Facility Part A Prospective Payment System (a method of reimbursement used by Medicare that pays a predetermined amount for a service) discharge assessment and the resident had a Medicare-covered stay with a start date of 5/1/2025 and an end date of 5/29/2024. The resident had severely impaired cognitive skills for daily decision making. Resident #89's Health Care Proxy documented the resident's adult male child was their health care proxy. Resident #89's Durable Power of Attorney documented the resident's adult male child and adult female were co-power of attorneys and needed to make decisions together. The Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 letter documented Resident #89's effective end date of services was 5/29/2025. The handwritten note on the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage documented the Notice of Non-coverage Center for Medicare and Medicaid Services-10055 were unable to be provided as the resident was unable to sign for themselves, they were unable to reach the resident's adult female child, and did not have a mailing address for the resident's adult female child. The resident was removed from Medicare part A services on 5/30/2025. 2) Resident #271 had diagnoses including ataxia (lack of muscle coordination), history of traumatic brain injury, and legal blindness. The 1/30/2025 Minimum Data Set assessment documented it was a discharge assessment and the resident had a Medicare covered stay with a start date of 1/1/2025 and an end date of 1/30/2025. The resident had severely impaired cognitive skills for daily decision making. The 1/27/2025 Discharge and Care Summary documented the resident was discharging home with home health and 24-hour care assistance. The information in the discharge and care plan summary guide was reviewed and a copy provided to the resident. The Skilled Nursing Facility Beneficiary Protection Notice form documented a handwritten note by facility staff that a Notice of Medicare Non-coverage had not been issued to the resident because they were discharged home. During a phone interview on 6/27/2025 at 11:08 AM, Minimum Data Set Nurse #14 stated they assisted with issuing Notices of Medicare Non-Coverage this year until the Director of Rehabilitation took over. The issuance of Notices of Medicare Non-Coverage was discussed in their utilization review meetings. If a resident was determined to not meet skilled nursing care needs, a resident was issued a 48-hour notice prior to the discontinuation of services. The notice was issued to the resident unless they were not cognitively intact. If the resident was not cognitively intact, they contacted the power of attorney or contact person in the resident's chart. When the notice was issued, they made sure the resident or resident representative understood the notice and the appeal process. If the contact with the resident representative was made over phone, a certified letter would be sent that contained the Notice of Medicare Non-coverage. If a resident had a facility planned discharge, they should receive a Notice of Medicare Non-coverage. Resident #271 had a planned discharge and should have been issued a Notice of Medicare Non-coverage. During a phone interview on 6/27/2025 at 12:20 PM, the Director of Rehabilitation stated they just recently took over the issuance of Notice of Medicare Non-coverages for the facility. They stated they believed they were the person who issued the Notice of Medicare Non-coverage to Resident #89. They attempted to notify the responsible party if they could not issue the notice to the resident. If they could not notify the responsible party, the Notice of Medicare Non-coverage was issued anyway. They stated in the past the facility attempted to obtain an address if they did not have one. If the resident was unable to sign for themselves, they did not always call the secondary contact on the list if they could not get a hold of the first contact. They stated they did not have the electronic medical record access to be able to see who the healthcare proxies or power of attorneys were. During an interview on 6/27/2025 at 12:41 PM, the Administrator stated the responsibility of issuing Medicare cut letters recently switched from the Minimum Data Set department to the Director of Rehabilitation. If a resident was not able to be issued the Notice of Medicare Non-coverage due to their cognition and the facility was unable to get ahold of the responsible party, a certified letter should be sent. If they did not have an address to send a certified letter to, they reached out to Corporate for further guidance. Resident #89 should not have been taken off Medicare Part A without a notice being issued to the appropriate party. They attended the Utilization Review meeting where Notices of Medicare Non-coverage was discussed. Prior to the meeting end, they discussed when the notice would be issued and who the notice would be issued to, so everyone knew what was going to happen. If a resident was discharged to home and it was planned by the facility, a Notice of Medicare Non-coverage should be issued. Resident #271 should have been issued a Notice of Medicare Non-coverage as it was a planned discharge. It was important for the Notice of Medicare Non-coverage to be issues appropriately so the resident and their representative were informed of their right to appeal. 10 NYCRR 483.10 (g) (18)

Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025 the facility did not ensure licensed nurses had specific competencies and skills sets necessary to care for residents' needs for two (2) of two (2) licensed staff (Registered Nurse Manager #7 and Licensed Practical Nurse #6) reviewed. Specifically, Resident #51 had a tracheostomy (an opening in the neck into the windpipe to provide an airway) and Registered Nurse Manager #7 and Licensed Practical Nurse #6 had insufficient training and knowledge of emergency procedures for accidental decannulation (tracheostomy tube removed in error). Additionally, the Minimum Data Set did not accurately reflect the resident's respiratory status. Findings included: The facility policy Tracheostomy Care, last reviewed 8/27/2021, documented in the event of an emergency and the tracheostomy was dislodged, cover the site with a 4 x 4 gauze and call 911 to have the resident sent to the hospital for a replacement. The facility policy Emergency Tracheostomy Procedure, revised 8/27/2021, documented the emergency response when a tracheostomy was dislodged was nursing staff should initiate a code blue (facility wide emergency response), contact a supervisor and call 911, administer oxygen as needed over the mouth and nose, and if the resident was not breathing the use of a non-rebreather mask or a bag mask device would be used. Resident #51 had diagnoses including intracerebral hemorrhage (bleeding in the brain), tracheostomy, and bronchiectasis (a lung condition where mucus clogs the airway). The 5/8/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, received oxygen, and did not receive suctioning or tracheotomy care. The Comprehensive Care Plan, revised 6/27/2025, documented Resident #51 had a tracheostomy. Interventions included: supplies were kept at the bedside and included a spare tracheostomy tube and an ambu bag (an emergency breathing assistance device); 28 percent oxygen via their tracheostomy collar at 5 liters continuously to maintain an oxygen saturation of 90 percent or greater; critical supplies included an oxygen tank, humidification for the tracheostomy, tracheostomy care supplies, spare cannulas, a specialized wheelchair, and medications. The 11/15/2024 physician orders documented keep an ambu bag at the bedside at all times, attempt cardiopulmonary resuscitation, keep a spare tracheostomy tube at the bedside, and administer continuous oxygen at 2 Liters via tracheostomy. During an observation and interview on 6/26/2025 at 9:01 AM, Licensed Practical Nurse #6 stated Resident #51's tracheostomy care was completed earlier in the morning. They accurately described the steps involved in tracheostomy care. The resident was observed with a tracheostomy with 2 Liters of oxygen via tracheostomy collar. Licensed Practical Nurse #6 stated in the event of an accidental tracheostomy dislodgment they would not replace the tube. They would call the Supervisor or the Nurse Manager and follow their instructions. During an interview on 6/26/2025 at 9:15 AM, Registered Nurse Unit Manager/Supervisor #7 stated if there was a tracheostomy decannulation they would call the Nurse Educator for further instruction on what steps needed to be taken. The skills evaluation checklist Tracheostomy Care Competency documented areas of care reviewed included preparation and assessment; cleaning of the trach; and site and stoma care. The competency did not include emergency procedures for accidental decannulation. Completed staff competencies documented Licensed Practical Nurse #6 and Registered Nurse Educator #8 signed the evaluation checklist for tracheostomy care competency on 5/30/2025. Registered Nurse Manager #7's competency dated 6/2/2025 documented only their signature. The competency was not signed by the instructor. During an interview on 6/26/2025 at 9:20 AM, Registered Nurse Educator #8 stated the Nurse Manager/Supervisor was responsible for the management of emergent situations involving tracheostomy dislodgment. They expected all nursing supervisors to have the knowledge base to manage an emergent decannulation. They reviewed trach care with licensed staff but would defer to the respiratory therapy department for accurate instruction during a tracheostomy decannulation emergency. During an observation on 6/27/2025 at 9:45 AM, Resident #51's bedside had an emergency supply checklist of items present for emergencies. Written instructions documented if the tube fell out, the site should be covered with Vaseline gauze and the resident would be sent, with their supplies, to the hospital for tube replacement. During a telephone interview on 6/27/2025 at 10:00 AM, Respiratory Therapist #9 stated time was crucial in a decannulation instance, and a rapid decline was highly possible. All licensed staff should react to decannulation with prompt and competent actions. Items such as the petroleum gauze was no longer recommended due to its flammability and should be removed from the checklist and from the bedside. An emergency response procedure for decannulation depended on whether the tracheostomy was cuffed (has a balloon like feature at the end of the tube) or uncuffed, and all staff should know the difference. All licensed nursing staff competencies were completed by the in-facility education department. During an interview at on 6/30/2025 at 12:45 PM, Registered Nurse Unit Manager #5 stated training was done yearly for tracheostomy care and as needed. All licensed staff was clinically prepared for tracheostomy related emergencies. They recently re-educated all licensed staff after realizing there was a lack of clarity related to emergency tracheostomy situations. They stated it was important for all licensed nurses to have the knowledge and skills to manage emergency situations. During an interview on 6/30/2025 at 1:20 PM, the Assistant Director of Nursing stated all nurses completed their competencies yearly. Nurses who worked with high acuity residents like those with tracheostomies should be competent with the skill prior to working with that resident. A registered nurse supervisor used to be in the building 24 hours a day but that was no longer the case. The Assistant Director of Nurses stated a dislodged tracheostomy should have the stoma covered with gauze, place oxygen nasally if needed, and call 911 and the supervisor. During a follow-up interview on 6/30/2025 at 2:03 PM, Registered Nurse Educator #8 stated all nursing staff should be able recite the process related to tracheostomy emergency care. It was not acceptable for any licensed staff to lack the knowledge and skills necessary to act in an emergent airway situation. Death of a resident could have resulted if there was not proper process in place during an emergency. 10 NYCRR 415.26(c)(2)

Based on observations, record review, and interviews during the recertification survey conducted 6/23/2025-6/30/2025, the facility did not review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for two (2) of two (2) residents (Resident #106 and #102) reviewed. Specifically, there was no documented evidence informed consent was obtained for the use of the side rails for Resident #106 and the informed consent for Resident #102 was not done timely. Findings include: The facility policy Proper Use of Side Rails, reviewed 1/2025 documented the purpose of the guidelines were to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Guidelines for use included consent for side rail use would be obtained from the resident or legal representative, after presenting potential benefits and risks. 1) Resident #106 had diagnoses including morbid obesity. The 5/14/2025 Minimum Data Set assessment documented the resident was cognitively intact, required substantial/maximal assistance with bed mobility, was dependent with transfers, and did not use bed rails. On 6/11/2025 the Assistant Director of Nursing documented a bed rail/restraint evaluation for Resident #106. Bilateral bed rails were placed on the resident's bed to aide independence with bed mobility. On 6/11/2025 a physician order documented bilateral bed rails. On 06/11/2025 the use of the bilateral bed rails was added the resident's Comprehensive Care Plan. Interventions included discussing and recording the risks and benefits of bed rails with the resident, family/caregivers, ensuring valid consent on the chart prior to initiating restraint, and ensuring safety was maintained while utilizing bed rails. During an observation on 6/23/2025 at 2:07 PM, Resident #106 had bed rails on each side of their bed. There was no documented evidence in the medical record informed consent was obtained from the resident or resident representative related to the use of bed rails. During an interview on 6/27/2025 at 11:00 AM, Assistant Director of Therapy #4 stated Resident #106 had bilateral bed rails for bed mobility, and they were unsure if they had a signed consent because nursing was responsible for obtaining them. During an interview on 6/27/2025 at 11:30 AM, Registered Nurse Unit Manager #5 stated Resident #106 had bilateral bed rails for bed mobility so they should have had a consent form completed when they were installed, but they did not. They were recently notified Resident #106 did not have a signed consent, so they had obtained one that week, but it was in a pile somewhere and had not been put into the resident's electronic medical record yet. During an interview on 6/30/2025 at 1:07 PM, the Assistant Director of Nursing stated side rails required a physician order, and quarterly assessments were completed by nursing and therapy to ensure they were still safe for the resident. Consents should be obtained by the nurse managers prior to the side rail instillation. Resident #106 had bed rails, and they were unsure if they had a signed consent. 2) Resident #102 had diagnoses including fracture of the right tibia (shin bone), muscle weakness, reduced mobility. The 6/6/2025 Minimum Data Set assessment documented the resident was cognitively intact, required partial/moderate assistance with bed mobility, was dependent with transfers, and did not use bed rails. On 4/17/2025 a physician order documented bilateral bed rails. On 04/17/2025 the use of the bilateral bed rails were added the resident's Comprehensive Care Plan. Interventions included discuss and record with the resident, family/caregivers, the risks and benefits of bilateral bed rails . On 6/3/2025 the Assistant Director of Nursing documented a bed rail/restraint evaluation for Resident #102. Bilateral bed rails were placed on the resident's bed to aide independence with bed mobility. The physical restraint/assistive device informed consent form was signed by Resident #102 on 6/14/2025. There was no documented evidence informed consent was obtained prior to 6/14/2025. During an observation on 6/23/2025 at 11:50 AM, Resident #102 had bilateral bed rails on their bed. They stated the bed rails had been on their bed since their admission to the facility. During an interview on 6/27/2025 at 11:00 AM, Assistant Director of Therapy #4 stated therapy would evaluate a resident and if they thought they needed assistance with bed mobility they would reach out to nursing and recommend bed rails. Nursing would obtain medical clearance, obtain signed consent from the resident, and complete restraint/side rail evaluations. Resident #102 had bilateral bed rails for bed mobility, and they were unsure if they had a signed consent because nursing was responsible for obtaining them. During an interview on 6/27/2025 at 11:30 AM, Registered Nurse Unit Manager #5 stated therapy evaluated the need for side rails and would notify them when they were recommended. They would obtain consent from the resident before the side rails were placed, reach out to maintenance for placement, and complete a side rail evaluation form that was done quarterly. Resident #102 had bilateral bed rails for bed mobility. They thought the resident already had a signed consent because they were not told they needed one. During an interview on 6/30/2025 at 1:07 PM, the Assistant Director of Nursing stated side rails required a physician order, and quarterly assessments were completed by nursing and therapy to ensure they were still safe for the resident. Consents should be obtained by the nurse managers prior to the side rail instillation. Resident #102 had bed rails, and they were unsure if they had a signed consent. 10NYCRR 415.12(h)(1)(2)

Based on record review, observation, and interview during the abbreviated survey (NY00341788), the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 resident floors (second, third, and fourth floors). Specifically, the second and third floors had hot water that was not maintained at acceptable temperatures and the second, third, and fourth floors had clean linen supplies that were stained. Findings include: 1) Hot Water Not Maintained The facility's Safety of Water Temperature policy, reviewed 1/2024, documented maintenance was responsible for conducting periodic tap water temperature checks and recording the water temperatures in a safety log. The policy did not include any concerns for a lack of hot water. The Daily Water Readings form for 5/2024 documented each morning the hot water of a random room would be measured. For 5/2024, all of the hot water temperatures documented were within the acceptable temperature range of 90 degrees Fahrenheit to 120 degrees Fahrenheit. The form did not include the actual room where the hot water temperature check was made, or what resident floor the temperature was taken. The facility's Maintenance Request log documented: - on 3/27/2024, the sink in room [ROOM NUMBER] would not turn on, and that was corrected on 3/27/2024. - On 4/15/2024, the bathroom in room [ROOM NUMBER] had barely any water pressure on the hot side, and that was corrected on 4/18/2024. No other issues related to water were noted on the second or third floor for 4/2024 and 5/2024. On 5/14/2024, between 11:45 AM and 12:20 PM, the following hot water temperatures were taken on the third floor: - shower room [ROOM NUMBER], hot water was 78 degrees Fahrenheit. - Resident room [ROOM NUMBER], hot water was 67 degrees Fahrenheit. - Resident room [ROOM NUMBER], hot water was 75 degrees Fahrenheit. On 5/14/2024, between 12:20 PM and 12:35 PM, the following hot water temperatures were taken on the second floor: - shower room [ROOM NUMBER], hot water was 78 degrees Fahrenheit. - Resident room [ROOM NUMBER], hot water was 82 degrees Fahrenheit. - Resident room [ROOM NUMBER], hot water was 82 degrees Fahrenheit. On 5/14/2024, between 2:45 PM and 3:00 PM, the following hot water temperatures were taken on the third floor: - resident room [ROOM NUMBER], hot water was 74 degrees Fahrenheit. - Resident room [ROOM NUMBER], hot water was 76 degrees Fahrenheit. During an interview on 5/14/2024 at 3:34 PM, the Administrator stated the acceptable hot water temperature range was 90 degrees Fahrenheit to 120 degrees Fahrenheit. They stated they were not aware that the hot water on the second floor and third floor was below 90 Fahrenheit, and it was not acceptable. The Administrator stated after being made aware of unacceptable water temperatures, they adjusted the cold-water valve that had fed the town water into the facility steam water mixing system. They stated staff would contact the maintenance department if there was a water temperature issue and the maintenance department would adjust the water system. The Administrator stated they were not aware the daily temperature recordings from 5/2024 did not document the room in which the hot water was tested , or which floor the room was located. They stated it was important that the facility hot water was maintained between 90 degrees Fahrenheit to 120 degrees Fahrenheit for the safety of residents and staff. During an interview on 5/15/2024 at 9:15 AM, Registered Nurse Manager #7 stated acceptable hot water temperatures ranged from 90 degrees Fahrenheit to 120 degrees Fahrenheit. They were aware of prior hot water issues at the facility, and as the second-floor Unit Manager they had previously contacted the maintenance department about the hot water not being maintained. During an interview on 5/16/2024 at 2:34 PM, Maintenance Technician #3 stated they completed the daily water temperature checks and filled out the Daily Water Readings form. They completed the checks at around 6:30 AM every day by checking the boiler and then working their way down from the roof which took about an hour to complete. They stated the Tempered Water was two gauges on the pipe in the boiler room, the Utility Water was a gauge in the boiler room, and the Dual Temp was also a gauge in the boiler room. They stated they did not record the temperatures that they measured on the resident floors and those were usually the same readings as the Tempered Water. Maintenance Technician #3 stated they only received complaints about the hot water when they had had issues with the boiler, and they would adjust accordingly. Those issues and adjustments were not documented, they just looked to see if it went to the normal temperature. During an observation and interview on 5/16/2024 at 2:40 PM, with the Administrator, Director of Maintenance, and Maintenance and Engineering Coordinator #4 present, the boiler system plumbing was reviewed. The boiler had two lines that split to two mixing valves, with two cold water lines that connected at the mixing valves. One cold water line came from the water softener, the other came from the main water line. The Administrator, Director of Maintenance, and Maintenance and Engineering Coordinator #4 each stated they did not know why only a portion of the water that fed into the building was treated by the water softener. During an interview on 5/16/2024 at 3:55 PM, Certified Nurse Aide #5 stated they had issues with the hot water in the past and were unable to provide care as a result. The lack of hot water prevented them from giving residents their showers and nighttime care at times. The hot water had gotten slightly better recently but had been a problem for several months. The water temperature seemed to be better after 8:00 PM than at 3:00 PM. They stated they would not shower in the facility's water because it was too cold and would not shower a resident either because it was too cold, and they had rescheduled showers or proceeded with other bathing care options such as dry wipes when the water was cold. During an interview on 5/16/2024 at 4:05 PM, Certified Nurse Aide #6 stated they have had issues with the hot water for the past two years. Sometimes it took 10-15 minutes to get hot water, and others times, hot water would not come, and they would have to use a basin and mix water from the coffee machine to give a resident a bed bath instead of a shower. They stated that typically happened about once a week. They stated they would not shower in the water from the facility because it was too cold, and as a result had to resort to other means available to provide care to the residents. Certified Nurse Aide #6 stated they reported the lack of hot water to the other aides and nurses, who would have documented that in the log and relayed that to maintenance. During an interview on 5/16/2024 at 4:12 PM, Registered Nurse Manager #7 stated they received complaints about the hot water a couple of times and those were reported to administration and maintenance. They stated they preferred the water to be hot, did not think the water at the facility was hot enough for themselves to shower, but it was within the regulations. When the residents stated the water was too cold, they were offered to shower at another time or were provided with a bed bath. During an interview on 5/16/2024 at 4:20 PM, Resident #3 stated they were not able to wash their personal care device due to the lack of hot water at the facility. They stated about 2 or every 3 attempted showers would be cancelled due to the lack of hot water. The laundry had also been impacted and at one time had to be sent out because the facility did not have any hot water, or it was delayed about a week due to the lack of hot water. During an interview on 5/16/2024 at 4:58 PM, Certified Nurse Aide #9 stated they have had problems with the hot water every day and that had prevented them from providing care to the residents. They stated they would verbally report that they were not able to provide care due to the lack of hot water to their Supervisor and wrote it in the maintenance logbook. It could take hours to get hot water on the Unit, or it did not come at all which was not right for the residents to wait for care. They would not shower in the water at the facility because it was always cold and never hot. During an interview on 5/16/2024 at 5:06 PM, Certified Nurse Aide #10 stated they have had problems with the hot water on average 3 times a week which had resulted in them looking for alternate methods to provide care to the residents. They stated they would start with hot water, but that would run out and go completely cold after a couple minutes. They would let that go 15 to 20 minutes to see if it warmed up again to resume care, which was not right to have the residents wait. They stated they would report that to the nurse and asked them to call maintenance because the residents needed showers. They stated the hot water was better after 7:00 PM, but they were typically trying to give showers between 2:00 and 3:00 PM and the water was too cool then. They stated they would not shower in the facility's water because it was too cold for them. During an interview on 5/16/2024 at 5:16 PM, Resident #4 stated the facility had been having trouble with the hot water, they were unable to get a shower, and the facility had been providing a bed bath instead. During an interview on 5/16/2024 at 5:39 PM, Licensed Practical Nurse #11 stated they had received complaints from residents about the water temperature almost every time they attempted to provide care with the hot water because it was too cold. They stated they wrote those complaints in the maintenance book and attempted to get ahold of maintenance, but those staff left at 3 PM so nothing would be done until those staff came in the next morning. They stated they were told not to let the hot water run because it would run out. If they had hot water, it only stayed hot for about 5 minutes. Licensed Practical Nurse #11 stated they would not shower in the water at the facility because it was uncomfortably cold. The lack of hot water had prevented them from providing care at least once a week, sometimes more. During an interview on 5/16/2024 at 6:00 PM, the Administrator stated they had replaced both mixing valves a few months ago. Today, a seized valve on a line that fed one mixing valve was replaced and they hoped that would fix the problem. To assist the issue in the building, they had moved the laundry services to an overnight shift so there would be less competition with the hot water. They stated there were not aware of any issues with the hot water that prevented the laundry from having been completed or delayed. 2) Clean Linen Supplies Looked Unclean On 5/14/2024, between 12:53 PM and 1:15 PM, the following rooms were fully stocked with clean linen supplies, and there were clean linens that were stained and looked unclean: the fourth floor north clean linen room; the fourth floor south clean utility room; the third floor north clean linen room; the third floor south clean utility room; the second floor north clean linen room, and the second floor south clean utility room. During an interview on 5/14/2024 at 1:20 PM, the Director of Housekeeping and Laundry stated they had been employed as Director for 3 years and had noticed that the town water would turn the white clean linens into an ivory yellow color when washed. They stated they told the previous Administrator about this but had not told the current Administrator. The Director of Housekeeping and Laundry stated they had not mentioned the discolored clean linens during the quarterly quality assurance meetings. They stated all clean linen supplies would get washed prior to bringing them to the resident floors. During an interview on 5/14/2024 at 3:27 PM, the Administrator stated they had never been told that the town water was staining the clean linen supplies, and that there has always been plenty of clean linen supplies for the residents. They stated it was important that all clean linen supplies look clean so residents would not complain that the linens were unclean. The Administrator stated they had not heard of any staff or resident family members complaining of missing linens or that the existing clean linens did not look clean. During an observation and interview on 5/16/2024 at 2:40 PM, with the Administrator, Director of Maintenance, and Maintenance and Engineering Coordinator #4 present, the boiler system plumbing was reviewed. The boiler had two lines that split to two mixing valves, with two cold water lines that connected at the mixing valves. One cold water line came from the water softener, the other came from the main water line. The Administrator, Director of Maintenance, and Maintenance and Engineering Coordinator #4 each stated they did not know why only a portion of the water that fed into the building was treated by the water softener. 10 NYCRR 415.29(j)(1) 43754

Based on record review and interview during the recertification and abbreviated (NY00326912) surveys conducted 10/30/2023-11/7/2023, the facility did not 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. Specifically, the facility's water Legionella (a type of bacteria usually found in water causing Legionnaires' disease) quarterly testing had positive Legionella results for the second quarter of 2023 and the facility water was not resampled. Also, Legionella testing had not been completed for the third quarter of 2023. Findings include: The facility Legionella Water Management Program: last reviewed 1/2021 documented part of the infection prevention and control program, the facility has a water management program which was overseen by the water management team. The team consists of the Infection Preventionist (IP), the Administrator, the Medical Director, the Director of Maintenance, and the Director of Environmental services. The purpose of the program was to identify areas in the water system where Legionella bacteria would grow and spread, and to reduce the risk of Legionnaire's disease. The Water Management Program will be reviewed at least once a year if the control limits were not consistently met. The facility Legionella Management Plan, last reviewed in 4/2023 documented: - samples were collected and tested through a qualified Center for Disease Control (CDC) - Elite laboratory. This work was carried out quarterly, by a Program Team Leader. - This document covered routine and emergency/remediation procedures to be used when Legionella counts exceed 30% positive. Legionella testing will be used to drive any remediation actions. The second quarter of 2023 Legionella testing was completed on 3/21/2023 and 8 of 16 water samples were positive for Legionella. Additional water testing was completed on 4/3/2023 and 7 of 16 water samples were positive for Legionella. The facility could not produce documentation verifying that the water was retested for the second quarter of 2023. The facility could not provide documentation the water had been quarterly tested for the third quarter of 2023. During an interview on 11/1/2023 at 8:40 AM, the Administrator stated that they could not find the Legionella testing results for third quarter of 2023, and the facility water was required to be tested quarterly for Legionella. They stated that there should have been retesting done after the 4/2023 water samples were found to have positive Legionella results. During an interview on 11/3/2023 at 12:10 PM, the Assistant Maintenance Director stated they were not aware the water samples in 4/2023 had been positive for Legionella and that the previous Maintenance Director was the one who had taken these water samples. During an interview on 11/1/2023 at 8:49 AM, the IP registered nurse (RN) #20 stated they were aware of water testing as it was discussed during the quality assurance (QA) meetings. The most recent QA meeting was 4 weeks ago but they could not recall if water was discussed then. They followed all infections in the facility and documented them on a spread sheet line list. They started in the role of IP one year ago and were told to wait for an all clear regarding water and Legionella but they did not have any part in the testing of the water for Legionella. There were currently no residents that were Legionella positive in the facility. They were not aware of the testing requirements and were not familiar with a policy or plan regarding Legionella. They were not aware of Legionella in the water but stated they had not been given the all clear, so they had to test residents that were positive for pneumonia for Legionella, and this was completed by testing the urine. 10NYCRR 415.19(a)

Based on observation and interview during the recertification survey conducted 10/30/2023-11/7/2023, the facility did not maintain an effective pest control program so that the facility was free of pests for 2 of 3 nursing floors (Units 3 and 4) and the main kitchen. Specifically, Unit 3, Unit 4, and the main kitchen had house flies and fruit flies. Findings include: The following observations were made: - on 10/30/2023 at 10:28 AM, there was 1 house fly in resident room [ROOM NUMBER] that was flying around and landing on the resident. - on 10/30/2023 at 11:47 AM, there were 3 fruit flies in the Unit 3 dining room near a garbage can. - on 10/30/2023 at 12:46 PM, there were 3 dead house flies and 1 dead fruit fly on the Unit 4 dining room windowsill. - on 10/30/2023 at 1:33 PM, there was a house fly at Unit 3 nursing station that was flying around and landing on a resident. - on 10/31/2023 at 8:37 AM, there were 3 dead house flies and 1 dead fruit fly on the Unit 4 dining room windowsill. - on 11/2/2023 at 9:37 AM, there were approximately 50 fruit flies located on the walls and ceiling tiles of the main kitchen. - on 11/2/2023 at 4:28 PM, there were 2 fruit flies in the Unit 3 dining room near a garbage can. During an interview on 11/3/2023 at 10:00 AM, dietary aide #34 stated that there had been a couple of fruit flies in the Unit 3 dining room, and they would keep the food trays clean in the kitchenette to minimize the flies. They stated they would tell the maintenance department if they saw fruit flies in the kitchenette. During an interview on 11/3/2023 at 9:09 AM, the Housekeeping and Laundry Director stated if staff were to see flies, they should notify the maintenance department, and the maintenance department would contact the pest control vendor. They stated that dead fruit flies should not have been on the wall near the hand sanitizer. During an interview on 11/3/2023 at 11:22 AM, the Food Service Director stated that the pest control vendor came to the facility routinely every two weeks and was documented in a book. They stated that the maintenance department or the housekeeping department was responsible for keeping the main kitchen ceiling tiles clean to prevent fruit flies. They stated they would let the maintenance department know when the ceiling tiles had to be cleaned. 10NYCRR 415.29(j)(5)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00322422 and NY00315912) surveys conducted 10/30/2023-11/7/2023 the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 9 of 9 residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner. Specifically, during a confidential group meeting (resident council) residents stated their call bell may be answered but there were not always staff available to assist with activities of daily living (ADLs) such as going to the bathroom. Additionally, deficiencies related to staffing levels were identified in the areas of ADL Care Provided for Dependent Residents (Residents #51, #53, #74, and #90). Finding include: The facility policy Staffing last revised on 1/2023 documented the facility would provide adequate staffing to meet the needed care and services for their resident population. Licensed registered nursing staff and licensed nursing staff were available to provide and monitor the delivery of resident care services and certified nursing assistants were available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. The Facility Assessment last updated 9/2022 documented the facility had a total of 120 beds, and the population served was long term care, sub- acute, and unit 2 was primarily infection control step down and rehabilitation unit. Staffing levels documented: staff schedules were maintained in a staffing computer program, and staffing levels were reviewed by facility and corporate and were determined based on census and case mix index. The assessment documented on page 10 was blank for the acuity determination process and documented the typical staffing breakdowns were per acuity and describe above. There was no documentation of the number of residents who required assistance of 1- 2 staff for dressing, bathing, transfers, eating, or toileting. During a resident council meeting on 10/30/23 at 2:00 PM, 9 residents reported that their call bell would be answered timely, but it was usually not a staff person who was able to assist them with their needs. They mentioned that a resident assistant (RA, staff not trained to provide ADL care) would turn off their call bell and there would be no follow up by a certified nurse aide (CNA) or licensed staff. During a telephone interview on 10/30/2023 at 4:02 PM, the facility Ombudsman stated the residents complained to them about missing their showers due to staffing issues. Actual staffing for 10/30/23-11/3/2023 documented the following: - on 10/30/2023 facility census was 103; 7 AM- 3 PM shift 4 registered nurse (RNs); 6 AM- 2 PM 5 CNAs; 6 AM- 9:30 AM 1 CNA; 11 AM- 2 PM 1 CNA; 6 AM- 2 PM 6 licensed practical nurse (LPNs); 2 PM- 10 PM 2 RN supervisors, 8 CNAs and 6 LPNs; 10 PM- 6 AM 1 RN Supervisor, 3 LPNs and 6 CNAs; 4 AM- 6 AM 1 LPN. - on 10/31/2023 facility census was 103; 6 AM - 2 PM shift 7 CNAs with 1 LPN working as a CNA, 6 LPNs, and 3 RNs, 8 AM- 4 PM 6 RAs; 12 PM- 3 PM 1 RA; 2 PM-10 PM 6 CNAs, 4 LPNs, 1 RN; 7 PM - 11 PM 2 RNs; 10 PM -6 AM 4 CNAs, 3 LPNs; 11 PM- 7 AM 2 RN supervisors; - on 11/1/2023 facility census was 103; 6 AM- 2 PM 7 CNAs; 6 AM- 9:30 AM 1 CNA; 11:30 AM- 2 PM 1 CNA 8 AM- 4 PM 5 RAs; 12 PM- 3 PM 1 RA; 7 AM- 3 PM 2 RAs, 6 LPNs and 4 RNs 2 PM-10 PM 5 CNAs, 3 LPNs; 2 PM- 5 PM 1 CNA; 5 PM- 10 PM 1 CNA; 6 PM- 10 PM 1 CNA; 3:30 PM- 8:30 PM 1 CNA; 2 PM - 10 PM 3 LPNs; 4 PM- 9 PM 1 LPN; 6 PM - 10 PM 1 LPN; 2 PM - 6 PM 1 LPN; 2 PM - 8 PM 1 LPN; 2 PM- 10 PM 1 RN supervisor; 5 PM- 9 PM 1 RN supervisor; 7 PM - 11 PM 1 RN; 10 PM- 6 AM 6 CNAs, 3 LPNs, 1 RN. - on 11/2/2023 facility census was 102; 6 AM- 2 PM 5 CNAs with 1 LPN working as a CNA; 7 AM- 3 PM 1 CNA; 6 AM- 7 AM 1 CNA; 8 AM- 4 PM 4 RAs; 7 AM - 3 PM 3 RAs, 6 LPNs and 5 RNs; 2 PM-10 PM 5 CNAs; 6 PM- 10 PM 1 CNA; 2 PM- 8 PM 1 CNA; 3 PM - 10 PM 1 CNA, 7 LPNs with 2 LPNs working 4 hours, and 1 RN supervisor; 10 PM -6 AM 5 CNAs with 1 CNA working 4 hours, 4 LPNs with 1 LPN working 4 hours 11 PM- 7 AM 1 RN supervisor. - on 11/3/20/23 facility census was 102; 6 AM- 2 PM 4 CNAs and 1 LPN working as a CNA, 3 CNAs working a partial shift of 4 hours; 8 AM- 4 PM 5 RAs; 7 AM- 3 PM 3 RAs, 6 LPNs, and 5 RNs. An undated resident roster for Unit 3 documented that 14 of 40 residents required assistance of 2 for ADLs, and 1 resident required assistance of 3. During an observation on 10/30/2023 at 1:55 PM, an unidentified staff was in the elevator complaining to another unidentified staff about being called in on their day off to float to another unit that was short staffed. During an interview on 11/1/2023 at 9:21 AM CNA #39 stated they routinely worked with only 2 CNAs for 40 residents. There was a night shift get up list but if they only have 1 CNA, they were unable to get anyone up. They stated they would get the residents that required assistance of 2 up first and then get the residents that required assistance of 1 up. There were RAs on the unit, but they could not do personal care. CNA #39 stated they were the only permanent full-time CNA, and they worked with a lot of floats or per diem staff which made providing care harder. During an interview on 11/2/2023 at 10:06 AM, CNA #30 stated it was very stressful to have only 2 CNAs on the floor to provide care. They stated they had one entire side which included 20 residents. They felt the resident care was always rushed. They stated nurses did not answer the call bells and they expected the CNAs to always answer them. They stated they felt rushed to get people up to eat. Residents needed to be checked and changed before getting them up for breakfast. They stated the unit did not regularly have 3 RAs assigned. They stated the weekend staffing was horrible, there was usually only 2 CNAs and 1 nurse on the floor with RN supervisors. They stated typically during a regular week there would be 2 CNAs and 1 nurse. During an interview on 11/3/2023 at 9:48 AM, LPN #27 stated the CNAs did their jobs, but when they only had 2 CNAs, they ended up skipping shaving, nail care, or mouth care on the residents that were unable to ask to have it done. They stated Resident #74 had not been out of bed into their chair the entire week because the resident required two staff to get out of bed. During an interview on 11/3/23 at 11:44 AM, CNA #31 stated they did not have time to get all the resident care done. Some residents scheduled for showers were switched to bed baths to get the care done. There had been times on the weekends when there was only 1 CNA. Resident #74 did not get out of bed this past Monday. They stated there had been times when they left for the day and did not turn and position all their residents. During an interview on 11/3/2023 at 12:45 PM Staffing Coordinator #47 stated they were responsible for coordinating schedules for the licensed nursing staff, CNAs, and RAs. They stated the RA could not provide direct care but was available to assist the CNA with passing trays, answering call bells, and sitting with residents. They stated they determined the staffing needs based on the electronic scheduling system. They stated the minimum number was 2 CNAs per unit and 2 LPNs per unit and an RN must always be in the building. They stated no matter what unit or shift there should be 2 CNAs on. Sometimes on the night shift, there might be only one CNA. The units had 40 residents, and 2 CNA was not enough. They stated a unit should not be staffed with one CNA because some of the residents required assistance of 2 and the care would not be able to get done with 1 CNA and one nurse. They stated they tried to staff the units with heavier census with more staff. They tried to schedule 4 CNAs during the day shift, but most of the time 3 CNAs and 2 nurses were only available. They stated the facility did not use agency staff. They stated they had worked as a CNA and having 2 CNAs for 40 residents meant the staff would have to rush care and it would be difficult to give good care to the residents. During an interview on 11/3/2023 at 1:21 PM, the Director of Nursing (DON) stated RAs assisted with phone calls, answered call lights, and relayed messages to CNAs and LPNs. They stated optimal staffing would be 3-4 CNAs on the day shift, 3 CNAs on the evening shift, and 2 CNAs on the night shift. They stated they had been running with 3 CNAs on days, 3 CNAs on evenings, and 2 CNAs on nights. They just raised the pay rates for nursing staff and had a recruiter. The DON stated there were 2 LPNs on days and evenings and 1 on nights. They were not aware that Resident #74 had not been out of bed on a regular basis as care planned and this should have been reported to upper-level nursing. During a telephone interview on 11/6/2023 at 2:02 PM, with the DON and the Administrator, the DON stated they did not have a minimum requirement for CNAs on the units, but never fell below 2 CNAs on a unit. This was not the preferred number of CNAs. The staffing was determined by unit census and acuity. They sometimes had an issue with low weekend staffing especially in the summer. The RA was hired to answer call bells, bring residents to activities, make beds, clean rooms, and sit with residents and they did not provide direct personal care. They stated they felt the facility was staffed adequately to meet the needs of the residents. They stated it was important to have adequate staffing to adequately implement the residents plan of care. The Administrator stated the facility assessment was last reviewed on 9/2022, they were not aware the acuity determination for resident care was blank and said they were probably responsible to complete this and would have to review it. 415.(a)(1)(i-iii) 46276 48895

Based on observation, record review, and interview during the recertification and abbreviated (NY00316983, NY00323441, NY00326912) surveys conducted 10/30/2023-11/7/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 3 of 3 resident floors (Units 2, 3, and 4), and the main kitchen. Specifically, the Unit 2 dining room had unclean curtains; Unit 3 had a strong urine odor, unclean fall mats, shower nozzles, shower chair, and floors and walls near the elevator in the kitchenette; Unit 4 had unclean walls and floors in the kitchenette, and a strong urine odor; the main kitchen had unclean walls and equipment; and Units 2, 3, and 4 had hot water that was not maintained between 90 degrees Fahrenheit (F) and 120 degrees F. Finding include: The facility policy Cleaning and Disinfection of Environment Surfaces revised 1/2023 documented housekeeping surfaces (e.g., floors and tabletops) would be cleaned on a regular basis, when spills occurred, and when these surfaces were visibly soiled. Environmental surfaces would be disinfected (or cleaned) on a regular basis, when spills occurred, and when the surfaces were visibly soiled. Walls, blinds, and window curtains in resident areas would be cleaned when these surfaces were visibly contaminated or soiled. The undated Units 2, 3, and 4 Daily Housekeeping Checklist for resident rooms documented daily cleaning on the unit included: empty all trash, wipe down handrails, clean toilets, dust mop and spot mop floor messes, clean dining room, and clean Hoyer/sit to stands. CLEAN and HOME LIKE ENVIRONMENT The following observations were made on 10/30/2023: - at 9:50 AM, there was a strong urine odor on Unit 4 near the elevator area. - at 10:01 AM on Unit 3 there was a strong urine odor in resident rooms [ROOM NUMBERS] and urine soaked briefs in the bathroom trash can. The shower room was unclean and had a shower chair with a yellow stained towel placed on it. The floor mat in resident room [ROOM NUMBER] was ripped with exposed soiled foam. - at 11:27 AM, the Unit 3 elevator floor was unclean. - at 11:47 AM, the cabinets in the Unit 3 kitchenette had condiment containers with dried liquid stains on them and the edges of the floor were layered with dirt and debris. - at 1:35 PM, the 3042 shower room spray nozzle was on the ground. - at 1:57 PM, there was a strong urine odor on Unit 4 from the elevator area to resident room [ROOM NUMBER]. - at 2:38 PM, the Unit 2 dining room window curtains were unclean. During observations on 10/31/2023 at 9:00 AM there was a strong urine odor in the Unit 4 dining room. At 12:05 PM, the Unit 4 kitchenette walls and floor was not clean. The following observations were made on 11/2/2023: - at 8:21 AM, the Unit 3 elevator floor was coated with dried dirt and debris. - at 9:32 AM in the main kitchen the wall behind the oven was not clean; there was duct tape covering a hole in the exhaust vent over the oven; the front, sides, and tops of the two deep fryers were not clean; and the wall behind the dish machine was not clean. - at 10:39 AM, the Unit 2 dining room wall near the kitchenette was not clean. There was a 1 foot x 1 foot section of the wall that was damaged. During an interview on 11/03/2023 at 8:56 AM, housekeeping aide #41 stated they cleaned the dining room after every meal and had swept and scraped any food remnants off the floors and walls. They stated they cleaned the nurse's station, swept, and mopped the staff bathrooms, and cleaned resident rooms starting with the south wing of Unit 3. They stated dietary staff was responsible for keeping the refrigerator and cabinets clean. Housekeeping aide #41 stated that a resident room would be terminally cleaned when a resident would leave a room. They stated resident room cleaning included cleaning the dresser drawers inside and out and moving all items away from the walls before cleaning the walls and floor. During an interview on 11/3/2023 at 9:09 AM, the Housekeeping and Laundry Director stated there was one housekeeper for each resident unit, one night shift worker, and one person assigned to trash collecting during the day. They stated that the housekeeper assigned to a unit would clean the resident rooms, the dining room, the kitchenette, the shower rooms, the clean and dirty utility rooms, and the resident bathrooms daily. They stated the housekeeping staff would never leave their unit without completing all their tasks. The floors were cleaned daily, and the walls were cleaned weekly and as needed. They stated the floors in resident rooms with urine odors should be checked and cleaned twice a day, the urine odor was caused by residents urinating on the floor, and dirty briefs should be thrown in the soiled utility room to eliminate odors. They stated the housekeeping staff was responsible for cleaning the kitchenette, cleaning the dining room floors, walls, windows, and tables. They stated that every resident should have a clean living space to ensure their health, dignity, and safety was maintained. They stated they rounded the facility every day and was not aware of the unclean areas. During an interview on 11/3/2023 at 1:35 PM, the Assistant Maintenance Director stated there were maintenance logbooks located at each resident floor nursing station, and that sometimes staff would log an issue but not include specific room numbers or specific resident names. They stated that they would go to a floor to correct an issue, and then be asked to do other tasks. They stated they were aware of the unclean floors and walls, and that there was room for improvement. They were not aware of any urine odors on the resident floors, or of the dirty window curtains in the facility. During an interview on 11/3/2023 at 2:30 PM, the Administrator stated that the housekeeping department was responsible for cleaning the floors, walls, window curtains, and other surfaces within the facility. They stated they had previously mentioned dirty window curtains to the housekeeping staff. The Administrator stated that if a resident had incontinence issues, the housekeeping department would be made aware to get to the root cause on how the urine odor could be minimized. They stated that resident rooms were on a daily cleaning schedule and deep cleaning of resident rooms was done when the resident left the facility. HOT WATER During an observation on 10/30/2023 at 10:01 AM, the water in resident room [ROOM NUMBER] did not get hot. During an observation on 10/30/2023 at 10:16 AM, the water in resident room [ROOM NUMBER] bathroom did not get hot. During an interview on 10/31/2023 at 9:23 AM, Resident #90 stated they had not taken a shower in weeks. They stated there was no hot water in the shower and they would not take a shower in cold water. Resident #90's comprehensive care plan (CCP) revised on 10/2/2023, documented the resident was scheduled for a shower or bath every Thursday on the evening shift. During a subsequent interview on 11/2/2023 at 10:19 AM, Resident #90 stated they had not taken a shower because the water was cold in their personal room shower. They stated the shower in the hall, near the resident's room had been out of service for weeks and they would not go down the hall to the other side of the unit for a shower, partially dressed. They stated they had not been offered a shower in weeks, they felt dirty, and could not recall the last time they showered. During an observation on 11/2/2023 at 10:26 AM, Resident #90's shower hot water was turned on and the water was cold and progressed to lukewarm only after several minutes. During an interview on 11/2/2023 at 11:09 AM, certified nurse aide (CNA) #7 stated Resident #90 was independent with personal hygiene. They stated that Resident #90 refused to take a shower because the water was cold and had refused to walk to the shower on the north side of the unit. CNA #7 stated that the shower on the south side of the unit, closer to Resident #90's room, had been out of order for two or three weeks. They stated they were unsure of the last time that Resident #90 showered. During an interview on 11/2/2023 at 12:55 PM, registered nurse (RN) Unit Manager #1 stated Resident#90 had refused to shower and based on review of the electronic medical record (EMR), and they had not showered in over one month. During an observation on 11/02/2023 at 12:53 PM in the basement boiler room the water temperature as the water passed through the mixing valves could not be checked as there were no ports to release and check the temperature of the water. The water temperature gauge in the boiler room was set at 112 degrees F. The hot water in the basement bathroom, located next to the boiler room temperature measured at 121 degrees F. During an interview at the time of the observation, the Assistant Maintenance Director stated that the hot water pipe would go from the basement to each floor in between resident rooms [ROOM NUMBERS], resident rooms [ROOM NUMBERS], and resident rooms [ROOM NUMBERS]. There was a short water loop on the south wing and a longer water loop on the north wing. On 11/2/2023, between 1:20 PM and 1:40 PM, Unit 4 had the following measured hot water temperatures: - resident room [ROOM NUMBER] 88 degrees F. - room [ROOM NUMBER] (south shower room) 85 degrees F. - resident room [ROOM NUMBER] 67 degrees F. The water was resampled nine minutes later, and measured 95 degrees F. On 11/2/2023, between 1:45 PM and 2:00 PM, Unit 3 had the following measured hot water temperatures: - resident room [ROOM NUMBER] 126 degrees F. - resident room [ROOM NUMBER] 121 degrees F. - resident room [ROOM NUMBER] 84 degrees F. - resident room [ROOM NUMBER] 86 degrees F. - resident room [ROOM NUMBER] 84 degrees F. On 11/2/2023, between 2:10 PM and 2:22 PM, Unit 2 had the following measured hot water temperatures: - resident room [ROOM NUMBER] 83 degrees F. - resident room [ROOM NUMBER] 89 degrees F. During an interview on 11/3/2023 at 10:30 AM, the Administrator stated that the facility hot water was required to be between 90 degrees F and 120 degrees F. They stated after reviewing the water temperatures measured on 11/2/2023, between 1:20 PM and 2:22 PM, the water temperatures under 90 degrees F and the water temperatures over 120 degrees F were not acceptable. The Administrator stated that it was not acceptable for the water temperatures in resident room [ROOM NUMBER] to fluctuate from 67 degrees F to 95 degrees F within 9 minutes, or for the water temperatures on Unit 3 to fluctuate from 84 degrees F on the north wing to 126 degrees F on the south wing. They stated that the residents may have preferences for certain hot water temperatures and the facility may not be able to provide it. The Administrator stated that the facility had tried to maintain the hot water at 115 degrees F. 10 NYCRR 415.29(j)(1) 48511 48632

Based on observation and interview during the recertification and abbreviated (NY00323441, NY00322422, and NY00326912) surveys conducted 10/30/2023-11/7/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, and at an appetizing temperature for 2 of 2 meals reviewed (10/30/2023 and 10/31/2023 lunch meals). Specifically, food was not served at palatable and appetizing temperatures. Findings include: During an observation on 10/30/2023 at 12:49 PM, a lunch tray was delivered to Resident #51 in the Unit 4 dining room. The tray was tested , and a replacement was ordered for the resident. At 12:51 PM, the food temperatures were measured with the following results: the chicken was 103 degrees Fahrenheit (F), the vegetables were 116 degrees F, and the potatoes were 121 degrees F. The chicken was chewy, overcooked and not hot, the potatoes were not palatable and were not hot, and the mixed vegetables were not hot. During an observation on 10/31/2023 at 12:00 PM, a server was taking the temperatures of the food in the steam table with a stick thermometer, then wiping that thermometer with a paper towel, then temping another food item. There were no appropriate sanitizer wipes in the Unit 4 kitchenette. At 12:12 PM, after all the food temperatures had been measured in the steam table, the thermometer was placed in an empty cup, and the outer sleeve for the thermometer was missing. During an interview on 10/31/2023 at 12:12 PM, The Food Service Director stated the stick thermometer should be disinfected between food items with a sanitizer wipe and was not aware that there were no wipes in the fourth floor kitchenette. During an interview on 10/31/2023 at 12:25 PM, the Food Service Director stated they tried to do ten test trays a month, and that food items on the steam table were required to have their temperatures taken prior to being served to the residents. During an observation on 10/31/2023 at 12:34 PM, a lunch tray was delivered to resident room [ROOM NUMBER]. The tray was tested , and a replacement was ordered for the resident. At 12:36 PM, the food temperatures were measured with the following results: the tuna casserole was 105 degrees F, and the potatoes were 118 degrees F. The tuna casserole was not flavorful or hot, and the meatballs were not hot. During an interview on 10/31/2023 at 12:34 PM, the Food Service Director stated that tuna casserole at 94 degrees F was not acceptable, and hot food items should be served at 135 F or hotter. During an interview on 11/3/2023 at 11:22 AM, the Food Service Director stated that the hot food items were prepared and then placed into hot holding carts, brought upstairs to the resident units, and then transferred from the hot holding carts to the kitchenette steam tables. They stated that hot food item temperatures should be at least 135-140 degrees, and each individual item could vary but that is the temperature danger zone. The Food Service Director stated that the test tray forms were not detailed, that the test tray form was a basic meal observation audit, and that test trays would be completed by the Administrator and other managers. 10NYCRR 415.14(d)(2)

Based on observation, interview, and record review during the recertification and abbreviated (NY00315912 and NY00323441) surveys conducted 10/30/2023-11/7/2023 the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 2 residents (Residents #26) reviewed. Specifically, Resident #26 received an item they ordered online, the facility did allow the resident to use the item and did not give the resident sufficient time to return the item within the required vendor time frame. Findings include: The facility policy Resident Rights, reviewed 1/2023, documented employees shall treat all residents with kindness, respect, and dignity. The facility policy also documented residents can retain and use personal possessions to the maximum extent that space and safety permits. Residents will be supported by the facility in exercising their rights. The facility policy Personal Property, reviewed 1/2023, documented residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. Resident #26 was admitted to the facility with diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease (COPD, a lung disease). The 8/21/2023 Minimum Data Set (MDS) assessment documented the resident had intact cognition and required extensive assistance for most activities of daily living (ADLs). The comprehensive care plan (CCP) dated 6/1/2023 documented the resident had diabetes and did not want to take prescribed diabetic medications due to the resident's independent research indicated risk for thyroid complications and requested use of CBD (cannabidiol, a chemical found in marijuana) gummies. The facility incident and accident investigative summary dated ongoing documented: - on 5/13/2023, the resident received the item, CBD gummies, and the facility confiscated the item. Resident #26 was informed the provider would be in to speak with them on the following Monday 5/15/2023. - on 5/15/2023, the resident informed the nurse practitioner they wanted to take the ordered item for diabetic management as opposed to current medications. - on 5/15/2023, staff met with the resident and the resident stated they were informed they could speak with the attending doctor that week to determine if orders for the CBD could be written. The facility continued to secure the ordered item until a decision was made. - on 6/1/2023, staff met with the resident and discussed the status of the resident being able to utilize their item. The resident was informed by staff the doctor would be approached writing an order for the item to be administered by nursing staff and that the process was still ongoing. - on 6/2/2023, the resident was informed that the doctor was willing to write orders if a facility protocol was in place and the facility was in contact with the pharmacy to see if the item could be supplied through them. - on 6/23/2023, the resident expressed the desire to use the item, a staff note documented the item was researched and determined to not be Federal Drug Administration (FDA) approved as a dietary supplement or regulated. The staff would inform the resident. - on 6/27/2023, the provider note documented the resident wanted to utilize the item every time the provider talked to them but there was no protocol for ordering CBD gummies at the facility. - on 6/29/2023, the resident was provided by the Assistant Director of Nursing (ADON) and registered nurse (RN) Unit Manager (UM) #32 with FDA printed information on the lack of approval as a dietary supplement. - on 8/7/2023, the resident asked for reimbursement of the CBD gummies they purchased and could not use. The resident was informed that they could not store or manage the product on their own and staff could not administer the product without a medical order. Staff informed the resident they would contact the company about a return. - on 8/10/2023, the company the item was ordered from was spoken to and the item was unable to be returned as it was past the 30-day return policy. The facility would inform the resident and their item would be stored in the nursing office until the resident released it to family or the resident was discharged . During an interview on 10/30/2023 at 11:19 AM, Resident #26 stated staff confiscated the CBD gummies in May, and they did not physically see the item again until six weeks ago. The resident stated they were under the impression the pharmacy sent jackets for the CBD bottles to be placed in and that the lawyers had to write a policy prior to the resident being able to receive the gummies. They stated they were informed by the Administrator and the DON that the gummies were not approved by the FDA, and they could not receive them. Resident #26 stated they wanted to be reimbursed for the cost of the gummies which was why they called the police. During an interview on 11/2/2023 at 10:17 AM, licensed practical nurse (LPN) #24 stated Resident #26 had ordered over-the-counter medications in the past and the protocol was to alert the Unit Manager for further guidance. LPN #24 stated they or the Unit Manager would take away the medication from the resident and would explain why the medication was taken. During an interview on 11/2/2023 at 11:41 AM, registered nurse (RN) Unit Manager (RN UM) #32 stated Resident #26 had been observed ordering items that were not allowed due to protocol. RN UM #32 stated any medications ordered by the resident were kept in the medication room until family could pick them up. During an interview on 11/02/2023 at 4:43 PM, the Director of Nursing (DON) stated whenever Resident #26 received an item, staff would assist with the packages due to the resident's arthritis. When the CBD gummies arrived, staff confiscated them until the provider and management staff were in the following Monday 11/15/2023, and the resident agreed. The DON stated there was no policy for CBD gummies and there was no intent to put one in place. The DON stated they were unsure of the time frame between the CBD gummies being confiscated and the answer on their use. The DON stated they were informed CBD items would not be something that would be considered in the facility at that time as they were not FDA approved. The DON stated the CBD gummies were locked in the Administrator's office. During an interview on 11/3/2023 at 11:39 AM, the Administrator stated that they had just started when Resident #26 received the CBD gummies and was not involved. The Administrator confirmed the CBD gummies were in their office until Resident #26 allowed for them to be released to family or they were discharged . 10NYCRR 415.5(a)

Based on observation, record review, and interview during the recertification and extended survey conducted from 8/24/21- 9/1/21, the facility failed to ensure that residents who need respiratory care, including [CONDITION(S)] care and tracheal suctioning, were provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 2 residents (Residents #92 and 320) reviewed. Specifically, the facility failed to have emergency equipment available for two residents with tracheostomies and staff were unaware of the location of emergency equipment, and their role in performing routine and emergency [CONDITION(S)] care. - Resident #320 had a [CONDITION(S)] tube size 7 millimeters (mm), the suction cart lacked appropriate suction catheters and appropriately sized inner cannulas (fits into outer tube, size 8 cannulas were present), and staff were unaware an emergency [CONDITION(S)] kit was not readily available at the bedside. - Resident #92 had no readily available emergency equipment including a back-up [CONDITION(S)] kit and suction equipment on 8/26/21 at 9:03 AM when care was observed in the resident's room. Staff were unaware of the size and type of the [CONDITION(S)] required, or if suitable emergency [CONDITION(S)] supplies were available in the building for this resident. At 5:11 PM, there was still no emergency back-up [CONDITION(S)] kit or suction equipment at the resident's bedside. The facility's failure to provide appropriate respiratory care placed Residents #92 and #320 who had tracheostomies at immediate risk for serious harm or death if their airways were not maintained. This resulted in Immediate Jeopardy and Substandard Quality of Care. Findings include: The undated facility policy [CONDITION(S)] Care documented [CONDITION(S)] tubes should be changed as ordered and as needed (at least monthly). [CONDITION(S)] care should be provided as often as needed, at least once daily for old, established tracheostomies, and at least every eight hours for residents with unhealed tracheostomies. A replacement [CONDITION(S)] tube must be available at the bedside at all times. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. On 8/26/21, the policy was updated to include in the event of an emergency and the [CONDITION(S)] is dislodged, cover with 4x4 gauze and call 911 to have the resident sent out for a replacement. The facility policy Emergency [CONDITION(S)] Replacement dated 1/2021 documented the facility will ensure that emergent [CONDITION(S)] replacement will be performed by licensed nursing staff. Always keep a spare [CONDITION(S)] tube with obturator (assists in inserting the [CONDITION(S)] tube into the airway) the same size as what the resident has on hand in case the tube is accidentally coughed out. The undated facility policy Suctioning Lower Airway documented to verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning. Review the resident's care plan to assess for any special needs of the resident. 1) Resident #92 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/6/21 Minimum Data Set (MDS) admission assessment did not document the resident's cognitive patterns. The resident was totally dependent with assistance of 1-2 persons for all activities of daily living (ADL) and required oxygen therapy, suctioning and [CONDITION(S)] care. The admission note dated 7/30/21 and signed by the Director of Nursing (DON) and licensed practical nurse (LPN) Unit Manager #8 at 12:29 PM documented the resident had respiratory concerns including oxygen per orders and a [CONDITION(S)]. There was no documentation of the [CONDITION(S)] ([CONDITION(S)]) size, required care, or an assessment of the [CONDITION(S)]. The comprehensive care plan (CCP) initiated 8/2/21 documented the resident had an alteration in respiratory system related to [CONDITION(S)] status. Interventions included administer treatments (nebulizers) and medications per physician orders. There was no documentation of the care required for the resident's [CONDITION(S)]. The electronic Kardex (care instructions) reviewed and dated 8/26/21 did not include documentation referencing the resident's [CONDITION(S)] or respiratory status. The 7/30/21 After Visit Summary from the rehabilitation facility the resident was discharged from did not include orders for the [CONDITION(S)] or care of the [CONDITION(S)]. The 7/30/21 order by nurse practitioner (NP) #15 documented oxygen via [CONDITION(S)] collar 28% humidification every shift. There was no documentation of a [CONDITION(S)] size or required care for the [CONDITION(S)]. The 7/30/21 NP #15 admission progress note documented a physical exam included a [CONDITION(S)] with [CONDITION(S)] collar in place. The plan was to suction the [CONDITION(S)] to maintain the airway. There was no documentation of the size of the [CONDITION(S)] or required care for the [CONDITION(S)]. The 8/16/21 NP #15 progress note documented lung sounds were clear, respirations were unlabored, and [CONDITION(S)] with [CONDITION(S)] collar in place. There was no documentation of the size of the [CONDITION(S)] or required care for the [CONDITION(S)] instructions. The 8/20/21 order by NP #15 documented [CONDITION(S)] care every shift and as needed (PRN). During an observation on 8/26/21 at 9:03 AM, LPN #14 performed daily [CONDITION(S)] care on Resident #92. LPN #14 stated the [CONDITION(S)] was a disposable one. LPN #14 removed one new inner cannula from a box on the resident's nightstand labeled Shiley #8 DIC 7.6 mm 79 mm (Shiley, a brand of [CONDITION(S)] tubes). The inner cannula did not fit the resident. LPN #14 stated there were no specific orders for the [CONDITION(S)] size, care and/or treatment frequency. The LPN stated they were not sure what size [CONDITION(S)] the resident had. The LPN stated they would look at the resident's hospital orders to see what size [CONDITION(S)] the resident should have. LPN #14 stated that they had experience with [CONDITION(S)] care from a previous job but had not received any training at this facility. During the observation a staff member from central supply brought up a Shiley #6. The LPN attempted to insert the Shiley #6 and this fit the resident. LPN #14 stated the resident's [CONDITION(S)] site was clean, the skin was dry and intact, there was no irritation, and the resident was on 28 % humidification and there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated there was not an extra [CONDITION(S)] at the bedside for emergency purposes. The August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The August 2021 treatment administration record (TAR) documented [CONDITION(S)] care every shift and as needed. There were no documented required [CONDITION(S)] care details for the size of the inner cannula, cleaning/removing [CONDITION(S)] ties, or oxygen. During an interview on 8/26/21 at 10:56 AM with registered nurse Unit Manager (RNUM) #13 they stated the resident was admitted to the 4th floor one week ago. The RNUM stated a resident with a [CONDITION(S)] should have orders that include the type and size of the [CONDITION(S)] and how to care for the [CONDITION(S)]. The RNUM #13 confirmed via the electronic record there were no orders for Resident #92's [CONDITION(S)]. The RN said they did not think there was suction at the resident's bedside. The RNUM stated they did not think that it was standard to have suction at the bedside if there were no issues with the [CONDITION(S)]. During an observation of Resident #92's room on 8/26/21 at 11:11 AM there was no suction machine, ambu bag or extra [CONDITION(S)] supplies at the bedside. At 11:13 AM, LPN #14 confirmed there was not an extra [CONDITION(S)] at the resident's bedside. The LPN stated it was there yesterday and it was not there today. On 8/26/21 at 11:15 AM during an observed phone conversation between LPN #14 and Central Supply, LPN #14 requested an extra cannula and Central Supply stated they did not have one. During an interview on 8/26/21 at 12:38 PM, speech language pathologist (SLP) #16 stated they have had 8 or 10 residents with trachs. The SLP stated they thought Resident #92 had a Shiley #6 but would have to double check the orders. SLP #16 stated that when residents were admitted with a [CONDITION(S)], they were supposed to have suction at the bedside. The SLP stated there was also a respiratory therapist (RT) available to consult for respiratory issues. During an interview on 8/26/21 at 12:50 PM, LPN #17 stated they had not received training at the facility related to [CONDITION(S)] care. The LPN stated it was standard of care for a resident with a [CONDITION(S)] to have suction at the bedside, and there should be an extra [CONDITION(S)] taped on the wall or in a drawer. If a resident had a [CONDITION(S)] there should be orders that included the size of the [CONDITION(S)], care and how often and suction if needed. The orders would be listed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/26/21 at 12:57 PM, RNUM #13 searched Resident #92 room for an extra [CONDITION(S)] and was unable to locate one. The RN said it should be taped to the wardrobe closet or wall. During an interview on 8/26/21 at 1:04 PM, RNUM #13 stated if the resident had a [CONDITION(S)] dislodged or if there was a [MEDICATION(S)] plug, they would call Central Supply to a get spare [CONDITION(S)] tube at the bedside as soon as possible. The RNUM stated that it would be an emergency and they would try to maintain the airway the best way they could, cover the area with the humidified oxygen, call 911 and get the patient to hospital, and call the RT. During an interview on 8/26/21 at 2:52 PM RNUM #13 stated the resident was discharged to the facility without any specific orders for [CONDITION(S)] size and type. The RN stated if the resident decannulated accidently, they would call 911 and notify the facility RT. Nurses were not supposed to reinsert the cannula but they would need an extra [CONDITION(S)] at the bedside. RNUM #13 stated they read the facility [CONDITION(S)] care policy and that there should be an extra [CONDITION(S)] tube at the bedside. RNUM #13 received a copy of the hospital discharge summary when the resident was released from the rehabilitation center and stated the resident's [CONDITION(S)] was changed on 5/31/21 and downsized to a 6 Shiley. During observation on 8/26/21 at 4:45 PM, Resident #92 did not have suction equipment or an extra [CONDITION(S)] at the bedside. 2) Resident #320 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/23/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance of one for most activities of daily living (ADLs), received oxygen therapy and [CONDITION(S)] care. The 8/19-8/20/21 physician orders documented [CONDITION(S)] care twice a day and as needed, change inner cannula daily with morning [CONDITION(S)] care and oxygen via [CONDITION(S)] at 8 liters per minute. There was no order for suctioning needs, [CONDITION(S)] securement ([CONDITION(S)] ties) changes, or oxygen tubing and [CONDITION(S)] collar cleaning or changes. The comprehensive care plan (CCP) initiated 8/23/21 documented the resident had alteration in respiratory status related to [CONDITION(S)], [CONDITION(S)] status, pneumonia, and respiratory failure. Interventions included administer treatments and medications per physician order and oxygen. There was no documented evidence for required interventions for [CONDITION(S)] size and care. The 8/26/21 physician order documented [CONDITION(S)]-Shiley disposable inner cannula [MEDICATION(S)] 70XLTIN. On 8/26/21 at 11:42 AM, Resident #320 was observed sitting in a chair. A communication board was available. The resident wrote that their [CONDITION(S)] was a size 7. The resident's [CONDITION(S)] had a drain sponge around the opening and was receiving oxygen via a [CONDITION(S)] collar (a plastic device that cups the [CONDITION(S)] opening and is secured around the neck.) There was a small amount of thick tan secretions in the inner cannula tubing and [CONDITION(S)] collar that the resident wiped away with a tissue. A cart containing a suction machine was at the foot of the bed. The cart contained an empty box for size 7 inner cannulas, 2 individual size 8 inner cannulas, and sterile water in individual small bottles and had no required suction kits in the cart. Resident #320 wrote that they told the staff to order more size 7 cannulas. There was no extra [CONDITION(S)] visible at the bedside. When interviewed on 8/26/21 at 12:40 PM, licensed practical nurse (LPN) #7 stated they had provided care for residents with trachs in the past and had received training at a previous employer but not at this facility. The LPN stated they did not do suctioning but called a registered nurse (RN) if suction was needed. PN #7 stated that in an emergency, they would need a suction machine, an inner cannula, sterile water, and oxygen. The LPN stated that there should be an extra [CONDITION(S)] in the resident's room. LPN #7 stated that if the [CONDITION(S)] became dislodged, the resident's airway could close. The LPN asked the resident if there were more supplies, and the resident pointed to their closet. An extra [CONDITION(S)] kit size 7 was found in the bottom of a grocery bag in the bottom of the closet and was placed on the suction cart. When interviewed on 8/26/21 at 12:43 PM, supply room aide #1 stated the only [CONDITION(S)] supplies they had were those left over from previous residents. If needed, the nurse would send the aide an email when they needed more ordered. The aide stated they had ordered more size 7 supplies that morning at 10:53 to be sent overnight. The supply aide stated they were unaware how to obtain the supplies in an emergency. They would call a sister facility to see who had the item in stock and go pick it up. The 8/26/21 at 10:53 AM supply aide #1 email documented they requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .) The following [CONDITION(S)] supplies were observed in the supply room: 3 boxes size 8 Shiley complete [CONDITION(S)] kits; 2 boxes size 6 Shiley complete [CONDITION(S)] kits; 2 boxes size 4 Shiley complete [CONDITION(S)] kits; 14 boxes size 6 Shiley disposable inner cannulas; and 245 individual size 14 French (Fr.-the tubing circumference) [CONDITION(S)] suction kits. There were no supplies for size 7 trachs required for Resident #320, and no documentation in the record that Resident #92 had a size 6 [CONDITION(S)]. When interviewed on 8/26/21 at 12:57 PM, LPN Unit Manager (LPNUM) #8 stated that when a resident with a [CONDITION(S)] was admitted from the hospital, the hospital sent enough supplies to last until the facility could obtain their own supply. Resident #320 had a size 7 [CONDITION(S)], and supply aide #1 was responsible for ordering the [CONDITION(S)] supplies. The Admissions department emailed the supply aide to let them know what size to order on admission. The LPNUM stated to care for a resident with a [CONDITION(S)], they would have suction, [CONDITION(S)] kits for cleaning, and since the inner cannulas were disposable, they would need new inner cannulas. LPNUM #8 stated that there should always be an extra [CONDITION(S)] at the bedside in case the [CONDITION(S)] became dislodged. The LPNUM stated they were unsure if Resident #320 had an extra one. Staff were required to be educated on [CONDITION(S)] care every year and that was done by the Staff Education RN #10. LPNUM #8 stated they had their education a year ago, and the LPNUM stated they were not told if their staff had completed the education. LPNUM #8 stated they did not know if the staff currently working had [CONDITION(S)] competencies completed; someone else did the schedule for their unit, and the LPNUM did not ask. When interviewed on 8/26/21 at 3:00 PM, RN Director of Education #10 stated they were unsure how the suction carts were set up. That was left to the Unit Managers. The RN did not know what education was provided to the staff regarding trachs. RN#10 said they thought the online education program the facility used might have some competencies. If staff were due to complete education, the system sent them an email alerting them the education was due. LPNs did not perform deep suctioning so there was always an RN in the building. The RN stated they had not completed the online [CONDITION(S)] courses so was unsure if the course included what to do if the [CONDITION(S)] became dislodged. RN#10 stated that they had not seen the facility policy but there was usually a spare [CONDITION(S)] kit at the bedside and a set of clamps so one could open the airway and put the [CONDITION(S)] back in. RN #10 was not sure if the facility RNs were expected to re-insert a [CONDITION(S)] if one became dislodged but stated the Director of Nursing (DON) would know. RN#10 stated they were unsure how often staff were to complete [CONDITION(S)] competencies, but thought it was once a year. RN #10 stated they were unsure how many nurses were trained in [CONDITION(S)] care, but they would eventually be the one to keep track of that. RN#10 stated they had not received any [CONDITION(S)] care education at the facility and had not been told what to teach. When interviewed on 8/26/21 at 3:58 PM, the DON stated when residents with trachs were admitted , Admissions used a checklist that lists any specialty equipment the resident needed. That list is given to the concierge who sets up the room for the resident. A nurse-to-nurse report was completed with the hospital, but the hospital staff did not typically know the [CONDITION(S)] brands or sizes. Staff got the [CONDITION(S)] size after the resident arrived. The [CONDITION(S)] sizes for Residents #320 and #92 were not in their charts so they were able to obtain that information from the respective hospitals on 8/26/21. The DON expected staff to be aware of a resident's [CONDITION(S)] size at admission, and there was to be at least one back-up [CONDITION(S)], an ambu-bag (device to deliver breaths) and inner cannulas. If the facility did not have an extra [CONDITION(S)], the DON notified the corporate DON, and the sister facilities were checked. If those facilities had none, one would be ordered and sent by overnight mail. The Unit Manager was responsible for putting in the orders for [CONDITION(S)] care. There was a unit manager admission follow-up checklist that was to be used to verify any additional needed information such as the size of the [CONDITION(S)], or size of the catheter for example. Medication orders were reviewed monthly but other care orders did not have a scheduled review; those were reviewed at the resident care conferences. The unit manager checklist review would have been completed the morning following admission. If there were no orders for [CONDITION(S)] care, it should have been caught on their admission review. In-services on [CONDITION(S)] care were recently completed. RN #10 did checklist competencies for trachs for the LPNs and RNs. The DON stated all RNs had been trained by RN #10 to re-insert a [CONDITION(S)] if one became dislodged and RN #10 would have records of that training. RN #10 assigned the educational material for the staff in the online education program. There were some topics that were automatically assigned in the system by title, but RN #10 was supposed to know what in-services employees were supposed to have based on their job titles. Staff were to have their [CONDITION(S)] care competencies completed annually and were re-educated if there was an incident. The RN supervisors were to check the suction carts and the equipment that went with them. There should be an extra [CONDITION(S)] available when a resident was admitted , and it was the expectation that the concierge and the Unit Manager were to ensure this. -------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified, and the facility Administrator was notified on 8/26/21 at 7:21 PM. The Immediate Jeopardy was removed on 8/27/21 at 1:52 PM based upon the following corrective actions taken: - The facility's regional respiratory therapist (RT) arrived onsite on the evening of 8/26/21 after the IJ was called and began to provide expert education to staff on [CONDITION(S)] care for use in the corrective plan. - Newly obtained Physician orders were reviewed and deemed appropriate by the RT. Emergency equipment and [CONDITION(S)] supplies were obtained and located at the residents' bedsides. - The facility updated their [CONDITION(S)] care policy, including clarification that if accidental decannulation occurred, nursing would not attempt re-cannulation; the airway would be protected to maintain a patent airway, the resident would be oxygenated, and 911 would be called. - By the next morning 8/27/21, 35 nurses (RNs and LPNs) had been educated on [CONDITION(S)] care using PowerPoint classroom training presented by the regional RT. Training was continuing through 10:00 PM that evening. As other nurses presented for work, they also received this training on emergency management and response to maintaining a [CONDITION(S)] and airway, prior to providing resident care. 10NYCRR 415.12(k)(5)(4)

Based on observation, interview, and record review during the abbreviated survey (NY 835), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #1) reviewed for quality of care. Specifically, Resident #1 underwent orthopedic surgery and daily dressing changes were not implemented as ordered following the surgery. Eighteen days after the surgery, the original dressing was removed by the orthopedic surgeon and the surgical incision site was necrotic (dead tissue present). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Findings include: The 8/2017 facility Medication and Treatment Orders Policy documents when initiating a wound care order, orders are to be written for wound care per wound protocol and entered into the chart for the practitioner to review and sign when on-site. The Nurse Supervisor/Charge Nurse must notify the Unit Manager for follow up with the prescriber or attending physician to determine if the treatment is to be continued or adjusted. Nursing will re-assess wounds after an order change to determine if it is effective or needs further follow-up from the practitioner. Resident #1 had [DIAGNOSES REDACTED]. The 1/23/2020 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance with bed mobility and transfers. The resident had a surgical wound and no pressure ulcers. The hospital discharge report dated 1/16/2020, documented the resident fell at home and fractured the left tibia and fibula. The plan was to follow-up for outpatient surgery while at the nursing facility. Orders included to keep the left splint on, move toes often, and follow-up with the orthopedic surgeon on 1/20/2020. The 1/20/2020 orthopedic surgeon's consult documented a surgical procedure to repair the fracture was planned. The resident was to wear the left splint and was to be non-weight bearing to the left leg. The 1/23/2020 orthopedic surgery summary documented a surgical repair of the left tibia was done. Instructions included to change the dressing to the knee/leg daily starting on 1/27/2020. The 1/23/2020 physician's orders [REDACTED].#2 documented to change the resident's dressing to left knee/leg daily beginning on 1/27/2020 and to complete neurovascular checks (evaluation of the sensory and motor function and circulation) to the lower left leg every 4 hours x 5 times and then every shift for 5 days. The 1/23/2020 at 11:10 PM, RNS #2's progress note documented the resident returned from the hospital with the left leg wrapped with an ACE (elastic) bandage and splinted. The resident was to remain with surgical dressing until 1/27/2020. The resident was to follow-up with the orthopedic surgeon on 2/6/2020, pedal pulses were present (pulses in the top of the foot), there was no [MEDICAL CONDITION], and the resident was moving their toes. Nursing progress notes from 1/28/2020 through 1/31/2020 contained no documentation regarding the resident's surgical wound, surgical dressing changes, or neurovascular checks. The 1/31/2020 and 2/7/2020 nurse practitioner's (NP) progress notes documented she saw the resident for a pressure ulcer that had developed on the left foot from the casts worn prior to surgery. There was no documentation regarding the resident's surgical wound. The January 2020 Treatment Administration Record (TAR) did not document the resident's dressing was changed as ordered on [DATE] and did not document completion of daily dressing changes from 1/28/2020 through 1/31/2020. The TAR did not document the resident received neurovascular checks to the lower left leg every 4 hours x 5 times, then every shift for 5 days from 1/23/2020 through 1/29/2020. The February 2020 TAR did not document the resident received daily dressing changes to the surgical wound from 2/1/2020 through 2/9/20/20. The 2/10/2020 orthopedic surgeon's note documented the resident's ACE bandage was removed and there was eschar (dry, dead tissue) and necrotic (dead) soft tissue along the edges of the surgical incision. The resident was over 2 weeks post-op for a left tibia and fibula fracture. The plan was to apply a dry dressing daily. Recommendations included a wound clinic evaluation for possible hyperbaric (pure oxygen treatment for [REDACTED]. The 2/10/2020 at 5:13 PM, wound documentation note by the Director of Nursing (DON) documented the surgical incision measured 11 cm (centimeters) with a scant amount of exudate (drainage), no odor and surrounding tissue was normal. The resident was seen by the surgeon and the post-op dressing was removed. The 2/10/2020 at 5:42 PM, DON's progress note documented the surgical incision had moist yellow brown eschar and no signs of infection. The 2/10/2020 physician's orders [REDACTED]. The first documented note by the attending physician since the resident's surgery was dated 2/12/2020 and documented nursing asked him to see the resident's surgical wound. The physician documented yesterday, the wound was slightly blackened and more red and today, the wound looked much better, had no drainage, and had less black areas and redness. The wound measured 3 cm x 2 cm with 100% eschar, and the plan was to continue with the same wound care. On 2/26/2020 at 1:47 PM, the resident stated in an interview, when admitted on [DATE], there was a splint type cast (2 solid boards from the knee to the bottom of the foot) that was wrapped with an ACE bandage. The resident had surgery on 1/23/2020 and was told that the surgeon sent orders to the facility about how to care for the leg. The resident stated upon return to the facility after surgery, there was just an ACE wrap on the leg and no one at the facility removed the dressing or checked the resident's feet or circulation from the day of surgery until the follow-up with the orthopedic surgeon on 2/10/2020. The resident never said anything to staff because the resident thought they knew what they were doing. On 2/27/20 at 9:07 AM, the resident was observed in a recliner having bandages cut off the left leg. Two unidentified staff and the Assistant Director of Nursing (ADON) were present. The ADON measured the resident's wounds. The resident's original incision line on the left lateral leg was 11 cm x 0.7 cm and was 100% black eschar. On 2/27/2020 at 11:00 AM, the orthopedic surgeon stated in a telephone interview, he saw the resident for surgery on 1/23/2020. After surgery, he discontinued the splint and wrapped the resident's leg with an ACE wrap and sent instructions to the facility to change the dressing daily starting on 1/27/2020. When he followed-up with the resident on 2/10/2020, the dressing had not been changed and moist necrotic tissue was present in the wound. He stated if the facility had done the dressing changes as ordered the resident's wound may not have been as bad as it was. On 2/27/2020 at 12:38 PM, RNS #2 stated in a telephone interview, she was the Nursing Supervisor on 1/23/2020 when the resident returned from surgery. She entered the orders into the electronic record and thought they would automatically populate on the TAR. She stated that did not occur and the orders for the dressing change and neurovascular checks were not implemented. She stated the neurovascular checks were to be done to ensure the resident had adequate blood supply and feeling in the left leg. She stated the error in entering the order caused the resident to not have neurovascular checks or a dressing change for 18 days after surgery. On 2/27/2020 at 1:20 PM, the DON stated in an interview, she first became aware of the resident not having a dressing change after surgery when the resident returned form the orthopedic follow-up appointment on 2/10/2020. When the Supervisor put the order in the electronic record, the Supervisor did not add the scheduling details, so the order was not carried over to the TAR. She recalled nursing asking her about the dressing change and she told them there was an order, but she did not realize it did not populate on the TAR. She stated nursing never brought it to her attention again, so she assumed it was being changed. The wound team typically followed surgical wounds and it was the job of the Nurse Manager to send the referral to the team. She was not sure why that was not done and why the resident's surgical wound was not seen by the wound team. Wounds were discussed in morning report when they worsened. The resident's wound was not being seen by the wound team therefore it was not talked about in morning report. She stated the resident's dressing change was not done timely. On 2/28/20 at 9:26 AM, RN Manager #6 stated in an interview, she was out of work from 1/24/2020 to 1/31/2020. As the Nurse Manager, she was responsible to refer residents to the wound team and that was not done for the surgical wound. The resident was scheduled to be seen by the wound team on 1/26/2020 for a pressure ulcer and she did not know why the wound team did not also look at the resident's surgical incision that day. She stated the dressing change was not done for 18 days. When she returned to work on 1/31/2020, she did not follow up with the resident's surgical incision and could not find any paperwork related to the discharge orders. The resident's family member brought to her attention the dressing had not been changed since surgery and the family member faxed to the facility the 1/23/2020 orders on 2/10/2020. She stated the error was avoidable. The nurse that admitted the resident on 1/23/2020 did not schedule the treatment on the TAR. On 2/28/2020 at 11 AM, the Medical Director stated in a telephone interview, he expected nursing to assess wounds and do dressing changes based on the surgeon's order. When the resident went 18 days without a dressing change, it was not done timely. He was aware the resident was found with necrotic tissue after the dressing was changed on 2/10/2020 and it was hard to say whether that could have been avoided had the dressing been changed timelier. On 2/28/2020 at 11:20 AM, the NP stated in a telephone interview, she was at the facility once weekly and only saw residents for wound care. She was notified of a resident's wounds when she arrived at the facility and the ADON or DON presented her with a list of residents to see while she was there. The ADON or the DON were usually present with her during wound rounds. She typically did not follow surgical wounds unless there was a referral for a wound that was not healing or was infected. She first saw the resident on 1/31/2020 for a pressure ulcer and she did not know at the time the resident had a surgical wound because pants covered the dressing. After the resident saw the surgeon on 2/10/2020, one of the facility NP's called her the next day and said the resident's surgical wound looked bad and wanted to know what she should do. She told her to follow the surgeon's orders. She stated the facility should have changed the dressing timelier and 18 days was too long. 10NYCRR 415.12

Based on observations, record review, and interviews during the abbreviated survey (NY 992), the facility did not ensure residents received adequate supervision and assistance devices to prevent accidents for 4 of 5 residents (Residents #1, 2, 4, and 5) reviewed for smoking. Specifically: - Resident #1 was a known smoker in a non-smoking facility who regularly verbalized her desire to smoke and had been found smoking outside and in possession of smoking materials on several occasions. The facility failed to complete safety assessments or develop and implement a plan of care to ensure her safety when she continued to smoke despite re-education. On (MONTH) 24, 2019, Resident #1 caught on fire while smoking and staff used a fire extinguisher to douse the flames. The resident was hospitalized with second- and third-degree burns. - Residents #2, 4, and 5 were known smokers who were found smoking and/or in possession of smoking materials and the facility did not complete safety assessments or develop and implement plans of care to ensure their safety. The facility failed to develop and implement a plan to safeguard the facility's other 111 residents from accidents caused by smoking. This resulted in actual harm that was Immediate Jeopardy/Substandard Quality of Care for Resident #1 and no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy for Residents #2, 4 and 5. Findings include: The (undated) Smoke Free Facility Policy documented if a resident was identified as a smoker, nursing would communicate that information with the interdisciplinary team. The nurse and physician would discuss smoking cessation options with the resident/family. Any resident identified as non-compliant with the facility's non-smoking policy would have immediate corrective action including notification of the Nurse Manager and social worker; documentation by staff in the medical record and follow up counseling by the social worker. If continued non-compliance occurred, the case would be discussed with administration relative to discharge planning. The facility would possess all smoking and lighting material at all times. Smoking material was kept in the smoking cart and returned to resident and/or family upon discharge. 1) Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 6/21/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 2 for bed mobility and transfers and supervision with set up for locomotion off the unit. The resident had impairment of both arms and one leg. The section indicating current tobacco use was blank. On 12/6/18 the resident signed confirmation she had read the facility's Smoke Free Facility policy and agreed to abide by the policy. This was included with the facility's Admission Agreement. The 12/6/18 physician's orders [REDACTED]. The order was discontinued on 2/1/19. The resident's comprehensive care plan (CCP) initiated on 12/7/18 documented the resident was to be escorted to facility activities. The CCP contained no documented plan for the resident to sign herself off the unit on her own and did not document the resident's smoking history. The CCP, revised 1/8/19, documented the resident had limited physical mobility related to decreased mobility and right sided weakness. The CCP did not document the resident's smoking history or need for nicotine patch. The 5/8/2019 physician's progress note documented the resident's main complaint was that she wanted to be allowed to smoke. The physician documented it was a non-smoking facility so her family would have to take her off the grounds to smoke. He also documented she could have a nicotine patch if she wanted one but most likely did not need one as she had not smoked in a quite a while. The 7/23/19 at 7:14 PM, licensed practical nurse (LPN) #1's progress note documented the resident was found off the unit and was very upset she could not smoke cigarettes. She wanted to be allowed to come and go from the building to the parking lot and wanted to smoke when and where she pleased. The resident was not redirectable, the Supervisor was made aware and the resident would be monitored for safety. LPN #1 documented the resident was noted to have decreased use of her hand that day. The 7/25/19 at 12:41 PM, LPN #9's progress note documented the resident had cigarettes removed from her room and they were now locked in the medication room. The note contained no further documentation about the occurrence. There were no documented changes made to the resident's plan of care and no documentation of how the facility would prevent recurrence after she was found with cigarettes in her room. The 7/27/19 physician order [REDACTED]. There was not a corresponding medical progress note documenting why this medication was ordered. There was no documentation on the (MONTH) 2019 Medication Administration Record [REDACTED]. Nursing progress notes documented: - On 7/29/19 at 11:42 AM, the resident asked LPN #2 to get her a cigarette out of the medication room and not tell anyone. The Nurse Manager was aware, and the plan was to continue to monitor. - On 7/31/19 at 12:51 PM, the resident asked LPN #2 to sneak her a cigarette from the medication room. The Nurse Manager was aware. - On 8/2/19 at 11:01 PM, the resident's electric wheelchair was not working, and she used a manual wheelchair. The resident requested to go outside after dinner and LPN #1 offered to accompany her for safety while in the manual wheelchair. The resident was upset and yelled I want to go alone. I don't need you babysitting me and keeping me from smoking! - On 8/4/19 at 6:48 PM, the resident was found outside smoking by registered nurse Supervisor (RNS) #3. She surrendered two lighters, a single cigarette and was re-educated on the facility's non-smoking policy. - On 8/5/19 at 12:29 PM, the resident asked LPN #2 to sneak her a lighter from the medication room. The resident was re-educated on the nonsmoking policy and told she could not have the lighter. The Nurse Manager was aware, and the plan was to continue to monitor. The note contained no further documentation related to the occurrence. - The 8/7/19 at 9:17 AM, the resident made a request to the social worker to be moved to another facility where she would be allowed to smoke. The resident stated it would be good for her because she kept getting caught smoking. - The 8/9/19 at 2:34 PM, an occupational therapy (OT) evaluation was requested due to decreasing mobility in the resident's right hand. - On 8/11/19 at 1:34 PM, the resident signed herself out to go outside to the front of the building. When the resident returned, she stated to LPN #2, I only had one cigarette on me. The Supervisor was aware, and the plan was to continue to monitor. - On 8/12/19 at 2:24 PM, the resident still wanted to go out and smoke, and the Nurse Manager was aware. The CCP from 7/23/19 to 8/12/19, did not document the resident was non-compliant with smoking and did not document interventions or education to assist the resident with smoking behaviors. physician's orders [REDACTED].>- On 8/13/19, give nicotine gum, 2 mg every 4 hours as need for smoking cessation. The 8/23/2019 nurse practitioner's (NP) progress note documented the resident reported she enjoyed smoking and her mother was bringing her cigarettes. The resident felt that smoking was the only thing she had left that she enjoyed, and she had no intention of quitting. She did not use the nicotine gum and was thinking about transferring to a facility that allowed smoking. There was no documentation on the (MONTH) 2019 MAR indicated [REDACTED]. On 8/24/19 at 6:02 PM, RN #3 documented he was notified the resident was on fire near the fountain outside. The resident was extinguished by certified nurse aide (CNA) #4, 911 was notified and on the scene, and the physician was notified. The 8/25/19 Investigative Summary documented at approximately 3:45 PM on 8/24/19, the resident signed herself out, was found on fire a short time later and the fire was extinguished by a CN[NAME] The summary documented the resident was alert and oriented and independent with self-propelling her wheelchair. The resident made a conscious decision despite education on the facility nonsmoking policy. The investigation did not document determination of how the resident continued to obtain smoking materials, did not develop and implement a plan to ensure the safety of other known smokers, or safeguard the facility's other residents from accidents caused by smoking. The 8/24/19 at 8:09 PM, hospital report documented the resident [MEDICAL CONDITION] a clothing fire consisting of second/third-[MEDICAL CONDITION](second-degree are partial thickness, third-degree are full thickness) to the right cheek, left chest wall, lateral portion of left breast, right breast, abdomen, medial (midline) left thigh, right forearm and right wrist and left upper extremity. The resident reported she sprayed herself with cologne to cover up the smell of smoking and her clothing caught fire. The 8/26/19 at 10:52 AM nursing progress note by LPN #2 documented the resident's nightstand was unlocked and 2 packs of cigarettes were found. On 8/26/19 at 1:25 PM, the Assistant Director of Nursing (ADON) stated in an interview, the facility's non-smoking policy went into effect in 10/2018. She stated the facility no longer assessed residents for smoking safety because the facility was nonsmoking. Residents signed the nonsmoking policy/contract upon admission and were re-educated when they were noncompliant. During an interview on 8/27/19 at 12 PM, the ADON stated Resident #1 was not safe to smoke related to the contractures and one-sided weakness. She stated the resident often asked staff to sneak her cigarettes and she was caught smoking at times with the adult day care registrants. She stated when residents were caught breaking the smoking policy staff documented, reported, re-directed, re-educated, offered smoking cessation, and offered a lateral transfer. She stated after incidents occurred, they discussed it in morning report and the social workers should have been searching resident rooms for smoking materials. On 8/26/19 at 2:32 PM CNA #4 stated in an interview, the resident had multiple instances of asking to smoke, everyone knew she smoked but she had never witnessed the resident smoking. Staff redirected the resident when she verbalized wanting to smoke. The resident could sign herself out to the front of the building, but she could not leave the grounds without family. CNA #4 stated she was aware of one instance of the resident smoking a few weeks ago, another resident reported this to her so she notified the Supervisor and nurses. She stated on 8/24/19 she witnessed flames from the resident's waist to neck and extinguished the flames. On 8/27/19 at 8:55 AM, the Director of Social Services stated in an interview, the resident wanted a lateral transfer to a facility where she could smoke, and the Director of Social Services completed the referral. She stated she had not heard the resident had been caught smoking but if she had, the resident should be educated and a discharge plan for the resident should be discussed. She stated the only room searches were after the incident on 8/25/19 and were done by the ADON. She did not know if any smoking materials were recovered. On 8/27/19 at 9:10 AM, social worker #6 stated in an interview the resident had issues with smoking and she frequently discussed with the resident that if the behavior continued, the resident would be transferred to another facility that allowed smoking. She witnessed the resident smoking outside by the fountain or near the benches in the weeks prior to the incident. She was not sure how the resident got cigarettes or a lighter and she never asked her. She stated sometimes she saw the resident smoking when she was leaving her shift for the day so she would re-educate the resident the next day when she came to work. She stated she reported the resident's smoking during the morning meetings and to the Director of Social Services and she was directed to continue educating and make referrals to another facility. She was not sure if any assessments had been completed to determine if the resident could safely smoke. The resident had one hand that was not functional, and she was not sure if the resident could hold a cigarette. On 8/27/19 at 9:35 AM, LPN #7 Unit Manager stated in an interview, the resident had decreased mobility, difficulty with transfers and ambulation, and decreased use of her right hand. She had been caught smoking upwards of 10 times but never by him. When a resident was caught smoking or found with smoking materials the process was to write a nursing note and report to social services for follow up education. Safety assessments for smoking were no longer completed once the facility became nonsmoking. On 8/27/19 at 9:55 AM, LPN #2 stated in an interview the resident talked about smoking nearly every day and tried to get cigarettes from her. She reported the behavior to the Nurse Manager and social worker. She was instructed to report and document the behavior and was not sure who gave the resident cigarettes. On 8/27/19 at 11:05 AM, LPN #1 stated in an interview, the resident used to sneak outside when staff members were busy. The resident was not allowed to smoke but the LPN had smelled smoke on the resident in the past. The resident would swear she did not have materials on her and told the LPN other residents were giving her materials to smoke. She stated she always reported incidents to the Supervisor. Interventions to assist the resident included nicotine gum and re-education. She stated she did not believe the resident was safe to smoke. On 8/27/19 at 2 PM, LPN #22 stated in an interview about 3 weeks ago she gave the resident a cigarette and felt no harm in giving her a cigarette at that time. She stated the resident was physically impaired and should have been under supervision while smoking. On 8/28/19 at 2:56 PM, RN #3 stated in an interview, he was notified the resident was smoking on 8/4/19 near the adult day care smoking area. He confiscated the resident's cigarettes and lighters and offered to get her something for smoking cessation which she refused. The resident would not tell him where she got the cigarettes from. On 8/29/19 at 10:42 AM, nurse practitioner (NP) #5 stated in a telephone interview, she evaluated the resident on 8/23/19, the day before the accident as someone told her they caught the resident smoking. She stated that was the first time she heard the resident smoked. When she evaluated the resident that day, the resident smelled of smoke and she did not ask the resident where she was getting her cigarettes from. The resident had a contracted right hand and she was not sure if the resident would be able to safely smoke on her own. She stated if she had been made aware the resident smoked and was found with smoking materials, she would have evaluated her more frequently and attempted other interventions. On 8/27/19 at 1:11 PM, The Director of Education and Employee Health stated in an interview she conducted the new employee 2-day general orientation and she did not train staff on the smoking policy. 2) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 7/3/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required supervision for most activities of daily living, limited assistance with locomotion on and off the unit, and he used tobacco. The 6/26/19 admission nursing progress note written by registered nurse (RN) Manager #21 documented the resident was a current smoker. The 6/26/19 RN #21 Manager Smoking Evaluation documented the resident was a smoker, he could light his own cigarette, and smoking not allowed while in the facility. The facility did not need to store a lighter and cigarettes, and the plan of care was used to assure the resident was safe while smoking. The 6/27/19 and 8/20/19 nurse practitioner (NP) #5's progress note documented the resident's social history included smoking. There was no documentation the resident was offered smoking cessation treatment. The 7/1/19 attending physician's progress note documented the resident had a history of [REDACTED]. The 7/1/19 Director of Physical Therapy's (PT) progress note documented the resident was found with a cigarette and lighter in his chair while at therapy. The paraphernalia was taken away and given to the Nurse Manager and the resident was educated on the non-smoking policy. The 7/7/19 licensed practical nurse (LPN) #10's progress note documented the resident left the floor a dozen times a day to smoke. The 8/7/19 social worker #6's progress note documented the social worker met with the resident to review the non-smoking policy and the resident agreed to follow the rules. His smoking items were given to nursing to lock up and the resident could ask for them if he went out on pass. The 8/19/19 social worker #17's progress note documented the resident was offered a lateral transfer to a facility which allowed smoking and the resident accepted. The comprehensive care plan (CCP) was updated on 8/24/19 and documented the resident was non-compliant with smoking paraphernalia in the facility, smoking on facility grounds and he had been educated on the non-smoking policy in the facility. There was no prior documentation the resident's smoking habits had been addressed. On 8/26/19 at 1:25 PM, the Assistant Director of Nursing (ADON) stated in an interview, the facility's undated non-smoking policy went into effect on 10/2018 when the facility was bought by the current company. She stated the facility no longer assessed residents for smoking safety because the facility was nonsmoking. Residents signed the nonsmoking policy/contract upon admission and were re-educated when they were non-compliant. The surveyor asked why the resdent had a smoking evaluation if the facility was not using them and she stated the evaluations were present in the electronic medical record system so the nurse who completed it must have known the resident was a smoker and saw the evaluation was in the system so she completed it. On 8/27/19 at 8:55 AM, the Director of Social Services stated in an interview, the resident was a known smoker at the facility and was being transferred to another facility where he could smoke. She stated when a resident was caught smoking, they reeducated and worked on discharge planning. During an interview on 8/28/19 at 11:54 AM, the ADON stated the resident was found with a burn mark in the shape of his cigarette on his slipper. She stated she interviewed him and the staff and determined the burn mark occurred before his admission. The ADON stated social work was responsible for documenting non-compliance with smoking on the CCP. During an interview on 8/29/19 at 9:15 AM, PT #14 stated she had not seen the resident smoking, could often smell cigarette smoke on his clothes, and she did not report it. During an interview on 8/29/19 at 10:00 AM, certified occupational therapy assistant (COTA) #13 stated if she saw residents smoking, she reported it to her supervisor and the Administrator. Resident #4 was one of the most common smokers and he would go to the neighbor's lawn next to the facility to smoke. She stated the staff found bags of loose cigarettes in the resident's room. During an interview on 8/29/19 at 10:47 AM, recreation aide #15 stated she had heard staff talking about residents smoking and three of the residents (Resident 1, 2, and 4) were exchanging cigarettes amongst themselves. Resident #4 interrupted a Bingo activity once to ask Resident #1 for cigarettes. 3) Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 3/14/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and did not currently use tobacco. The 7/7/19 licensed practical nurse (LPN) #10's progress note documented the resident was seen outside pushing her wheelchair up a hill to smoke. The resident was hospitalized from 7/16 to 8/5/19. The readmission registered nurse (RN) #11's progress note documented the resident was readmitted and was a current smoker. The smoking evaluation completed by licensed practical nurse (LPN) Manager #7 on 8/5/19 documented the resident was a smoker, smoked 2-5 times per day, and liked to smoke in the mornings, afternoon, and evenings. The facility needed to store her lighter and cigarettes, and she had a plan of care in place to ensure safety. On 8/6/19 the CCP documented the resident was a problem smoker. No interventions were documented to ensure her safety. The 8/7/19 social worker #12's progress note documented she spoke with the resident about the resident's smoking. The resident was aware of the non-smoking policy and was in agreements with the rules. On 8/15/19, interventions were added to the CCP to offer medications for smoking cessation, gum and patches and to refer to medical interventions to promote smoking cessation at the request of the resident. The 8/24/19 Assistant Director of Nursing (ADON) progress note at 5 PM, documented she went to the resident's room to re-educate the resident on the non-smoking policy and asked her to sign the smoking agreement that residents sign on admission. The resident yelled foul language at the ADON, refused to sign the agreement, and stated it was her right to smoke. Her room was searched, and no cigarettes were found. On 8/24/19, a new problem of non-compliance with the smoking policy was added to the resident's CCP. The CCP documented the resident was non-complaint with smoking paraphernalia in the facility and smoking on facility grounds. The resident was educated on the non-smoking policy. Interventions included documenting all behaviors and attempting to identify patterns to target interventions. The 8/25/19 at 10:20 AM, RN Supervisor #3's progress note documented the resident was seen on the corner of the sidewalk smoking. She refused to sign the non-smoking policy and give up her smoking paraphernalia. The 8/25/19 at 11:51 AM, RN Supervisor #3's progress note documented the resident was smoking on facility property. The resident refused to sign the non-smoking policy. The 8/25/19 at 2 PM, LPN #2's progress note documented the resident signed herself out earlier in the day and the Supervisor showed up shortly thereafter as someone told him the resident was smoking. The resident said she would not be signing anything about non-smoking. The 8/26/19 at 11:59 AM, LPN Manager #7's progress note documented he searched the resident's room and found a lighter and locked it in the medication room. On 8/26/19 at 1:25 PM, the ADON stated in an interview, the facility's undated non-smoking policy went into effect on 10/2018 when the facility was bought by the current company. She stated the facility no longer assessed residents for smoking safety because the facility was nonsmoking. Residents signed the nonsmoking policy/contract upon admission and were re-educated when they were non-compliant. The surveyor asked why the resident had a smoking evaluation if the facility was not using them and she stated the evaluations were present in the electronic medical record system so the nurse who completed it must have known the resident was a smoker and saw the evaluation was in the system so she completed it. On 8/27/19 at 8:55 AM, the Director of Social Services stated in an interview, she was not aware the resident was a smoker until that day in morning report. She stated this past weekend, the ADON did room searches after the 8/25/19 incident and she did not know if any materials were recovered from any of the smokers. She stated she updated the resident's CCP when she was told she was a smoker and the plan was to reeducate the resident on the non-smoking policy and work on discharge planning if the resident was non-compliant. On 8/27/19 at 9:10 AM, social worker #6 stated in an interview, she witnessed the resident outside smoking in the past. The resident was non-compliant with the non-smoking policy. She stated when she saw the resident smoking, she reminded her the facility was non-smoking. She was not sure where the resident got her smoking material from. from. She stated smoking was discussed in morning report and she was directed to continue educating and make referrals to another facility. On 8/27/19 at 9:35 AM, LPN #7 Manager stated in an interview, he knew the resident smoked in the smoking area designated for the adult day care registrants. He stated he took a lighter from the resident today, so he knew she did not currently have one. He did not know if she had smoking materials in her possession before today. On 8/27/19 at 10:25 AM, concierge #16 stated in an interview, the resident had been caught smoking in the past and she was told to review the non-smoking policy with her and the other smokers. She stated the policy referenced a smoking cart, but the facility did not have one. She stated materials should be locked up in the medication room. She stated the resident was outside smoking a lot and when she was caught, she was told she could not smoke. She did not know where the resident got smoking materials from. On 8/28/19 at 2:56 PM, RN #3 Supervisor stated in an interview, he first became aware the resident was a smoker on 8/25/19, when Resident #3 told him the resident was outside smoking. He informed her she could not smoke on the premises, he reeducated her, and she refused to sign the non-smoking agreement. During an interview on 8/29/19 at 10:00 AM, certified occupational therapy assistant (COTA) #13 stated if she saw residents smoking, she told her supervisor and the former Administrator. Resident #2 was one of the most common smokers at the facility. ______________________________________________________________________________________ Immediate Jeopardy was removed on 8/29/19 at 12 PM prior to exit based on the following corrective actions taken. The facility: - Assessed the 3 current smokers for smoking safety and had their care plans updated. - Reviewed the smoking contract with the 3 current smokers. All agreed to sign and adhere to the contract. - Offered all 3 smokers smoking cessation products. - Searched all 3 smokers' rooms for smoking materials and had smoking material locked in the medication room. Room searches for smoking materials will be conducted weekly until a pattern of compliance is established. - Interviewed the remaining 111 residents to determine any further smokers in the facility. Additionally, all residents will be assessed quarterly related to safe smoking. - Determined Incident and Accident reports would be completed for all future incidents of smoking non-compliance. -Educated staff on any revisions to the facility's protocol related to smoking non-compliance and educated staff what to do if a resident was seen attempting to smoke or in possession of smoking material on facility grounds. 10 NYCRR 415.12(h)(2)

Based on observation, record review and interview during the abbreviated survey (NY 867) the facility did not ensure 1 of 3 residents (Resident #1) reviewed for quality of care received treatment and care in accordance with professional standards of practice. Specifically, Resident #1 had worsening circulation in her left foot, there was a delay in notifying the medical provider of ordered test results and nursing did not report additional details from the test results which could indicate the need for additional treatment. This resulted in actual harm to Resident #1 that is not immediate jeopardy. Findings include: The 10/2018 facility Change in Condition Policy documented should a resident experience a medical change in condition, it is the expectation the registered nurse (RN) on duty will perform a full assessment of the resident and document such change in the medical record and notify the physician of such changes. Upon a change in the resident's condition, the licensed nurse on duty will promptly notify the RN Supervisor and make him/her aware. A change in condition may include, but not limited to refusal of treatment or medications (2 or more consecutive), or significant change in physical condition. The Nurse Supervisor will notify the resident's attending physician or on-call physician. Resident #1 was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident had [DIAGNOSES REDACTED]. The 3/21/19 Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired, required extensive assistance with bed mobility and transfers and did not have impairment to her lower extremities. A 6/20/19 at 10:17 PM licensed practical nurse (LPN) #6 progress note documented the resident complained of left lower limb and foot pain. The resident was given routine Tylenol. There was no documentation of discoloration of the left foot. A 6/21/19 (no time documented) nurse practitioner (NP) #11 progress note documented staff noticed a slight discoloration to the resident's left foot, which appeared mottled (red or purple spotting/blotching). The great toe was somewhat purple and no pedal (foot) pulses could be identified by staff. The NP documented she was concerned about the discoloration to the left foot which was new, and it was consistent with an arterial obstruction. The plan was to obtain both a venous ultrasound (a test to determine blood flow in the veins) and an arterial ultrasound (a test to determine blood flow in the arteries) for further evaluation. Depending on those results the NP documented she would determine appropriate referral if required. If the discoloration of the left foot worsened or the resident developed any pain staff were to notify medical immediately. There was no correlating nursing progress note referencing the NP's evaluation and instructions. A 6/21/19 physician order [REDACTED].#17 documented to obtain a venous and arterial ultrasound of the left lower extremity. A 6/21/19 at 7:42 PM radiology report documented a venous ultrasound of the left lower extremity was completed. The report documented it was faxed to the facility with results indicating no evidence of [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot). The report documented the results were reviewed by the facility physician on 6/24/19 at 10:29 AM. A 6/21/19 at 11:17 PM LPN #16 progress note documented the resident had bruising to the top of the left foot and toes. A 6/22/19 at 1:44 AM LPN #14 progress note documented the resident had bruising to the top of the left foot and toes. A radiology results report for a left lower extremity arterial ultrasound performed on 6/22/19 at 9:56 AM documented there was [MEDICAL CONDITION] disease noted throughout the left lower extremity. The blood flow was antegrade (normal). The peak systolic velocities were unusually low (blood flow rate after heart contracts) possibly due to an iliac artery stenosis or occlusion causing the diminished flow in the left lower extremity. In view of the findings, clinical aspects should determine if computed tomography (CT) [MEDICATION NAME] or magnetic resonance (MR) [MEDICATION NAME] (tests used to view blood vessels) was necessary to evaluate the iliac artery. The report documented it was faxed to the facility (unknown time). The report documented the results were reviewed by the facility physician on 6/24/19 at 10:29 AM. A 6/23/19 at 2:11 AM LPN #14 progress note documented the resident's feet and hands continued to feel cold. A 6/23/19 at 9:16 PM Director of Nursing (DON) #15 documented the resident was presenting with abnormal vital signs including blood pressure (100/68), heart rate (83), respiratory rate (16), and decreased intake with weight loss. The resident's left foot was deep purple to above the ankle, cold with a faint pulse and painful. Changes were reviewed with NP #5 on 6/23/19 at 12:00 AM who recommended a venous ultrasound and blood testing. 6/23/19 physician orders [REDACTED].#15 and ordered by NP #5 documented a venous ultrasound of the left lower extremity. A radiology report documented a second venous ultrasound to the left lower extremity was performed on 6/23/19 at 9:00 PM. There was no evidence of [MEDICAL CONDITION]. There appeared to be some fluid in the soft tissues around the common femoral vein and superficial femoral vein. The report recommended clinical evaluation of the fluid since it is not been seen on the prior study of 6/21/19. The report documented the results were reviewed by the facility physician on 6/24/19 at 10:29 AM. A 6/24/19 at 12:50 AM LPN #14 progress note documented the left foot/lower leg remained purplish in color and cold to touch, an ultrasound was performed and was to be evaluated by medical. A 6/24/19 (no time) NP #11 progress note documented she had evaluated the resident on 6/21/19 for new discoloration to the left foot. The left leg venous ultrasound was negative for [MEDICAL CONDITION] and the left leg arterial ultrasound indicated reduced blood flow. The radiologist recommended a CT for further evaluation of iliac/aorta. The entire foot extending up to just beyond the ankle was a dark purple. The resident had no pedal pulses and had abdominal pain. On exam, the resident was moaning and shifting position, appeared in acute distress, and had difficulty focusing and keeping her eyes open. Despite a negative arterial ultrasound, it was obvious the resident had an arterial occlusion most likely in the iliac area. Her condition was critical and ultimately fatal if not addressed soon. The resident would be transported to the hospital as soon as possible. There were no nursing progress notes for 6/24/19 documenting the resident's condition after evaluation by the NP. A transfer form dated 6/24/19 documented the resident was transferred to the hospital at 4:02 PM. The reason for transfer was listed as other. There were no nursing progress notes addressing the resident's transfer to the hospital. The 6/24/19 emergency department (ED) final report documented the resident had a clinical history of a cold, purple pulseless left lower extremity. Moderate pain was present in the left calf for one week. A left lower extremity ultrasound was performed. The resident had an abdominal aortic aneurysm (AAA, a bulging of the aorta) measuring 5.6 centimeters (cm) x 4.7 cm x 4.5 cm with a thrombus (blood clot) and occluded left posterior and anterior tibial (leg) arteries and dorsalis pedis (foot) arteries. The resident was transferred to a second hospital for vascular surgery on 6/24/19 at 7:55 PM. A 6/24/19 at 10:38 PM hospital physician assistant (PA) progress note (from the second hospital) documented the resident was admitted with an AAA with a thrombus (clot) and occluded lower extremity arteries. The resident would likely require a left [MEDICAL CONDITION] or an above the knee amputation as the leg had signs of irreversible ischemia (lack of blood flow); diffuse purple staining, decreased movement, and no sensation or pain at the level of the foot/ankle. A 6/27/19 hospital PA progress note documented the failure to seek medical care for an acutely ischemic left foot greater than 48 hours, contributed to the need for amputation. A 6/28/19 hospital discharge note documented that on admission, the resident had a cold, mottled, purple left foot and calf. The resident had a large AAA, a right internal iliac artery aneurysm with [MEDICAL CONDITION] (blood clot) consistent with rupture, and arterial occlusion in the left leg. The resident underwent [REDACTED]. During an interview with CNA #20 on 7/1/19 at 8:36 AM, she stated she worked the 10:00 AM - 6:00 PM shift on the weekend of 6/21-6/23/19. The resident's foot turned a little blue and within 24 hours the discoloration worsened, and the resident's left leg and foot kept getting colder. She stated during the night of 6/23/19 the resident's foot got darker and extended from the toes up the foot. During an interview with LPN #16 on 7/3/19 at 9:55 AM, she stated she worked the evening and night shift on 6/21/19. When she had arrived at 2:00 PM she was told the resident had new bruising to the top of her foot. She stated she went to view the foot and saw there was bruising from the toes to mid-way up the left foot. The resident had complained of pain and she administered Tylenol. She remembered talking to a supervisor regarding the resident but did not document on it and did not recall who the supervisor was. During interviews with RN Unit Manager #17 on 7/2/19 at 2:00 PM, on 7/3/19 at 10:50 AM and on 7/5/19 at 9:40 AM, she stated when she arrived to work on 6/21/19 the resident's left leg was pale and cool to the touch. When NP #11 arrived that day, the NP went in to see the resident and ordered a venous ultrasound. RN #17 then entered the order and contacted radiology to set it up. She stated the results would be uploaded in to the resident's electronic record by radiology and someone would have to actively go in and obtain the results. The results were not back when the RN Unit Manager left between 4:00 PM - 5:00 PM. On 6/24/19 she and NP #11 went in to see the resident and the resident's foot was dark purple from her toes to mid-shin. The shift report from the weekend had documented the resident had an ultrasound done and her foot was cold to the touch. She could not recall who worked that weekend, but she had talked to them to confirm the resident's noted condition. She stated she completed the hospital transfer form and it was documented the resident was transferred to the hospital on [DATE] at 4:02 PM. During an interview with RN Supervisor #24 on 7/3/19 at 11:28 AM, she stated she came in to work at 11:00 PM on 6/23/19. She had not worked on 6/21 or 6/22 and she was not made aware there were concerns with the resident's condition when she arrived to work on 6/23. She stated if someone had notified her an ultrasound had been done, she would have checked the electronic record. She stated if she saw the ultrasound recommended further follow up, she would have contacted a medical provider immediately. She stated she did not go and see the resident at all during the night shift and had not been notified of any changes to the resident's foot. During an interview with Assistant Director of Nursing (ADON) #25 on 7/2/19 at 12:33 PM, she stated NP #11 had noted on 6/21/19 the resident's foot was purplish and mottling and the NP ordered ultrasounds. On 6/24/19 she heard NP #11 and Unit Manager #17 discussing the resident's foot, so she went to look at it and then asked physician #22 to see the resident. The resident's foot was a lot darker and cold at that point. The resident was discussed in morning report on 6/24/19. RN Unit Manager #17 was going to review the results of the ultrasound that morning after report. The RN Supervisor that worked the night shift from 6/23-6/24/19 had not documented on the resident. During interviews with DON #15 on 7/2/19 at 3:25 PM, on 7/3/19 at 11:45 AM, and on 7/5/19 at 2:30 PM, she stated RN Unit Manager #17 had asked NP #11 to assess the resident on 6/21/19. Following that assessment ultrasound studies were ordered. She stated she came in to work for the overnight shift at 1:00 PM on 6/21/19 and she was not aware the resident had a venous ultrasound study when she received shift to shift report. Their electronic system did not trigger someone to review a report and a nurse would have to know to look for the results to view them. She was contacted during the day shift on 6/23/19 because the resident's foot was purple. She stated it was documented as bruising in the resident's record. She stated there was a difference between mottling and bruising and had the resident's foot been cold it would have been mottling and that meant something circulatory was going on. She contacted NP #5 who ordered a venous ultrasound. She stated she reported to NP #5 the resident's ultrasound was negative for a [MEDICAL CONDITION]. She did not notice there was further information on the radiology report. There was no monitoring for a potential change in the foot, and there should have been. During interviews with NP #5 on 7/1/19 at 3:30 PM and on 7/2/19 at 4:34 PM, she reviewed the resident's electronic record and stated she had not documented she had assessed the resident's leg or foot other than a previously documented calloused area. When she was contacted while she was on-call she would expect nursing to relay all information in order to determine care and treatment. She stated she was not aware of the resident's symptoms in their entirety when she was called on 6/23/19. She stated she was not aware the resident had a venous ultrasound done previously. She thought the resident had only an arterial ultrasound done and that was why she ordered the venous ultrasound. Had the change in coloring of the foot been explained further, she would have sent the resident to the hospital. She would have expected a plan to be in place to monitor the resident's foot. During an interview with NP #11 on 7/1/19 at 1:52 PM, she stated she saw the resident's left foot for the first time on 6/21/19. The great toe was more discolored, it looked mottled and was notably different than the right foot. She wanted an ultrasound completed to rule out a [MEDICAL CONDITION]. The results would either be faxed to the facility or would show in the resident's electronic record. She stated someone would have to actively seek out the results as it would not trigger a notification to staff. She stated she did not work on 6/22 or 6/23. The 6/22/19 radiology report should have been viewed by someone during that time and a CT/MR should have been completed as recommended by the radiology report. When she arrived at the facility on 6/24/19 she was notified by the DON the resident's foot was worse. She assessed the resident and the foot was much worse and was completely purple up to the ankle. The resident was uncomfortable, restless and her abdomen was tender. She reviewed the resident's 6/21 and 6/22 venous and arterial ultrasounds. She was made aware by DON #15 the on-call NP (NP #5) had ordered a venous ultrasound and labs on 6/23/19. The 6/23/19 ultrasound noted a decrease in blood flow, they could not see above the groin and it was recommended a CT scan be completed. She stated the resident had deteriorated over the weekend and for this resident even just a couple of hours could cause an abrupt change and lead to the need for amputation. She stated the resident's foot needed to be addressed immediately. After she had assessed the resident on 6/24/19 she notified DON #15 and contacted the family and stated the resident needed to go to the hospital. During interviews with physician #22 on 7/2/19 at 2:43 PM and on 7/3/19 at 1:35 PM, he stated there was a medical provider on-call scheduled on 6/22 and 6/23/19 and he was not on-call. He was aware an NP saw the resident on 6/21/19. He stated to his knowledge the resident's foot was not purple until 6/24/19 and there was a drastic change. On 6/24/19 the resident's left foot was cold to the touch, purplish in color that extended up to at least the ankle and there was no pulse and he determined the resident needed to be sent to the hospital to be evaluated. The resident had extremely bad circulation and he was concerned there was a blockage. He stated if the resident had a potential area of concern that was recognized on 6/21/19, he would have expected staff to monitor the resident over the weekend. He stated the nurse that reviewed the ultrasound results on 6/22/19 should have contacted a medical provider to determine if a CT/MR was urgent or not. He stated he did not know why the nurse that read the 6/23/19 radiology report findings only reviewed the documentation of negative for [MEDICAL CONDITION] and did not relay the additional information about the fluid in the soft tissues. He stated he was always available by phone and could be contacted to come in earlier if needed, and he was not contacted. 10NYCRR 415.12