Every finding on record at The Hurlbut

Based on observations, interviews, and record review conducted during the Recertification Survey from 07/24/2025 to 07/31/2025, the facility did not ensure each resident with pressure ulcers (ulcers on the skin due to prolonged pressure) received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection for two (2) (Residents #43 and #95) of three (3) residents reviewed. Specifically, for Resident #43, staff did not follow physician's orders when completing a pressure ulcer treatment. For Resident #95, there was a lack of consistent weekly pressure ulcer assessments (including staging, measurements, or a description of the wound) and ongoing monitoring of a left medial ankle pressure ulcer. Additionally, assessments completed for Resident #95 had conflicting documentation to include treatment instructions and location of the pressure ulcer. The findings are:The facility policy Medication Orders, dated September 2011, documented each resident must be under the care of a Licensed Practitioner and treatment orders include the specific treatment, frequency, duration, and rationale of the treatment.The facility policy Skin Care Guidelines, dated April 2021, documented pressure injury documentation should include, but not limited to, location, dimensions (size of the wound), color of tissue inside the wound bed and surrounding tissue, edges of wound, presence of drainage or eschar (black or brown dead tissue), stage of wound, and presence of pain/lack of sensation. Additionally, wounds should be evaluated by the skin care team every week.1. Resident #43 had diagnoses including diabetes, sacral (lower back) pressure ulcer, and blindness. The Minimum Data Set (a resident assessment tool), dated 05/15/2025, documented Resident #43 had moderately impaired cognition, had an unstageable (full-thickness skin and tissue loss that is covered by dead tissue) pressure ulcer, received pressure ulcer care, and the application of nonsurgical dressings and ointments.The current Comprehensive Care Plan, initiated on 05/15/2025, included Resident #43 had open areas to their sacral region and right buttock. Interventions included to provide treatment to the area as ordered, skin observations per facility policy, and medical provider evaluation as needed. A current physician's order, dated 05/13/2025, included to cleanse the area with saline (a solution of salt and water used as a wound cleanser), pat dry, apply Santyl (topical medication used to help clean and remove dead tissue from skin wounds) and Alginate AG (wound dressing with antibacterial silver for draining wounds) to area with slough (nonviable wound tissue) and cover with a foam dressing every day shift. Review of Resident #43's July 2025 Medication and Treatment Administration Records revealed daily wound treatments on 07/21/2025, 07/23/2025, 07/24/2025, and 07/25/2025 were documented as 9 (other/see progress notes). Review of progress notes from 07/21/2025 to 07/25/2025 included the following:- On 07/21/2025 at 10:37 AM, Licensed Practical Nurse #3 documented resolved. Documentation did not include if a medical provider was notified. - On 07/23/2025 at 10:24 AM, Licensed Practical Nurse #2 documented area noted with no open areas. Documentation did not include if a medical provider was notified.- On 07/24/2025 at 11:47 AM, Licensed Practical Nurse #2 documented no open area noted. Documentation did not include if a medical provider was notified. - On 07/25/2025 at 4:41 PM, Licensed Practical Nurse #1 documented skin intact. Documentation did not include if a medical provider was notified. Review of a late entry (documentation of information that was omitted from the original record but is added later) progress note, dated 07/28/2025 at 1:00 PM, Physician Assistant #1 documented they had spoken to Licensed Practical Nurse Manager #1 and the wound on the coccyx (tailbone) area was closed and to discontinue the Santyl for the wound. Physician Assistant #1 documented the area had reopened but the tissue was pink, and no sloughing (dead tissue) was noted. Skin prep (protective film applied to the skin) and Allevyn (foam dressing) was placed on the area. During an interview and observation on 07/29/2025 at 11:14 AM, Licensed Practical Nurse #4 stated Resident #43 had a current wound treatment order for Santyl and Alginate and they had not done the daily dressing change yet. At 11:43 AM, Licensed Practical Nurse #4 prepared to complete the wound treatment. Resident #43 had an open wound to their sacrum, approximately two (2) to three (3) centimeters long and one (1) centimeter wide. Licensed Practical Nurse #4 cleansed the wound with saline, applied Santyl to the wound bed, and covered the wound with a foam dressing. Licensed Practical Nurse #4 stated they did not put the Alginate on the wound because it was used for wounds with slough. Licensed Practical Nurse #4 stated they wrote a note in the medical provider book (used by nursing staff to communicate resident concerns to the medical provider) to discontinue the Alginate, and they would write a progress note to explain why the Alginate was not applied. During an interview on 07/29/2025 at 12:56 PM, Licensed Practical Nurse Manager #2 stated wound treatments would be signed off on the Treatment Administration Record. Licensed Practical Nurse Manager #2 stated the nurses should follow the treatment order and if something was not needed for the wound or if the treatment was not done, they should notify a medical provider immediately and have them look at the wound. Licensed Practical Nurse Manager #2 stated on 07/28/2025, they were informed by the nurse that Resident #43's wound had reopened. They cleansed the wound and applied skin prep and a foam dressing. Licensed Practical Nurse Manager #2 stated they spoke with Physician Assistant #1 regarding the Santyl and Alginate no longer being appropriate as the wound bed was pink, Physician Assistant #1 said they would see the resident and agreed to the treatment change. Licensed Practical Nurse Manager #2 stated they forgot to document a progress note. When the electronic medical record was reviewed at this time, Licensed Practical Nurse Manager #2 stated the current treatment order was for Santyl and Alginate and a progress note, dated 07/24/2025, documented by Licensed Practical Nurse #2 included there was no open area, but they were unable to determine if the treatment was administered as ordered. During an interview on 07/30/2025 at 10:30 AM, Licensed Practical Nurse #3 stated on 07/21/2025, they looked at Resident #43's wound and it had resolved as there was no slough and no open wound. Licensed Practical Nurse #3 stated they could not recall if they told Licensed Practical Nurse Manager #2 the wound had resolved, and they did not notify a medical provider but should have.During an interview on 07/30/2025 at 10:42 AM, Physician Assistant #1 stated they would expect the nurse to follow orders when administering wound treatments and if there was a change or a question about the ordered treatment, they would expect the nurse to notify medical before they provide the treatment. Physician Assistant #1 stated Resident #43's sacral wound had slough approximately two (2) weeks prior, but had been notified the wound had changed on 07/29/2025. Physician Assistant #1 stated Resident #43's ordered wound treatment included Santyl, Alginate and a foam dressing and they were not notified the wound had resolved on 07/21/2025. Physician Assistant #1 stated they would expect to have been notified as Santyl and Alginate would not be indicated if the wound was no longer open. During an interview on 07/31/2025 at 9:28 AM, Administrator #2 stated the nurses should follow the wound treatment orders in the electronic medical record and if they identified a change in the wound, they should notify the nurse manager or team leader, and the medical provider. If there was a change to the treatment, the order should be changed at that time or immediately following. Administrator #2 stated during the wound treatment observation on 07/29/2025 at 11:43 AM, Licensed Practical Nurse #4 should have notified the nurse manager or medical provider that alginate was not applied as ordered. 2. Resident #95 had diagnoses including diabetes mellitus, atrial fibrillation (abnormal heart rhythm), and neuropathy (nerve damage that can cause numbness, tingling, pain). The Minimum Data Set, dated [DATE], documented the resident had moderate cognitive impairment and one (1) stage two (2) (partial-thickness skin loss into but not deeper than the dermis) pressure ulcer that was not present on admission.The current Comprehensive Care Plan, initiated on 02/06/2025, documented Resident #95 had a stage two (2) pressure ulcer on the left medial ankle. Interventions included to administer treatments as ordered, monitor effectiveness, and follow facility policies/protocols for treatment of skin breakdown.Review of Resident #95's current Order Summary Report, dated 07/30/2025, included a treatment order to cleanse the left ankle wound with wound wash, pat dry, cover with a foam dressing, change every three days and as needed.Review of Resident #95's Wound Care Flow Sheets from 01/01/2025 to 07/30/2025 included the following Registered Nurse documentation:- On 01/30/2025, stage two (2) pressure injury medial left ankle, 1.1 centimeter x 0.9 centimeter. 100% granulation (formation of tissue in the process of healing) with a scant (very small) amount of bloody drainage.- On 07/02/2025, stage two (2) pressure injury left medial ankle, 1.5 centimeter x 0.8 centimeter. 100% granulation with a small amount of bloody drainage.Review of Resident #95's medical provider notes from 01/01/2025 to 07/29/2025 included the following documentation:- On 03/06/2025, open wound on left lower extremity, closely followed by the skin team, bleeding noted, dressing ordered. The note did not included measurements or staging of the wound.- On 03/20/2025, 03/25/2025, and 04/01/2025, stage two (2) chronic area on right lower extremity, wound bed is dry, 100% granulation, no redness, measuring 1.1 centimeter x 1 centimeter.- On 04/08/2025, stage two (2) chronic area on left lower extremity, eschar noted, no surrounding erythema (redness) or drainage, measuring 1.1 centimeter x 1 centimeter.- On 04/22/2025, 04/29/2025, 05/06/2025, 05/13/2025, 05/20/2025, 05/29/2025, 06/03/2025, and 06/10/2025, stage two (2) chronic area on right lower extremity, wound bed is dry, 100% granulation, no redness, measuring 1.1 centimeter x 1 centimeter.- On 07/02/2025, stage two (2) chronic area on left lower extremity, no improvement with increased measurements 1 centimeter x 1.7 centimeters, no erythema, partially scabbed and bleeding. Treatment changed to cleanse left ankle wound with wound wash, pat dry, cover with a foam dressing, and change every three days and as needed.- On 07/09/2025, stage two (2) chronic area on right lower extremity, wound bed is dry, 100% granulation, no redness, measuring 1 centimeter x 1 centimeter. Continue Triad (hydrophilic paste for light to moderate exudate [drainage] that helps maintain a moist environment for wound healing) to site and may cover with bordered gauze twice a day as needed only for bleeding.- On 07/30/2025, stage two (2) left ankle 1.7 centimeters x 1 centimeter, wound base pink and moist, small amount of bleeding from anterior (top) aspect, no surrounding redness, maceration (softened as a result of wetness), continue foam dressing.Review of the electronic medical record did not include documented evidence Resident #95's pressure ulcer to their left medial ankle was monitored and/or observed by the skin team or a medical provider for the weeks of 01/30/2025 to 03/06/2025, 03/06/2025 to 03/20/2025, 04/08/2025 to 04/22/2025, 06/10/2025 to 07/02/2025, and 07/09/2025 to 07/30/2025. Additionally, several of the assessments incorrectly documented the location of the pressure as the right lower extremity/ankle.During an observation on 07/30/2025 at 9:08 AM, Resident #95 had an open area on the left medial ankle with hyper-granulation tissue (an overgrowth of new tissue formed during the wound healing process) and active bleeding. Nurse Practitioner #1 wearing gloves only, placed unpackaged 4 inches x 4 inches gauze pads and wound cleanser directly on Resident #95's bottom fitted sheet of the bed. Nurse Practitioner #1 removed the old foam dressing from the left medial ankle and placed directly on the bottom fitted sheet of the bed, sprayed wound cleanser directly on the wound, dabbed the actively bleeding wound with several gauze pads, placed the contaminated pads directly on the fitted sheet of the bed, sprayed wound cleanser directly on the wound, dabbed the actively bleeding wound with several gauze pads, and placed the contaminated pads directly on the fitted sheet of the bed. Nurse Practitioner #1 then measured (1.1 centimeters x 1.7 centimeters) and placed a new foam dressing on the wound. During an interview on 07/29/2025 at 10:35 AM, Licensed Practical Nurse Unit Leader #1 stated pressure ulcer monitoring (skin rounds) is completed weekly with a team consisting of a medical provider, Unit Leader, and the Assistant Director of Nursing.During an interview on 07/29/2025 at 11:35 AM, Quality Care Coordinator #1 stated pressure ulcer monitoring should be completed weekly and include the location, measurements, progress, stage, and appearance (edges, wound bed, and any drainage) of wounds. During an interview on 07/29/2025 at 2:07 PM, Administrator #2 stated the 07/09/2025 medical provider recommendations for treatment of the left medial ankle stage two (2) pressure ulcer did not match the active physician's orders.During an interview on 07/30/2025 at 9:16 AM, Nurse Practitioner #1 stated pressure ulcer monitoring should be completed weekly, include the location, measurements, progress, stage, and appearance of wounds and treatment recommendations.During an interview on 07/30/2025 at 10:09 AM, Administrator #2 stated pressure ulcer monitoring should be completed weekly, and Resident #95's pressure ulcer was not monitored weekly.10 NYCRR 415.12(c)(2)

Based on interviews and record review conducted during a Recertification Survey from 07/24/2025 to 07/31/2025, the facility did not ensure pharmacist reported irregularities were reviewed by the attending physician and acted upon timely for two (2) (Residents #69 and #77) of five (5) residents reviewed. Specifically, the facility could not provide documentation supporting the consultant pharmacist's monthly recommendations were acted upon by the facility's Medical Director, attending physicians, or designees. For Resident #77 the facility could not provide evidence the Director of Nursing or an attending physician had reviewed the consultant pharmacist's recommendations for ten (10) of twelve (12) months reviewed, and for nine (9) of twelve (12) months reviewed for Resident #66. The findings are: The facility policy Pharmacy Services, dated November 2017, included the pharmacist would conduct a monthly drug regimen review for each resident in the facility. The pharmacist would report any irregularities (drugs that may be unnecessary or inappropriately dosed) to the attending physician, the Medical Director, and the Director of Nursing on a separate written report, and the reports must be acted upon. If the pharmacist identified an irregularity that required urgent action, they would immediately notify the Director of Nursing and the attending physician or the Medical Director.1. Resident #77 had diagnoses including dementia, depression, and adult failure to thrive. The Minimum Data Set (a resident assessment tool), dated 05/27/2025, documented the resident had severely impaired cognition and was taking an antidepressant. Review of Resident #77's current Comprehensive Care Plan, last revised 06/19/2025, revealed the resident received antidepressant medication related to depression. Resident #77's current physician's orders, dated 07/10/2025, included duloxetine hydrocholoride delayed release (a medication used to treat depression) 60 milligrams give one (1) tablet orally one (1) time daily.Review of the Consultant Pharmacist's Medication Regimen Reviews completed on 01/16/2025, 02/18/2025, 03/17/2025, and 05/21/2025 revealed recommendations from Pharmacist #1 to consider a taper (slowly decreasing the dose of a drug over time) attempt on duloxetine from 60 milligrams to 30 milligrams daily, and the last attempt occurred on 06/10/2024. Pharmacist #1 indicated a note was written to the physician. The facility was unable to provide documented evidence a medical provider received, reviewed, or acted upon the recommendations. Review of a Consultant Pharmacist's Medication Regimen Review, dated 06/22/2025, revealed Pharmacist #2 recommended a taper of duloxetine. A note to attending physician/provider, dated 06/22/2025, included the recommendation. Physician Assistant #1's response, dated 07/26/2025, included they disagreed with the recommendation, the duloxetine was used for neuropathy, and to leave as is.The facility was unable to provide medication regimen reviews from July 2024 to December 2024. During an interview on 07/30/2025 at 8:59 AM, Pharmacist #2 stated for Resident #77, they repeatedly recommended a gradual dose reduction (taper) each month for the resident's duloxetine hydrocholoride since October 2024 and a medical provider did not respond until May 2025. 2. Resident #68 had diagnoses including major depressive disorder, stroke, and insomnia. The Minimum Data Set, dated [DATE], revealed the resident had mildly impaired cognition and was taking an antidepressant.Review of Resident #68's current Comprehensive Care Plan, last revised 06/19/2025, revealed the resident received an antidepressant related to depression. Review of the Order Summary Report, dated 07/31/2025, included an active order for mirtazapine (a medication used to treat depression) 15 milligrams daily at bedtime and an order for trazodone (a medication used to treat depression, anxiety, and insomnia) 25 milligrams daily at bedtime, discontinued on 02/03/2025.Review of a Consultant Pharmacist's Medication Regimen Review, completed on 01/19/2025, revealed a recommendation from Pharmacist #1 to consider a taper attempt of trazodone. The facility was unable to provide documented evidence of a physician's response to the recommendation. Review of the Consultant Pharmacist's Medication Regimen Reviews, completed on 03/17/2025 and 04/23/2025, revealed consultant pharmacist recommendation for a taper attempt of mirtazapine from 15 milligrams to 7.5 milligrams at night. The facility was unable to provide documented evidence of a physician's response to the recommendations. A medication regimen review was completed on 05/21/2025 with a recommendation for a taper attempt of mirtazapine was not responded to by a provider until 06/30/2025. A medication regimen review completed in June 2025 with a recommendation for a taper attempt of mirtazapine was not responded to by a provider until 07/22/2025.The facility was unable to provide medication regimen reviews from July 2024 to December 2024. During an interview on 07/30/2025 at 8:59 AM, Pharmacist #2 stated for Resident #68, recommendations for a gradual dose reduction for the resident's trazodone had gone unanswered by a medical provider from November 2024 to January 2025. They stated in March 2025, they recommended Resident #68's dose reduction for mirtazapine and did not get a response from a medical provider until May 2025. Pharmacist #2 stated the process for medication reviews consists of consultant pharmacists reviewing the residents' electronic medical record monthly, checking for new physician's orders and indications for a gradual dose reduction (the process of identifying, decreasing, and potentially discontinuing the dose of a medication). Once the pharmacists determine their recommendations, a report is made and sent via email to the Assistant Director of Nursing, Administrator #1, Administrator #3, and the Medical Director. Pharmacist #2 stated there was a problem receiving provider responses to pharmacist recommendations since October 2024, and this past month they started receiving responses after the facility reportedly changed their monthly medication review process. During an interview on 07/30/2025 at 11:27 AM, Medical Doctor #1 stated monthly pharmacy recommendations are reviewed by the Nurse Practitioners and Physician Assistants who write their responses to the recommendations in a progress note. They stated the recommendations used to be communicated on paper and were sent to the Assistant Director of Nursing and then to the providers. Medical Director #1 stated they were only using progress notes to document responses to pharmacy recommendations. During an interview on 07/30/2025 at 11:34 AM with Physician Assistant #1 and Medical Doctor #1, Physician Assistant #1 stated they participate in meetings with nursing and doctors to review residents' medications and assess for the appropriateness of a gradual dose reduction. They stated the providers document their responses to a pharmacy recommendation in a progress note and sometimes received a sheet of paper they could write their responses on then return them to the Assistant Director of Nursing. Physician Assistant #1 stated the medical providers do not communicate directly with the pharmacists, but instead go through the Assistant Director of Nursing. During an interview on 07/29/2025 at 12:58 PM with Administrator #1 and Administrator #2, Administrator #2 stated pharmacy reviews were received and sent to the medical team for review monthly. Administrator #1 stated the facility had a peer review, completed June 2025, and they discovered the Consultant Pharmacist's Medication Regimen Reviews had not been reviewed by a medical provider. Administrator #1 stated they could not provide documentation of the Director of Nursing's review of the pharmacy recommendations monthly and they should have been reviewed by the medical team as they are a failsafe to ensure residents are getting the right medications at the right doses.During an interview on 07/31/2025 at 9:56 AM, the Director of Nursing stated they were aware the consultant pharmacist had brought up concerns with the monthly pharmacy review process in past Quality Assurance and Performance (QAPI) meetings and it was unclear what was being done with the recommendations. The Director of Nursing stated they would expect monthly pharmacy recommendations were received, reviewed, responded to timely, and uploaded to the electronic medical record. 10 NYCRR 415.18(c)(1)

Based on observations, interviews, and record review conducted during a Recertification Survey from 07/24/2025 to 07/31/2025, for one (1) (Resident #52) of two (2) residents reviewed, the facility did not ensure a resident's environment remained as free of accident hazards as possible. Specifically, there were multiple observations of a bottle of pills labeled as zinc (a supplement that helps the immune system and metabolic function) left at Resident #52's bedside and there were no medical orders in place for the medication or to self-administer (the practice of an individual taking their own prescribed or over-the-counter medications independently, without direct assistance or supervision) the medication. Additionally, there was no documented evidence the resident had been reviewed by the interdisciplinary team for their ability to safely self-administer the medication or a comprehensive care plan in place to include measurable goals and interventions, for self-administration. The findings are:Review of the facility policy Self-Administration of Medications, dated 10/20/2024, included, but was not limited to, the interdisciplinary team would discuss if the resident was appropriate for self-medicating (self-administrating), document the results of their discussion in the resident progress notes, and review at least quarterly. Nursing would obtain an order from the medical provider for which medications were approved for self-medicating and the nursing staff would sign the medication administration record for medications taken by the resident. All medications for self-medicating must be locked in a storage area, such as a locked drawer in their room, where the resident could self-access. The Comprehensive Care Plan would indicate self-administration of medications. Resident #52 had diagnoses including low back pain, glaucoma (an eye disease that damages the optic nerve), and benign prostatic hypoplasia (an enlarged prostate). The Minimum Data Set (a resident assessment tool), dated 07/07/2025, documented the resident was cognitively intact. Review of Resident #52's current Comprehensive Care Plan, last revised 07/17/2025, did not include measurable goals or interventions related to the self-administration or storage of medications at the bedside.Review of Resident #52's current physician's orders on 07/28/2025, did not include orders for zinc, to self-administer medications, or to store medications at the bedside. During observations on 07/24/2025 at 10:11 AM and 07/28/2025 at 9:30 AM, there was an over-the-counter bottle of zinc on Resident #52's bedside table.During an observation and interview on 07/29/2025 at 10:02 AM, there was a half-full bottle labeled zinc and vitamin D3 tablets on Resident #52's bedside table. During an interview at this time, Resident #52 stated they took one (1) tablet daily and had been taking it for 50 years for their prostate. Resident #52 stated the nurses should know they were taking it because nurses had asked about the medication before. During an interview on 07/29/2025 at 11:14 AM, Licensed Practical Nurse #4 stated medications were stored in the medication carts and residents could self-administer medications if they had an order. Licensed Practical Nurse #4 stated Resident #52 had an order for medication to be left at the bedside and they would go back to check if the medications were taken or if the resident needed reminding. Licensed Practical Nurse #4 stated Resident #52's family brought a vitamin in, left it at the bedside, and the resident would take it every morning. Licensed Practical Nurse #4 reviewed the electronic medical record at that time and stated Resident #52 did not have a current order for the zinc and vitamin D3 that was in their room. Licensed Practical Nurse #4 stated they thought a medical provider knew the resident took the zinc because a provider had talked to the resident and their family about it.During an interview on 07/29/2025 at 12:56 PM, Licensed Practical Nurse Manager #2 stated Resident #52 did not have a current order for zinc and they were not aware the resident was self-administering the medication without an order. During an interview on 07/30/2025 at 10:42 AM, Physician Assistant #1 stated if residents or families brought medications from home, the medications should be sent to the pharmacy to verify the contents and there should be an order to self-administer medications. Physician Assistant #1 stated if nursing staff was aware the resident self-administered medication, a medical provider should have been notified. They stated they were only recently made aware Resident #52 self-administered zinc. During an interview on 07/31/2025 at 9:28 AM, Administrator #2 stated a medical provider should be aware and have orders in place for a resident known to self-administer and store a medication in their room.10 NYCRR 412.12 (h)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey from 07/24/2025 to 07/31/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, raw shell eggs were stored above ready to eat foods, there was bare-hand contact with ready to eat food, and there was a missing section of floor tile that was dirty. The findings are: Review of the undated facility policy Food Storage (item #11e - refrigerated storage) included cooked foods must be stored above raw foods to prevent contamination. Raw animal foods should be separated from each other and stored on lower shelves (below cooked foods or raw fruits and vegetables) and in drip proof containers.During an observation on 07/24/2025 at 8:55 AM, there was a cardboard box with crates of raw shell eggs stored on the third shelf of a wire storage rack directly above a pan with plastic wrapped thin-sliced ready to eat meats (ham and salami) inside the walk-in cooler in the main kitchen. During an observation on 07/24/2025 at 9:01 AM, there was a 3 foot x 3 foot section of flooring that was missing tiles under the right side of the three (3)-bay sink in the main kitchen. The section of missing tiles was also observed to be dirty and discolored with food debris. During an observation on 07/24/2025 at 12:42 PM, Food Service Worker #1 used bare (ungloved) hands to hold, cut, and place a sandwich on a plate for Resident #47 during lunch service in the main dining area. In an immediate interview, Food Service Worker #1 stated they were trained not to wear gloves while handling food and the last training was in March 2025. During an observation on 07/25/2025 at 11:44 AM, crates of raw shell eggs were again observed to be stored over a pan of thin-sliced meats in the kitchen walk-in cooler. During an interview at this time, the Food Service Director stated they were not sure who stored the eggs that way, but they should have been stored on the bottom shelf. The Food Service Director also stated that they believed the floor tiles had been missing for a month and the tiles had been ordered for replacement. During an interview on 07/30/2025 at 8:26 AM, Food Service Director stated sandwiches would be wrapped in plastic, should be presented to residents with gloved hands, and when unwrapped, the sandwich should not be handled with bare hands. 10 NYCRR: 415.14(h), Subpart 14-1.30, 14-1.40, 14-1.43(c), 14-1.80, 14-1.110(d), 14-1.170

Based on observations, interviews, and record review conducted during a Recertification Survey from 07/24/2025 to 07/31/2025, 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 two (2) (Residents #43 and #95) of three (3) residents reviewed for pressure ulcers. Specifically, Resident #43 was on enhanced barrier precautions (techniques used to prevent transmission of infectious disease utilizing gloves and gowns with all high-contact care) and staff were observed providing wound care without the appropriate personal protective equipment (gown). Resident #95 did not have enhanced barrier precautions signage outside their room and staff were observed providing hands on care without appropriate personal protective equipment (gown and gloves). Additionally, there was lack of hand hygiene and glove changes during wound care for Resident #95. The findings are:The facility policy Enhanced Barrier Precautions, dated August 2024, included enhanced barrier precautions are an infection control intervention designed to reduce transmission of multidrug resistant organisms in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a multidrug resistant organism as well those at increased risk of multidrug resistant organism acquisition (for example- residents with wounds or indwelling medical devices). High-contact activities/interactions included, but were not limited to, wound care and transferring. Residents determined to need enhanced barrier precautions will have signage posted on the outside of the individual's room indicating the type of precautions and recommended personal protective equipment.The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revised 04/28/2025, documented gloves should be changed and hand hygiene performed before moving from a contaminated-body site to a clean body-site during resident care.1. Resident #43 had diagnoses including a stage two (2) pressure ulcer to the sacral region (bottom area of the spine), hemiplegia/hemiparesis (weakness or partial paralysis on one side of the body), and diabetes. The Minimum Data Set (a resident assessment tool), dated 05/15/2025, documented the resident had moderately impaired cognition, had an unstageable (full-thickness skin and tissue loss that is covered by dead tissue) pressure ulcer, and received pressure ulcer care. The current Comprehensive Care Plan, revised on 05/15/2025, included Resident #43 was on enhanced barrier precautions secondary to a pressure ulcer to the sacral area and right buttock. Review of the Order Summary Report, dated 07/30/2025, included several orders for wound treatments. There were no current orders for enhanced barrier precautions.During an observation on 07/24/2025 at 9:18 AM, there was an enhanced barrier precaution sign on Resident #43's room door and a cabinet with personal protective equipment nearby in the hallway.During an observation and interview on 07/29/2025 at 11:43 AM, Resident #43 was in bed, Licensed Practical Nurse #4 was wearing gloves (no gown) and performed wound care to Resident #43's sacral and buttock area. After wound care was performed, Licensed Practical Nurse #4 saw the sign on Resident #43's door for enhanced barrier precautions and stated they should have worn a gown, but they forgot to do so.During an interview on 07/31/2025 at 9:28 AM, Administrator #2 stated enhanced barrier precautions were used for residents with any open areas on their skin, there would be a sign on the resident's door, and the staff should wear gowns and gloves when providing care. Administrator #2 did not know why the staff did not wear a gown when performing wound care.2. Resident #95 had diagnoses including diabetes, atrial fibrillation (abnormal heart rhythm), and neuropathy (nerve damage that can cause numbness, tingling, pain). The Minimum Data Set, dated [DATE], documented Resident #95 had moderately impaired cognition and a stage two (2) (partial-thickness skin loss into but not deeper than the dermis) pressure ulcer that was not present on admission.The current Comprehensive Care Plan, initiated on 02/06/2025, documented Resident #95 had a stage two (2) pressure ulcer on the left medial ankle. Interventions included to administer treatments as ordered, monitor effectiveness, and follow facility policies/protocols for treatment of skin breakdown. The Comprehensive Care Plan did not document the Resident #95 was on enhanced barrier precautions.Review of Resident #95's current Order Summary Report, dated 07/30/2025, revealed a current order for a wound treatment. There were no current orders for enhanced barrier precautions.During an observation on 07/30/2025 at 9:08 AM, Resident #95 had an open area on the left medial ankle with hyper-granulation tissue (an overgrowth of new tissue formed during the wound healing process) and active bleeding. Nurse Practitioner #1 wearing gloves only, placed unpackaged 4 inches x 4 inches gauze pads and wound cleanser directly on Resident #95's bottom fitted sheet of the bed. Nurse Practitioner #1 removed the old foam dressing from the left medial ankle, placed it directly on the bottom fitted sheet of the bed, sprayed wound cleanser directly on the wound, dabbed the actively bleeding wound with several gauze pads, placed the contaminated pads directly on the fitted sheet of the bed, sprayed wound cleanser directly on the wound, dabbed the actively bleeding wound with several gauze pads, and placed the contaminated pads directly on the fitted sheet of the bed. Nurse Practitioner #1 then measured and placed a new foam dressing on the wound. Nurse Practitioner #1 did not change gloves or perform hand hygiene at any time during the wound dressing change. During an interview on 07/30/2025 at 9:16 AM, Nurse Practitioner #1 stated they were not concerned with placing the wound dressing supplies directly on the bottom fitted sheet of the bed, without a barrier, nor placing contaminated supplies directly on the bottom fitted sheet of the bed, without a barrier. Nurse Practitioner #1 stated they did not directly touch the wound nor the inside of the new dressing and would change their gloves and perform hand hygiene if their gloves had been visibly soiled.During an interview on 07/30/2025 at 9:32 AM, Licensed Practical Nurse Infection Preventionist #1 stated during a wound dressing change, the person performing the procedure should gather the supplies, wash their hands and don gloves, remove old dressing, remove gloves, wash hands and don gloves, cleanse wound, remove gloves, wash hands and don gloves, and place the new dressing to the wound. They stated hand hygiene and glove changes are done at these times to prevent reintroduction of bacteria into the wound, and no supplies, clean or dirty, should be placed directly on resident bedding as there may be bacteria present.During an interview on 07/30/2025 at 10:09 AM, Administrator #2 stated during wound care ,supplies for the treatment should be placed on the over bed table and not directly on the residents' sheets secondary to an increased risk of contamination. Additionally, gloves should be removed and hand hygiene performed after removing the old dressing, after cleansing the wound, and prior to placing a new dressing on the wound.During an observation and interview on 07/31/2025 at 10:09 AM, Certified Nurse Aide #1 assisted Resident #95 to a sitting position in bed by placing one arm under the residents' legs and one arm around the residents' upper torso. Once in a seated position on the edge of the bed, Certified Nurse Aide #1 placed both arms around Resident #95's upper torso while Resident #95 placed their arms around Certified Nurse Aide #1, Resident #95 pivoted and sat in their wheelchair. There was no enhanced barrier precaution signage on Resident #95's room door and there was no personal protective equipment nearby in the hallway. During an interview at this time, Certified Nurse Aide #1 stated Resident #95 was not on enhanced barrier precautions because it was not on the care plan and there was no signage on the door or set-up (personal protective equipment) outside of door.During an interview on 07/31/2025 at 9:49 AM, Licensed Practical Nurse Infection Preventionist #1 stated any resident with chronic wounds should be on enhanced barrier precautions. They stated Resident #95 was removed from enhanced barrier precautions in April 2025 as their wound had healed. Licensed Practical Nurse Infection Preventionist #1 stated they were unaware the resident was still receiving dressing changes and should be on enhanced barrier precautions to reduce the risk of spreading infections.10 NYCRR 415.19(a) (1-3)(b)(4)

Based on record review and interview conducted during the Standard Recertification Survey, it was determined that for three (Employees #1, #2, and #5) of six recently hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and/or misappropriation of resident property related to screening of prospective employees. Specifically, a nurse aide registry abuse screening was not completed for recently hired employees prior to starting work. The findings are: A review of the undated facility policy titled: Abuse, Neglect and Mistreatment Prohibition, Investigation, and Reporting included that all staff that are being considered for hire must also be checked with the New York State Nurse Aide Registry (Prohibition/Prevention Procedures, Section 3). On 2/14/24 from 8:30 AM to 9:48 AM, recently hired employee files were provided to the surveyor for review and included the following: Employee #1 was hired on 8/21/23 as the Dietary Director and the nurse aide registry screen for prior abuse findings was not completed until 8/30/23. Employee #2 was hired on 12/1/23 as a Dietary employee and the nurse aide registry screen for prior abuse findings was not completed until 12/14/23. Employee #5 was hired on 11/27/23 as a Laundry employee and the nurse aide registry screen for prior abuse findings was not completed until 12/1/23. During an interview on 2/14/24 at 8:59 AM, the Director of Human Resources and Payroll stated that there was a note in the file for Employee #5 file showing that they were on vacation so the website (Prometric, website used to run the nurse aide registry screen for prior abuse findings) was checked after the date of hire for Employee #5. During an interview on 2/14/24 at 9:15 AM, the Director of Human Resources and Payroll stated that they did a special orientation for Employee #2, so the hiring process was backwards. The Director of Human Resources and Payroll further stated that this was why things for Employee #2 were not done in a timely manner. During an interview on 2/14/24 at 9:17 AM, the Director of Human Resources and Payroll stated that they think that Employee #1 was hired when they were on vacation. On 2/14/24 at 11:17 AM, the Director of Human Resources and Payroll provided the surveyor with employee timesheets via email. Review of the employee timesheets included the following: Employee #1 worked 7 shifts prior to a nurse aide registry screen for prior abuse findings being completed. Employee #2 worked 8 shifts prior to a nurse aide registry screen for prior abuse findings being completed. Employee #5 worked 4 shifts prior to a nurse aide registry screen for prior abuse findings being completed. 10NYCRR: 415.4(b)

Based on observations, record review, and interview conducted during the Recertification Survey, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: On 2/13/24 from 8:35 AM to 11:50 AM the surveyor was provided with facility preventative maintenance, testing, and inspection records. A review of these records did not include testing documentation for carbon monoxide detectors located throughout the facility. During an interview on 2/13/24 at 10:21 AM, the Director of Environmental Services stated that there is a sticker on the carbon monoxide detector to show the date tested . The Director of Environmental Services further stated that they would ask the Maintenance Worker if they keep a log of testing. During an interview on 2/13/24 at 10:30 AM, the Maintenance Worker stated that they test carbon monoxide detectors every month, and they change the sticker on the detector to show the date tested . The Maintenance Worker further stated that they peel the old test sticker off the detector and throw it away. When asked if they kept a log of the old tests, the Maintenance Worker said no. On 2/13/24 at 2:27 PM four natural gas-powered dryers were observed to be located in the basement laundry room. Further observations included a Kidde-brand single-station carbon monoxide detector located on the wall with an affixed sticker showing that it was inspected 2/12/24. Review of the manufacturer's printed instructions on the back of the detector included: test weekly. No documentation was provided to show that this carbon monoxide detector was tested weekly or monthly from 5/13/22 (time of last survey exit) through 1/31/24. On 2/13/24 at 2:32 PM a natural gas-powered cooking range was observed to be located in the first-floor main kitchen. Further observations included a Kidde-brand single-station carbon monoxide detector located on the wall with an affixed sticker showing it was inspected 2/12/24. Review of the manufacturer's printed instructions on the back of the detector included: test weekly. No documentation was provided to show that this carbon monoxide detector was tested weekly or monthly from 5/13/22 (time of last survey exit) through 1/31/24. The 2015 Edition of the International Fire Code requires that carbon monoxide alarms shall be maintained in accordance with NFPA 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer's published instructions at least monthly. 10NYCRR: 415.29(a)(2), 711.2(a)(1), 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.6 2012 NFPA 720: 8.7.1

Based on interviews and record review conducted during the Recertification Survey, the facility did not maintain a Quality Assessment and Assurance Committee consisting at a minimum of the Director of Nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, one of who much be an individual in a leadership role, and the Infection Preventionist. Specifically, the facility could not provide evidence that the Infection Preventionist attended the Quality Assurance Improvement Performance meetings on a regular basis. This is evidenced by the following: Review of the facility's Quality Assurance and Performance Improvement meetings last three Sign-In Sheets dated 8/8/23, 10/17/23 and 1/23/24 did not include the presence of the Infection Preventionist. During an interview on 2/16/24 at 2:19 PM, The Administrator stated the Quality Assurance and Performance Improvement Committee meetings are held quarterly and members in attendance included departmental leadership, the Medical Director, the Director of Nursing, and the Administrator. The Administrator reviewed the Quality Assurance and Performance Improvement Sign-In Sheets for meetings dated 8/8/23, 10/17/23 and 1/23/24, and stated the Infection Preventionist was not listed on the sign-in sheets. The Administrator stated that they were aware that the Infection Preventionist was required to attend the Quality Assurance and Performance Improvement Committee meetings (per the regulations) and did not know why they were not in attendance for the last three meetings. During an interview on 2/15/24 at 1:06 PM, the Infection Preventionist stated that they had been a Corporate Infection Prevention Nurse since November 2023. The Infection Preventionist stated they had been covering as the Infection Preventionist at the facility for the past month, since the facility position was vacant and did not know why there was no IP at the meetings. During an interview on 2/16/24 at 2:42 PM, the Director of Nursing stated that an interim Invention Preventionist was hired in July 2023, followed by a part-time Infection Preventionist from September 2023 to December 2023. 10 NYCRR 415.19

Based on interviews and record review conducted during the Recertification Survey it was determined that for one (Residents #67) of five residents reviewed for immunizations, the facility was unable to provide documentation that the resident who was eligible had been offered, declined, and/or educated on the pneumococcal immunization or had received it prior to admission. This is evidenced by the following. The facility policy, Resident Influenza and Pneumococcal Vaccine, dated November 2023, included that each resident (upon admission) will be offered the pneumococcal vaccine and the influenza vaccine. Before offering the vaccines each resident/resident representative will receive education and information regarding the benefits and potential side effects of the immunizations. Resident #67 was admitted to the facility over two years ago and had diagnoses that included malnutrition, chronic obstructive lung disease and chronic pain. The most recent Minimum Data Set Resident assessment dated [DATE] revealed Resident #67 was cognitively intact, and that the pneumococcal vaccine had not offered. Review of Resident #67's immunizations in the electronic health record did not include any documented evidence that the pneumococcal vaccine had been offered, administered, declined by the resident or education provided. During an interview on 2/15/24 at 2:15 PM, the Administrator stated that the facility had documentation of Resident #67's influenza and covid-19 immunizations, but not pneumococcal. During an interview on 2/16/24 at 1:06 PM the Quality Care Coordinator stated within 14 days of admission vaccination eligibility is reviewed and vaccination requests are sent to medical. The Infection Control Nurse maintains a tracking tool of all admitted Long Term Care residents and the tool provided dates of resident admission to facility, and dates of vaccinations (pneumococcal, influenza and covid-19). Review of the tracking tool for pneumococcal vaccination with the Quality Care Coordinator at this time revealed multiple blank/undocumented dates of vaccination status for current residents, including Resident #67. The Quality Care Coordinator stated that not having dates of all current residents' pneumococcal vaccinations is a problem. During an interview on 2/16/24 at 2:20 PM the Infection Control Nurse stated they are responsible for making sure that all residents are vaccinated. They stated that the previous Infection Control Nurse worked part time and that a lack of staffing may have created gaps in the vaccination process. 10 NYCRR 415.19 (a)(3)

Based on observations, interviews, and record reviews conducted during a Recertification Survey it was determined that the facility did not consistently post the daily nurse staffing information to include the daily resident census, the total number and actual hours worked by the licensed and certified nurses and must post the data on a daily basis at the beginning of each shift and be readily accessible to residents and visitors. Specifically, the nursing staff information was not updated to reflect any staffing changes throughout the day per the regulations. This is evidenced by the following: In an observation on 2/12/24 at 12:59 PM, the printed daily nurse staffing posting dated 2/12/24 listed the resident census as 100. There was no documentation to reflect updated staffing changes if applicable. In an observation on 2/14/24 at 1:00 PM, the printed daily nurse staffing posting dated 2/14/24 listed the Resident Census as 100. There was no documentation to reflect updated staffing changes if applicable. Review of the printed daily nurse staffing postings dated 11/1/23 through 2/14/24 revealed the Resident Census was listed as 100 for every day. Additionally, there was no evidence that any changes had been made to reflect updated staffing changes throughout each day. Review of Resident Census reports for several days from 11/1/23 to 2/14/24 revealed the actual resident census was not 100 (as listed on the daily nursing staffing postings). During an interview on 2/16/24 at 11:07 AM, the Certified Nursing Aide/Scheduler said they had been in the position since July 2023 and were responsible for the nursing staff's schedules and the daily nursing staffing postings. The Certified Nursing Aide/Scheduler said the daily nursing staff postings included the number of nursing staff (Registered Nurses, Licensed Practical Nurses, and Certified Nursing Aides) in the facility, their number of hours worked and the resident census and that they printed it daily and posted it each morning. The Certified Nursing Aide/Scheduler said they were not aware they should make changes to the daily nursing staffing postings when there were call-ins (staff calling to report unable to report to work). Additionally, the Certified Nursing Aide/Scheduler stated they were not aware until a few days prior that they had to change the resident census on the daily nursing staffing postings. During an interview on 2/16/24 at 12:29 PM, the Director of Nursing stated the Certified Nursing Aide/Scheduler's role included doing the nursing schedules and printing out the daily nursing staffing postings. The Director of Nursing stated they were not aware that changes (to include the actual nursing staffing numbers and hours per shift and actual current resident census) were not being made to the daily nursing staffing postings as required. 10 NYCRR 415.13

Based on observations and interviews, and conducted during the Recertification Survey completed on 5/13/22, it was determined that for one of one main kitchen, the facility did not store, distribute, and serve food in accordance with professional standards for food service safety. Specifically, a storage unit containing potentially hazardous foods was not maintained in good repair, a refrigeration unit had a damaged seal, a handwash sink was not accessible, and a ceiling fan and tiles were dirty. This is evidenced by the following: 1. During the initial brief tour of the main kitchen on 5/9/22 from 8:45 a.m. to approximately 9:15 a.m., observations and interviews included the following: a. A 'curtain cooler' (portable one door refrigeration unit) used for production beverages was inoperable with regard to refrigeration, and the door did not latch closed. Trays with milk and other beverages were observed within this cooler and the temperature of chocolate milk in a cup was 59 degrees Fahrenheit (°F). During an interview at this time, the Food Service Director (FSD) stated that the milk was probably poured one half hour ago. Additionally, the FSD stated that the curtain cooler has been broken for about four years and is just used for tray line, and any leftover beverages are then moved to another operating cooler. b. The bottom plastic seal on a two-door 'Victory' cooler (refrigeration unit) was partially separating from the right door. 2. During a follow-up visit to the main kitchen on 5/11/22 from 10:50 a.m. to approximately 12:25 p.m., observations and interviews included the following: a. The designated handwash sink was blocked by a rolling tray of mugs stacked 5 trays high stored directly in front of the sink. b. In the curtain cooler near the handwash sink there were 5 trays containing beverages with ice sprinkled over the containers. The temperature of the milk was 59°F. The temperature of the milk in the nearby functional 'Victory' cooler (from which the milk had been moved from) was 43°F. During an interview at this time, the FSD stated that they had asked corporate multiple times to replace the curtain cooler and was told they could not afford it. When interviewed at this time the dietary aide stated that the drinks (including the milk) were in the Victory cooler and moved to the curtain cooler about 15 minutes prior. When interviewed at this time the Cook Supervisor stated the same process and added that sprinkled ice will not maintain cold temperatures. c. A square exhaust ventilation fan in the center of the ceiling in the kitchen had a build-up of dust and debris, including the nearby ceiling tiles and above the hand wash sink. 10NYCRR: 415.14(h) 10NYCRR: Subpart: 14-1.44, 14-1.95, 14-1.110(d), 14-1.171(a)(d), U.S. Food and Drug Administration's (FDA) Food Code Centers for Disease Control and Prevention's (CDC) food safety guidance

Based on observation, interviews and record review conducted during the Recertification Survey conducted 5/9/22 to 5/13/22, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. Specifically, three Certified Nursing Assistants (CNAs) did not apply the appropriate personal protective equipment (PPE) prior to entering and exiting resident's rooms that were on transmission-based precautions (TBP or quarantine) due to COVID-19 infections and/or exposures. This was evidenced by the following: The facility policy, R2 HCC Quarantine and Isolation Precautions COVID-19 Guidelines dated August 2021, under subtitles quarantine and isolation, documented that all staff are to comply with the recommendations of the CDC, and the Department of Health when using PPE. 1.In an observation on 5/9/22 at 10:09 a.m., CNA #1 (listed by facility as a temporary CNA) entered Resident room [ROOM NUMBER] (signage on door indicated the room was on TBP) wearing full (gown, gloves, mask and face shield) PPE and later exited the room still wearing the same PPE and then entered Resident room [ROOM NUMBER] to assist another resident. When interviewed CNA #1 stated the Registered Nurse/ Infection Preventionist (RN/IP) instructed them to wear PPE, but they did not know when to change their PPE and that they had not received any education about when to change PPE. 2.In an observation on 05/09/22 at 10:22 a.m., CNA #2 exited Resident room [ROOM NUMBER] (on TBP per signage) into the hall wearing gloves and a surgical mask (no other PPE), obtained a mechanical lift from the hallway and re-entered room [ROOM NUMBER]. In a 2nd observation at 12:53 p.m., CNA #2 exited room [ROOM NUMBER] again wearing gloves and a surgical mask (no other PPE), obtained a wheelchair from hallway and reentered room [ROOM NUMBER]. When interviewed at this time CNA #2 stated that that they did not know why there was a sign outside of room [ROOM NUMBER] indicating the use of PPE but when they asked the unit secretary, they were told it was for COVID-19 exposure. CNA #2 stated the expectation when residents have been exposed or are positive for COVID-19 is for staff to wear full PPE prior to entering the room. CNA #2 stated that when leaving a room on TBP, they are supposed to remove their PPE before exiting. CNA #2 said they thought the sign outside of room [ROOM NUMBER] was a mistake and that was the reason they had not put a gown on. CNA #2 stated that gloves should be changed after use and then hand hygiene performed before coming out of the room. 3.In an observation on 5/11/22 at 10:22 a.m., CNA #3 (listed on the facility list as having one dose of a multiple dose series on 11/18/21 and no 2nd dose of the COVID-19 vaccination), entered Resident room [ROOM NUMBER] wearing a N95 (respirator) mask and face shield but no gown or gloves. Signage on the door included a red stop sign that indicated room [ROOM NUMBER] was on TBP and all who enter must wear a N95 mask, face shield or eye protection, gown, and gloves. At 10:38 a.m., CNA#3 came to the door of room [ROOM NUMBER] still wearing only a N95 mask and face shield but no gown or gloves and requested a gown from a staff member in the hallway. At 10:43 a.m., CNA #3 was observed exiting room [ROOM NUMBER] wearing a gown, gloves, N95 mask and face shield while transporting soiled laundry to the dirty utility room where they removed their PPE and washed their hands. When interviewed at 10:51 a.m., CNA #3 stated they were aware they were supposed to be wearing a gown to enter a quarantined (on TBP) room but there were no gowns outside of room [ROOM NUMBER] and did not have time to walk down the hallway to get one. CNA #3 stated that there were no trash bins in room [ROOM NUMBER] to discard their used PPE. CNA #3 stated that they did provide care to both residents in room [ROOM NUMBER] and that they would have discarded the used PPE in the room before exiting if there had been a bin in the room. In an interview on 05/11/22 at 10:41 a.m., Licensed Practical Nurse (LPN) #1 stated that CNA#3 should not have entered the room without a gown since the room was on TBP and there is signage up on the door that is very specific (regarding what PPE to wear). LPN #1 stated staff should apply full PPE when entering a room on TBP to give care and should remove all PPE and perform hand hygiene when leaving. In an interview on 5/9/22 at 1:20 p.m., RN/IP stated that when a resident's room has a stop sign, the staff need to enter the resident's room wearing full PPE that consists of a N95 mask, gown, gloves, and face shield. Upon exiting the resident's room, the expectation is that the staff will remove the used gown and gloves and then wash their hands. 10 NYCRR 415.19

Based on observation, interviews and record review conducted during a Recertification Survey completed 5/9/22 to 5/13/22 the facility did not ensure that all staff, except for those staff who have been granted exemptions to the vaccination requirements or staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the Centers for Disease Control and Prevention (CDC) have received, at a minimum, one dose of a single-dose vaccine or all doses of a multiple vaccine series prior to providing care/treatment/services for the facility and/or its residents. This resulted in a 94.1% COVID-19 staff vaccination rate. In addition, the facility had 13 residents who were currently positive for COVID-19 and had observations of noncompliant infection control practices by staff. This was evidenced by the following: The Centers for Medicare & Medicaid Services (CMS) Quality Safety & Oversight (QSO) memorandum 22-07-ALL, Long-Term Care and Skilled Nursing Facility Attachment A, posted 12/28/21 and revised on 4/5/22, required that within 90 days of the issuance of the memorandum all staff are fully vaccinated for COVID-19, except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions. The facility policy N6 HCC Employee COVID-19 Vaccination & Exemption of Vaccination dated March 2022, documented that based on the regulations issued by New York State Department of Health and CMS, it is the policy of this facility that employees, contract staff, volunteers and any individuals providing care, treatment or other on-site services will be vaccinated against COVID- 19 or will have an approved exemption. This group of individuals does not include those groups deemed exempt by New York State. Vaccinations may be obtained at the facility, through a facility related vendor or off site and must be one of the approved vaccination sites. The facility will maintain records and track the vaccination status of employees, volunteers, and contract staff, including facility efforts to ensure compliance. Review of the facility list titled Residents with Confirmed Cases of COVID-19 provided by the facility on 5/9/22 included 13 current positive COVID-19 residents residing at the facility. Review of COVID-19 Staff Vaccination Matrix provided by the facility on 5/9/22 revealed the facility had 153 current staff members of which 129 were fully vaccinated, 12 were granted medical exemptions, 3 were temporary delay per CDC/new hire regulation, 7 were partially vaccinated with one dose of a multiple dose vaccination series and beyond their due date for the 2nd dose, 1 staff member had no records of any vaccination dose and 1 staff member was listed as having no vaccination doses and listed as terminated (no termination date listed). These staff members included nursing staff, dietary staff, and laundry staff. The staff vaccination rate was calculated as 94.1%. Observations included but not limited to the following: In an observation on 5/9/22 at 10:09 a.m., Certified Nursing Assistant (CNA) #1 (listed by facility as a temporary CNA) entered Resident room [ROOM NUMBER] (signage on door indicated the room was on TBP) wearing full (gown, gloves, mask, and face shield) Personal Protective Equipment (PPE) and later exited the room still wearing the same PPE and then entered Resident room [ROOM NUMBER] to assist another resident. When interviewed CNA #1 stated the Registered Nurse/ Infection Preventionist (RN/IP) instructed them to wear PPE, but they did not know when to change their PPE and that they had not received any education about when to change PPE. In an observation on 5/11/22 at 10:22 a.m., CNA #3 (listed as having one dose of a multiple dose series on 11/18/21 and no 2nd dose of the COVID-19 vaccination), entered Resident room [ROOM NUMBER] wearing a N95 (respirator) mask and face shield but no gown or gloves. Signage on the door included a red stop sign that indicated room [ROOM NUMBER] was on TBP and all who enter must wear a N95 mask, face shield or eye protection, gown, and gloves. At 10:38 a.m., CNA#3 came to the door of room [ROOM NUMBER] still wearing only a N95 mask and face shield but no gown or gloves and requested a gown from a staff member in the hallway. At 10:43 a.m., CNA #3 was observed exiting room [ROOM NUMBER] wearing a gown, gloves, N95 mask and face shield while transporting soiled laundry to the dirty utility room where they removed their PPE and washed their hands. When interviewed at 10:51 a.m., CNA #3 stated they were aware they were supposed to be wearing a gown to enter a room on TBP but there were no gowns outside of room [ROOM NUMBER] and they did not have time to walk down the hallway to get one. CNA #3 stated that there were no trash bins in room [ROOM NUMBER] to discard their used PPE. CNA #3 stated that they did provide care to both residents in room [ROOM NUMBER] and that they would have discarded the used PPE in the room before exiting if there had been a bin in the room. In an interview on 05/11/22 at 10:41 a.m., Licensed Practical Nurse #1 stated that CNA#3 should not have entered the room without a gown since the room was on TBP and there is signage up on the door that is very specific (regarding what PPE to wear). LPN #1 stated staff should apply full PPE when entering a room on TBP to give care and should remove all PPE and perform hand hygiene when leaving. In an interview 5/9/22 at 1:20 p.m. and on 5/10/22 at 1:35 p.m., the RN/IP stated that when a resident's room has a red stop sign staff need to wear full PPE, remove PPE and wash hands in the room prior to exiting. With regards to tracking staff COVID-19 vaccinations, the RN/IP stated that they track the doses by leaving a message for the staff member and keep track of the calls in a binder. The RN/IP stated the binder was up to date. The RN/IP stated that they track the staff regarding the 2nd doses of the vaccination and it is up to the Administrator to give the ultamatim. The RN/IP stated that the DON assists in tracking the 2nd dose and calls are documented on the list and kept in a folder with results and/or the need for more follow up. In an interview on 5/13/22 at 10:06 a.m., when asked about the staff vaccination rate, the Administrator declined to comment. 10 NYCRR415.19(a)(1-3)

Based on observations, interviews and record reviews conducted during an Abbreviated Survey (#NY 423), completed on 2/18/22, it was determined that the facility failed to develop and implement policies and procedures to ensure proper precautions to prevent the spread of COVID-19 in accordance with the Centers for Disease Control (CDC) recommendations and the regulations. The evidence is: The facility policy Covid-19 Vaccine for Staff, updated February 2022, included the facility would require all employees to have a COVID-19 vaccine approved by the CDC or provide a valid medical exemption, receive doses of the vaccine in a timely manner, and that the vaccines can be provided by the facility or a vaccine card from the community would be accepted. The policy does not include the following: 1. A process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19. 2. A process by which staff may request an exemption from the COVID-19 vaccination based on applicable Federal and state laws and the tracking and documentation of such requests. 3. A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines, and which supports staff requests for medical exemptions from vaccination includes all information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications. 4.A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 must be temporarily delayed as recommended by the CDC. 5. Contingency plans for staff who are not fully vaccinated for COVID-19. Review of 9 or 12 medical exemptions provided by the facility did not include either the authorized COVID-19 vaccine contraindicated or the recognized clinical reason for the contraindication. Additionally, unvaccinated staff were observed in the facility providing direct resident care without documented evidence of a valid medical exemption and not wearing a National Institute for Occupational Safety and Health approved N95 face mask or equivalent while providing direct care . This is evidenced by but not limited to, the following: a. Review of a medical exemption form for Staff #1 dated 2/9/22 and signed by the Nurse Practitioner (NP) did not include which of the authorized COVID-19 vaccines were clinically contraindicated or a recognized clinical reason for the contraindication per CDC guidelines. During observations on 2/16/22 from 11:30 a.m. through 12:22 p.m., Staff #1 was observed wearing a surgical mask (versus an approved N95 respirator) and no other Personal Protective Equipment (PPE) while passing medications to multiple residents, providing personal hands-on care, checking blood sugar levels, and feeding residents. When interviewed at 3:30 p.m. Staff #1 stated they had COVID-19 several weeks ago, had not been asked to be tested since and had not been asked to wear any additional PPE when giving direct care to residents. b. Review of a medical exemption for Staff #2, dated 2/3/22 and signed by the NP did not reveal a CDC recognized clinical contraindication that would exempt Staff #2 from receiving at least one of the COVID-19 vaccines. During observations on 2/16/22 at 2:08 p.m., Staff #2 was sitting at a table with several other staff and a resident representative wearing a surgical mask and not social distancing. In an interview at 3:11 p.m., Staff #2 stated that they wear a surgical mask and try to stay as far away as possible from residents and other staff. c. Review of a medical exemption form for Staff #3, dated 2/10/22 and signed by the NP, revealed the medical exemption did not include which vaccine would be contraindicated or any recognized health condition that would exempt Staff #3 from receiving any of the COVID-19 vaccines. During an observation on 2/16/22 at 3:35 p.m., Staff #3 was observed exiting a resident's room after care wearing a surgical mask. At 3:40 p.m., Staff #3 was observed with hands on assist with an agitated/combative resident, pushing their wheelchair and administering medications. When interviewed on 2/16/22 at 2:45 p.m., the Director of Nursing (DON) stated the facility did not make changes to PPE requirements or changes to the job descriptions or duties of the unvaccinated staff. When interviewed on 2/17/22 at 12:45 p.m., the Administrator stated that the facility policy provided on 2/16/22 was the only policy for staff vaccinations. After reviewing the policy requirements of the current regulation, the Administrator stated that the policy did not include precautions for unvaccinated staff with exemptions or pending requests for exemption or who have a temporary delay. The Administrator stated the policy did not include a system for staff to request an exemption, a system for the facility to evaluate medical exemptions, or to track staff with valid medical exemptions. The Administrator stated that they had been reviewing the medical exemption paperwork but had only reviewed it for a signature of a medical professional. The Administrator stated that there was not a contingency plan for the staff with medical exemptions. The Administrator added that the facility did not have an infection preventionist employed. 10 NYCRR 415.19 (a)(1-3)

Based on observations, interviews, and record reviews conducted during the COVID-19 Infection Control Focus Survey (complaint NY 364), it was determined that for 6 of 82 residents reviewed for COVID-19 infections, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of COVID-19. Specifically, the facility did not protect two asymptomatic non-COVID-19 residents (Residents #1 and #3) who were residing in the same room with residents who were either positive confirmed by lab for COVID-19 (Resident #2) or presumed positive by the medical provider due to respiratory symptoms (Resident #4). Additionally, Resident #6 who was not confirmed or presumed positive, continued to reside in the same room for seven days with Resident #5 who was COVID-19 positive. Resident #6 then tested positive after becoming symptomatic. This resulted in Immediate Jeopardy to resident health and safety. This is evidenced by the following: Review of the Center for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidelines, dated 4/2/20, included that long-term care facilities should separate residents who have COVID-19 from residents who do not, or have unknown status. Review of the undated Infection Control Policy, Emerging Infectious Disease Response includes that the facility Infection Policy will include a response plan for a community wide infectious disease outbreak such as pandemic influenza and include isolation areas and rooms. Isolation is defined as the separation of an individual or group reasonably suspected to be infected with a communicable disease from those who are not infected to prevent the spread of the disease. In the event there are confirmed cases of an emerging infectious disease in the facility, a resident is to be placed in an isolation room. 1. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A lab test, dated 3/31/20, was negative for COVID-19. Review of medical and nursing progress notes, dated 3/13/20 through 4/16/20, did not reveal documentation of any signs or symptoms of respiratory issues or fever. Resident #2 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/23/20 at 11:30 a.m. and again at approximately 6:00 p.m. Residents #1 and #2 were observed in the same room. The privacy curtain between the residents was open and the beds were approximately 6 feet apart. Neither resident was wearing a mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, and masks. 2. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical and nursing progress notes, dated 3/17/20 through 3/31/20, did not include documentation that the resident had signs or symptoms of respiratory issues or fever. A lab test, dated 3/31/20, revealed that the resident was negative for COVID-19. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical progress notes, dated 4/7/20 through 4/20/20, revealed the resident was presumed positive for COVID-19 due to recent exposure, general decline, increased confusion, lethargy, and congestion. On 4/23/20 at 11:30 a.m. and again at approximately 6:00 p.m. Residents #3 and #4 were observed in the same room. The privacy curtain was pulled approximately 1/2 down the bed between the residents, and the beds were approximately 6 feet apart. Neither resident was wearing a mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, and masks. 3. Resident #5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #6, who shared a room with Resident #5, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical and nursing progress notes revealed that Resident #6 tested positive for COVID-19 on 4/22/20. On 4/23/20 at 11:30 a.m. and again at approximately 6:00 p.m. Residents #5 and #6 were observed in the same room. Neither resident was wearing a mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, and masks. In an interview on 4/23/20 at 11:30 a.m., Certified Nursing Assistants (CNA) #1 and #2 stated they did not know which residents were positive and which were negative. Both CNAs stated they use the personal protective equipment when going into the rooms for both residents but do not change until they come out of the rooms. When interviewed on 4/23/20 at 3:30 p.m., the Director of Nursing (DON) and the Infection Preventionist stated that at first, they were moving residents out of their rooms when their roommates tested positive but as the number grew, they were having difficulty doing that. They said they moved many residents who were presumed negative to another facility approximately one to two weeks ago and now have an empty unit but have not moved any other residents to these rooms. The DON said that they originally had signs on all the doors to identify which residents were positive. The DON said she decided to take the signage down and presume that all residents were positive. The DON said that was what she understood should be done from the literature and in speaking with the Department of Health, therefore, the residents did not need to be separated. When asked why the facility did not separate the positive residents into the newly closed unit when available, the DON stated they did not think they needed to separate the residents. In an interview on 4/23/20 at 8:15 p.m., the Administrator stated that he was not aware that residents that were positive for COVID-19 could not room with residents who were presumed negative. The facility's allegation of compliance to remove the Immediate Jeopardy, dated 4/23/20, included that the involved residents (Residents #2 and #4) would be moved to appropriate rooms, and residents and families would be notified of the room changes. The Immediate Jeopardy was removed on 4/24/20 based upon surveyor observations. Observations on 4/24/20 at 4:30 p.m. revealed that Resident #2 and Resident #4 were moved to rooms that were occupied by residents who were already positive for COVID-19 or in single rooms. [10 NYCRR 415.19(b)(1)]

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of three residents reviewed for advanced directives, the facility did not ensure that there was an organized, effective system in place to ensure that residents' wishes regarding Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) are initiated and implemented according to their wishes. Specifically, Resident #30 and #383's wristbands did not match the Medical Orders for Life Sustaining Treatment (MOLST) or physician orders [REDACTED]. The facility policy, Do Not Resuscitate, dated (MONTH) 2005, revealed that the resident's code status will be identified by a white band on their wrist or ankle if they are a full code, and a blue band for DNR status. A medical order denoting the resident's coded status will be maintained on the monthly physician orders [REDACTED]. 1. Resident #30 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated [DATE], revealed that the resident was cognitively intact. Review of the resident's MOLST, dated [DATE] and signed by the resident, revealed that the resident's wishes were to attempt CPR. Physician orders, dated [DATE], revealed that the resident was a full code status. When observed on [DATE] at 10:30 a.m., the resident was wearing a blue wristband which means DNR. 2. Resident #383 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. When observed on [DATE] at 12:01 p.m., the resident was wearing a white wristband which means full code. Interviews conducted on [DATE] included the following: a. At 11:13 a.m., the Social Worker said that a blue wristband means the resident is a DNR. She said the secretary applies the wristband. b. At 1:18 p.m., the Unit Secretary said that a blue wristband means the resident is a DNR and a white wristband means the resident is a full code. She said that she or the nurse apply the resident's wristband upon admission. She said if if the MOLST changes, the Unit Secretary would be notified by medical and a new band would be placed on the resident. c. At 2:03 p.m., the LPN stated that Resident #383's MOLST was changed on [DATE]. She said the resident's wristband was not changed to blue. d. At 2:34 p.m., the Social Worker said that Resident #30's wristband was incorrect. (10 NYCRR 415.3(e)(1)(ii))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #133) of one resident reviewed for hospitalization , the facility did not ensure that the justification for a resident's transfer was documented in the resident's medical record. Specifically, there was lack of a documented summary for the resident's transfer to the hospital. This is evidenced by the following: Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record revealed that on 10/17/19 the Social Worker documented that the resident was admitted to the facility that afternoon. Physical Therapy documented that the resident was evaluated. The Nurse Practitioner saw the resident at 3:29 p.m. and the resident was calm but restless. There was no agitation, and the resident ambulated independently without an assistive device. There was no other documentation in the medical record regarding the resident's condition, behaviors, or status. An Admission Nursing Evaluation form, dated 10/17/19 at 3:28 p.m., revealed that a skin assessment was completed by a Registered Nurse. There was a 10/18/19 invalidation date on the form that included an invalidation note, The admission was refused, the resident was returned to the hospital due to elopement attempts, and the facility was not wanderguarded. When interviewed on 12/4/19 at 2:01 p.m., the Director of Nursing (DON) stated the resident's information was reviewed by the admission staff, and the resident was accepted to the facility. The DON stated the resident ambulated independently, and when the resident's friend left the facility, the resident began trying to exit the facility. The DON said she was called and was told that the facility could not provide a safe environment. The DON stated it was an Administrative decision to send the resident back to the hospital, and the admission was refused. The DON stated the supervisor should have documented the resident's behaviors and attempts to leave the facility. During an interview on 12/5/19 at 1:43 p.m., the Director of Social Work (DSW) stated the resident had been accepted to the facility, but the DON and Administrator stated they were going to refuse the admission. The DSW stated technically the resident was not admitted . She said there was no discharge summary or documentation for the reason for transfer. (10 NYCRR 415.3(h)(1)(ii)(a)(b))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #62) of five residents reviewed for accidents, the facility did not implement the person-centered care plan to address the resident's medical, physical, mental, or psychosocial needs. The issue involved the lack of implementing therapy recommendations for safe transfers following a recent fall from a mechanical lift (Hoyer) sling. This is evidenced by the following: Resident #62 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/8/19, included that the resident was cognitively intact and required extensive assist of two staff for transfers. Review of the current Certified Nursing Assistant (CNA) Profile required the assistance of two staff members to transfer via a Hoyer lift. Specific instructions included to position the resident's left arm by the left side during the transfer, not across the body, move the Hoyer lift only when the second person has hands on, and do not recline the wheelchair prior to lifting. Review of the Incident/Accident Report, dated 12/1/19, revealed the resident had fallen out of the Hoyer sling during a transfer and sustained a [MEDICAL CONDITION] requiring a transfer to the hospital. The investigation summary included recommendations from therapy to ensure the resident's left arm was straight along his side, not across the body, move the Hoyer lift when the second person has hands on, and do not recline the wheelchair prior to lifting. In an observation on 12/4/19 at 9:46 a.m., the resident was transferred from bed to a wheelchair via a Hoyer lift by CNA #1 and CNA #2. The resident's arms were positioned across the body and both staff members were handling the Hoyer and did not have hands on the resident while they were transferred. The resident remained still and did not move during the entire transfer. When interviewed at that time, CNA #1 stated the resident was always compliant during transfers and does not move at all. In an interview on 12/5/19 at 8:08 a.m., the Occupational Therapist stated that after the incident where the resident fell out of the sling, they did an investigation and determined that the resident may have moved during the transfer. She said due to the resident's paralyzed left side, their weight shifted, and they fell out. She said the team felt the resident needed to keep their left arm to the side as opposed to across the body to prevent a further incident and that the recommendations were on the report and on the care plan. She said it was her expectation that staff follow the recommendations. In an interview on 12/5/19 at 12:08 p.m., CNA #1 stated that she was not aware of the therapy recommendations that included keeping the resident's arm at the left side of the body, not across their body, and keeping hands on the resident during the transfer. CNA #1 said that she does care for the resident a lot and was just helping out that day. She said CNA #2, who was assigned to the resident, was a float. CNA #1 said that she needs to review the computer every time she assists with a resident. CNA #1 said that she was not aware of the recent changes. (10 NYCRR 415.11(c)(3)(ii))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #47) of three residents reviewed for care planning, the facility did not ensure that the resident was given the right, to the extent practicable, to participate or have a representative participate in the development of the resident's plan of care. This is evidenced by the following: Resident #47 was admitted to the facility for long term care on 11/13/19 with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/20/19, revealed the resident was cognitively intact and required assistance of staff for all activities of daily living. When interviewed on 12/4/19 at 1:02 p.m., the resident stated that they had a lot of questions about the possibility of going back home versus staying long term and about their pain medication that was changed. The resident said they had felt they were not being treated in a dignified manner since admission, especially after a recent fall. The resident stated they had not gone to any meetings with the facility staff to discuss the above concerns, nor were they ever invited to one. Review of a progress note, dated 12/2/19 by the Social Worker (SW), revealed that the initial resident care plan conference was held with staff members, and that the resident and their representative were invited to the meeting but declined to come. In an interview on 12/4/19 at 2:24 p.m., the resident's SW stated that the initial care plan meeting invite was done on the day of admission. She said the family was given a letter that was included in the admission paperwork as per their usual process. The SW stated that the family never got back to her about attending the scheduled meeting and it was held without them. She stated that she did not invite the resident because the resident was not in their room the morning of the meeting. She said she thought the resident may have been in therapy. At that time, the Director of Social Work stated that the resident should be invited to the meeting. When interviewed on 12/5/19 at 11:49 a.m., the resident's family representative stated that they thought they got a letter about a meeting during the admission process but they were so overwhelmed with all the paperwork they forgot about it. The representative stated they would like to attend a meeting but would have trouble taking the day off from work. The representative stated that they were not given any reminders of the meeting or offered a time change to accommodate their work schedule. The representative stated that they received a phone call from the facility the previous afternoon (after surveyor intervention) to schedule a meeting. (10 NYCRR 415.11(c)(2)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for three of seven residents reviewed for activities of daily living, the facility did not provide the necessary care and services to maintain personal hygiene. Specifically, Residents #38 and #62 were not provided nail care, and Resident #35 was not provided with timely incontinence care. This is evidenced by the following: 1. Resident #38 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/17/19, revealed the resident was cognitively intact and required extensive assistance for personal hygiene. The Comprehensive Care Plan and Certified Nursing Assistant (CNA) Care Card, both dated 3/14/19, revealed that the resident required the assistance of one staff member with bathing. During observations on 12/2/19 at 11:38 a.m., 12/4/19 at 9:18 a.m., and 12/5/19 at 8:09 a.m., all ten of the resident's fingernails were long and dirty. The resident said that they cannot cut their own fingernails and that their fingernails needed a trim. The resident said they have been trying to get someone to cut and clean their fingernails every day for quite a while. The resident said they had a shower on Tuesday evening, but no one looked at their nails. When interviewed on 12/5/19 at 12:54 p.m., Licensed Practical Nurse (LPN) Manager #1 said that the resident's fingernails should be checked daily with care, and staff are expected to clean and trim the resident's nails on shower days. She reviewed the shower schedule, and then stated that the resident was scheduled for a shower on Tuesday evenings (12/3/19). She observed the resident's nails with the surveyor and then stated the resident's nails should have been cut and cleaned. She said that she would have it done that day. In an interview on 12/5/19 at 1:08 p.m., assigned CNA #1 said the night shift gets the resident up, and she did not notice the resident's nails 2. Resident #35 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 9/14/19, revealed that the resident's cognitive skills for decision making was moderately impaired, the resident required the extensive assistance of one staff member for toileting, and the extensive assistance of two staff members for personal hygiene. The current Comprehensive Care Plan revealed that the resident was incontinent of bowel and urine, used incontinence products (briefs), and required the assistance of two staff members for incontinence care. There was no direction as to how often to check or change the resident. When observed on 12/3/19 at 11:09 a.m., the resident was in bed and the incontinent brief and the bed pad were both soaked with urine. There was a strong urine odor in the room. The top sheet was wet and also had dried urine stains. Interviews conducted on 12/3/19 included the following: a. At 11:38 a.m., CNA #2 and the surveyor observed the resident. CNA #2 said that the resident's room smelled like urine, and the resident's top sheet and bed pad had wet spots of urine as well as dried urine stains. CNA #2 said that she did not know when the resident was last changed. b. At 11:40 a.m., LPN #1 and the surveyor observed the resident. LPN#1 said it smelled like urine and there were urine stains on the top sheet. She said the resident should be checked or changed every one to two hours. She said she did not know when the resident was last changed but thought maybe an hour ago. When interviewed on 12/4/19 at 11:22 a.m., LPN Nurse Manager #2 said that the last time incontinent care was provided for the resident was on the night shift. She said there was some shifting of staff to other units to help with various tasks and she had asked a staff member to provide care and thought it had been done. 3. Resident #62 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/8/19, included that the resident was cognitively intact, required extensive assist of staff for personal hygiene and toileting, and was totally dependent on staff for bathing. The current Comprehensive Care Plan and current CNA Profile revealed that the resident required extensive assistance of two members for bathing and the assistance of one staff member for grooming. Observations conducted on 12/3/19 at 4:10 p.m., 12/4/19 at 9:46 a.m., and 12/5/19 at 1:45 p.m., all the resident's fingernails were filled with brown debris. In an interview on 12/5/19 at 1:45 p.m., the Registered Nurse Manager observed the resident's nails with the surveyor and stated that they had not been cleaned. She said the resident's fingernails needed to be cut and cleaned and that the CNAs need to let staff know when they need to be cleaned. When the resident was asked if their nails had been cut and cleaned recently or when last showered, the resident clearly stated no. (10 NYCRR 415.12(a)(3))