Every finding on record at Wedgewood Nursing and Rehabilitation Center

Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (Intake ID: 2673831), the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment for 9 of 15 resident rooms (Rooms #11, #13, #14, #15, #16, #17, #21, #22, and #23) and one (1) of one (1) ventilation system. Specifically, there were damaged baseboard radiators, exhaust ventilation was not functional resulting in foul odors, boxes of supplies were stored outside in the snow, there was a damaged electrical outlet cover, and a bathroom faucet was corroded. The findings include: Observations on 02/09/2026 at 9:10 AM included approximately eight (8) boxes of Medline supplies setting on a wooden pallet, covered with snow outside the loading dock. Observations on 02/10/2026 at 9:22 AM included a wooden pallet outside the loading dock with multiple boxes of supplies with snow on top, including but not limited to: disposable nebulizers, Micro-Kill One wipes, drain sponges, bed pans, and dry cleansing wipes. During an interview at this time, the Director of Environmental Services stated the supplies were probably delivered last Friday (02/06/2026).Observations on 02/10/2026 at 9:38 AM included the baseboard radiator cover in resident room [ROOM NUMBER] had come loose and exposed an approximately one (1)-foot-long section of the radiator fins.Observations on 02/10/2026 at 12:16 PM included the sink faucet was heavily corroded and flaking in the shared bathroom for rooms #15 and #17.Observations on 02/10/2026 from 12:20 PM to 12:30 PM included there was no air being drawn through ceiling exhaust grates in: the shared bathroom for rooms #11 and #13, the shared bathroom for rooms #14 and #16, and the shared bathroom for rooms #21 and #23. Additionally, there was a significant foul odor of urine and feces in the shared bathroom for rooms #11 and #13, and there were two (2) full garbage bins in this bathroom.Observations on 02/10/2026 at 12:33 PM included the cover plate for the four (4)-receptacle electrical outlet below the center television in room [ROOM NUMBER] was cracked and damaged exposing the interior of the lower electrical box.Observations on 02/10/2026 at 12:36 PM included the baseboard heater covers were heavily bent, chipped and damaged in room [ROOM NUMBER]. Additionally, the door to the bathroom in this room was very difficult to open due to the door catching on the flooring.During an interview on 02/11/2026 at 1:40 PM, the Director of Maintenance stated a vendor was onsite repairing the rooftop exhaust unit because it was not getting enough power to run properly.10 NYCRR: 415.29, 415.29 (h)(1, 2)(i)(1, 3)(j)(1)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 2656534, 2667467, and NY00382089/820392) completed on 12/04/2025, for one (1) of one (1) residential unit, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, comfortable, and homelike environment. Specifically, there were heavy urine and bowel odors upon entering the facility and, in the hallways, floors were dirty and/or in disrepair, walls had missing paint, a hand soap dispenser was broken, two (2) apex (a device used to assist residents with standing) machines were dirty and had duct tape on the frames, and the dumbwaiter (a small freight elevator used for moving items, such as laundry and food) was dirty. Additionally, the shower room was in disrepair and bathing fixtures were not available for resident use at a ratio of 1 per 20 residents. The findings are:The facility policy Use of Dumbwaiter for Soiled Laundry and Food Transport dated 04/14/2023 documented the dumbwaiter may be used to transport soiled laundry and food items under strict separation and sanitation protocols. The transport of soiled laundry must always be followed by proper containment, cleaning, and disinfection procedures before the dumbwaiter is used for food or any clean items. Each disinfection would be recorded in the dumbwaiter cleaning log, noting the date, time, and staff initials. 1. Observations on 11/03/2025 at 9:19 AM, included a heavy smell of urine and bowel upon entering the facility and the odors lingered in the hallways. Several resident room floors had different shades of dark debris. The hallway walls were painted bright blue color with many rectangular and square areas that were beige in color. During an observation and interview on 11/05/2025 at 12:26 PM, Certified Nursing Assistant #4 took a meal cart out of the dumbwaiter, the inside of the dumbwaiter had chipped paint and the back wall behind the metal bar was unclean and had debris of various colors. There was a cleaning schedule hanging on the wall outside of the dumbwaiter with only one cleaning date, 11/05/2025, documented. When interviewed at that time, Certified Nursing Assistant #4 stated the dumbwaiter was used for both dirty laundry and meal carts and they personally had never cleaned the dumbwaiter and had never seen anyone else clean it. Certified Nursing Assistant #4 stated the posted cleaning schedule had not previously been hanging there. Observations on 11/05/2025 at 1:30 PM, included soap dispensers for residential rooms #10 and #12 had soap in the dispenser but the dispenser did not function. Floor tiles in residential room [ROOM NUMBER] had several varying colors of dark, thick debris all over the floor. The hallway walls had chipped paint, and between residential rooms #12 and #14 there was an approximately two (2)-inch sharp nail partially sticking out of the wall about eight (8) inches above the handrail. The hallway walls were painted bright blue, with several areas where dispensers had been removed from the walls, and several random beige colored rectangular and square areas.Observations on 11/06/2025 at 1:08 PM, included an apex machine setting outside of residential room [ROOM NUMBER]. Both apex handles were covered with dirty duct tape with a long strip of the tape partially off one of the handles. There was debris on the base of the apex and dust on the top of both wheel coverings.During an interview on 11/06/2025 at 12:36 PM, the Director of Environmental Services stated they had received complaints that floors still looked dirty after cleaning and despite cleaning floor tiles on their hands and knees, some had old wax that trapped dirt and debris, and many needed to be replaced. The Director of Environmental Services stated there was at times a urine odor when they entered the facility, but it was typically gone by mid-morning. They stated the dumbwaiter should be cleaned each time the dirty laundry was removed, and the posted cleaning schedule was new and first placed outside the dumbwaiter on 11/05/2025. The Director of Environmental Services stated apex machines are supposed to be cleaned by nursing staff after each use and are cleaned by maintenance staff monthly. They stated the nail in the wall was a safety hazard and would be removed.During an observation and interview on 11/06/2025 at 2:22 PM, the Infection Preventionist stated both apex machines in the facility were dirty, and any equipment repaired with duct tape was difficult to clean and ensure removal of any potential organisms. During an interview on 11/06/2025 at 3:04 PM, the Director of Nursing stated the two (2) apex machines were dirty and needed a good cleaning. They stated apex machines should be cleaned after each use and duct tape should not be used as it acts like a reservoir for germs. The Director of Nursing stated missing paint, and patchwork did not make the facility a homelike environment.2. Review of a notification letter sent to residents, families and resident representatives dated 11/12/2205, revealed the primary shower room was currently undergoing renovation to improve the comfort and safety of residents. The shower room would be unavailable for approximately two (2) weeks and to ensure residents continued to receive proper hygiene care, bed baths would be provided as needed and arrangements for a portable shower sink had been made as an additional option.The facility was approved for 29 total beds, the facility census at the time of investigation was 24 residents.During a telephone interview on 12/01/2025 at 12:43 PM, the Director of Nursing stated there was only one (1) shower room for the 29 facility residents and the shower room had been out of service since the middle to end of October 2025. The Director of Nursing stated the facility had contracted with an outside vendor to complete the shower room renovation as it was more than the facility maintenance could handle. The contractors were now onsite, and the work should be done next week. The Director of Nursing stated the facility sent letters out to residents and their families about the shower room not being in use and the need for bedside bathing to take place. The Director of Nursing stated they did not know why the shower room was out of service for so long, and had not notified the Department of Health about the loss of shower use for residents.During a telephone interview on 12/01/2025 at 12:56 PM, the Director of Maintenance stated at the end of October 2025 while replacing broken floor tiles in the resident shower room, they found an issue with the wood subfloor which was old, in bad shape, and in need of repair. The Director of Maintenance stated the facility had a total of one (1) walk-in shower with two (2) shower heads. They stated the facility was reviewing vendor quotes and estimates and contractors, who had been working at a sister-facility, were finally available to work on the shower room floor. The Director of Maintenance stated the contractors started work last Friday (11/28/2025) and did not know if the facility notified the Department of Health when the shower room was no longer available for resident use.During a telephone interview on 12/03/2025 at 2:40 PM, the Administrator stated the Department of Health was not notified regarding the shower room closure because the renovations only included replacing drywall, tiles, and the subfloor. The Administrator provided the following timeline of events:- On August 8, 2025 during routine rounding, the facility staff observed broken floor tiles in the shower room.- On approximately October 13, 2025 the Director of Maintenance began to replace the broken tiles in the shower stall of the shower room. When removing additional tiles, it was discovered there was no proper subfloor. Tiles had been installed by a prior owner directly over what appeared to be aged wood planks. As tiles were removed, adjacent tiles cracked easily. The Director of Maintenance determined the job was significantly more extensive than expected, as nearly the entire tiled surface was laid on this deteriorated wood base.- On October 20, 2025 the facility's Chief Executive Officer agreed the entire floor would need replacement. They also noted uncertainty surrounding the condition of the walls once exposed. The Chief Executive Officer agreed the safest and most effective solution would be a full bathroom renovation.- On October 23, 2025 after trying to get a vendor in to complete the job it was decided to involve the Project Manager overseeing the renovations at a sister facility, this while the shower room was still in use.- On October 30, 2025 the shower room officially went out of service, as extensive tile removal had exposed the unstable wood subfloor, creating a safety hazard. The contractors proposed starting work on November 17, 2025 with a two (2)-week completion timeframe.- On November 12, 2025 a letter was sent to residents, families, and friends notifying them of the shower room closure for the foreseeable future.- On November 17, 2025 construction and drywall materials were delivered to the facility, and on November 24, 2025 demolition of the shower room began.- On December 1, 2025 the tile had been fully removed, and the deteriorated subfloor was exposed and awaiting replacement. 10 NYCRR: 415.29, 415.29(c), 415.29(d), 415.29(h)(1), 415.29(i)(1,2), 415.29(j)(1), 713-4.3, 2010 FGI: 4.1-2.2.2.8

Based on observations, interviews and record review conducted during an Abbreviated Survey (Intake ID: 2621922 and 2626565) completed on 12/04/2025, for one (1) (Resident #3) of three (3) residents reviewed, the facility did not ensure each resident is treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of their quality of life. Specifically, Resident #3 was observed in the dining room for several hours with a strong odor of bowel incontinence while in the presence of other residents. Additionally, Resident #3 requested to go to their room and staff yelled at the resident in a loud, demeaning tone and multiple residents were observed in the dining room and hallways wearing hospital gowns. The findings include:The facility policy Quality of Life - Dignity dated August 2009 included each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with respect and dignity at all times and shall be encouraged and assisted to dress in their own clothes rather than in hospital gowns.Resident #3 had diagnoses including altered mental status, muscle weakness and cerebral infarction (stroke). The Minimum Data Set (a resident assessment tool) dated 08/27/2025 documented the resident had mild cognitive impairment, did not reject care, was always incontinent of bowel and urine, and required extensive assistance from staff with transfers, toileting hygiene, showering/bathing, and dressing. The Comprehensive Care Plan revised on 09/12/2025 included Resident #3 had an activities of daily living (ADL) self-care deficit, limited physical mobility, and bowel and bladder incontinence. Interventions included but were not limited to: extensive assistance of one (1) staff for dressing and toilet use; total dependence on one (1) staff for wheelchair mobility; extensive assistance of one (1) staff for transfers; the resident used disposable briefs and should be changed every two (2) to four (4) hours and as needed. The current Kardex (care plan used by certified nursing assistance to direct care), reviewed on 11/04/2025, included Resident #3 used disposable briefs and should be changed every two (2) to four (4) hours and as needed.During an observation on 11/03/2025 at 9:19 AM, there were two (2) residents seated in the hallway wearing hospital gowns. The remaining residents in the facility were in their rooms wearing hospital gowns, except one (1) resident who was dressed in clothing.During an observation on 11/04/2025 at 9:07 AM, there were seven (7) residents in the dining room, Resident #3 and three (3) other residents were wearing hospital gowns.During an observation on 11/04/2025 at 12:20 PM, Resident #3 was seated in the dining room with their lunch meal placed in front of them and they had a strong odor of bowel incontinence. There were other residents also seated at the table with their meals.During an observation on 11/04/2025 at 2:43 PM, Resident #3 remained seated in the dining room, in the same spot as previously observed, and continued with a strong odor of bowel incontinence. Activities staff and two (2) other residents were seated across from Resident #3. At 2:45 PM, the Director of Nursing approached the table and leaned over to speak with Resident #3.During an observation on 11/04/2025 at 3:29 PM, Resident #3 requested to go to their room. Certified Nursing Assistant #1 walked into the threshold of the dining room and yelled out you need to wait for dinner in a loud, demeaning tone and then left the dining room. At 3:30 PM, Resident #3 asked again to go to their room, the activity staff loudly replied, not yet.During an interview on 11/04/2025 at 3:48 PM, Resident #3 stated they did not remember when their last bowel movement was and did not respond when asked if they were incontinent at that time. During an interview on 11/04/2025 at 3:51 PM with the Director of Nursing and Certified Nursing Assistant #1, the Director of Nursing stated they did not notice any odors from Resident #3. The Director of Nursing directed Certified Nursing Assistant #1 to check and change Resident #3 at that time. Review of Bladder and Bowel Elimination Reports (results from certified nursing assistant documentation) revealed Resident #3 was incontinent of urine and bowel on 11/04/2025 at 3:07 AM, 10:27 AM and at 8:47 PM. There was no documented evidence Resident #3 was checked, changed, or received incontinence care at any other time on 11/04/2025. During an observation and interview on 11/04/2025 at 3:59 PM, Certified Nursing Assistant #1 and Certified Nursing Assistant #3 assisted Resident #3 to their room for incontinence care. Resident #3 was found to have a bulging brief with a rolled non-disposable incontinence pad, saturated with bowel and urine, inside the brief. Resident #3's buttocks were reddened. When interviewed at that time, Certified Nursing Assistant #1 stated Resident #3 had bowel all over them and needed to be changed.During an observation on 11/05/2025 at 8:05 AM, there were nine (9) residents in the dining room. Five (5) of the residents were wearing hospital gowns and one (1) resident was wearing pajamas. During an interview on 11/06/2025 at 2:40 PM, Registered Nurse Manager #1 stated Resident #3 was at risk for aspiration and needed to be in the dining room for meals and staff try to keep the resident in the dining room because they attempt to self-transfer when they are in bed. Registered Nurse Manager #1 stated staff do not usually assist Resident #3 back to bed after 3:30 PM since dinner starts at 5:00 PM. During an interview on 11/06/2025 at 3:04 PM, the Director of Nursing stated many of the residents did not have their own clothes so the residents wear hospital gowns. The Director of Nursing stated it was not okay for staff to yell at residents and Resident #3 should have been able to go back to their room if they wanted to as this was their home. 10 NYCRR 415.5(a)

Based on observations, interviews and record review conducted during an Abbreviated Survey (Intake ID: 2626565, NY00382613/820391) completed on 12/04/2025, for two (2) (Residents #3 and #8) of two (2) residents reviewed, 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. Specifically, for Resident #3 staff did not perform hand hygiene after assisting with incontinence care and prior to touching multiple surfaces and equipment. For Resident #8, the facility did not appropriately implement the use of Enhanced Barrier Precautions (EBP, an infection control strategy that uses gloves and gowns during high contact resident care to reduce the spread of infection) and there was an observation of staff not using personal protective equipment (PPE; equipment, such as gown and gloves, worn to protect individuals and reduce the risk of exposure to and spread of infections) as required for high-contact care. The findings include:The facility policy Handwashing/Hand Hygiene dated August 2019 included all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Staff should use an alcohol-based hand rub containing at least 62 percent alcohol; or alternatively, soap and water after, but not limited to, the following situations: before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, and after contact with blood or bodily fluids. Hand hygiene is the final step after removing and disposing of personal protective equipment.1. Resident #3 had diagnoses including altered mental status, muscle weakness and cerebral infarction (stroke). The Minimum Data Set (a resident assessment tool) dated 08/27/2025 documented the resident had mild cognitive impairment, did not reject care, was always incontinent of bowel and urine, and required extensive assistance from staff with transfers, toileting hygiene, showering/bathing, and dressing. During an observation and interview on 11/04/2025 at 3:59 PM, Certified Nursing Assistant #1 and Certified Nursing Assistant #3 assisted Resident #3 to their room for incontinence care. Certified Nursing Assistant #1 removed the dirty brief and incontinence pad, cleansed stool and urine off the resident, and did not remove their gloves or wash their hands prior to touching multiple surfaces in the resident's room including, but not limited to, the resident's clothing, the resident's closet, the mechanical standing lift, and the resident's wheelchair. Certified Nursing Assistant #1 then wheeled Resident #3 into the dining room and touched the table, where other residents were seated, with their gloved hands. When interviewed at that time, Certified Nursing Assistant #1 stated Resident #3 had bowel all over them and needed to be changed. Certified Nursing Assistant #1 stated they should have removed their gloves and washed their hands before placing a clean shirt on the resident and touching all of the surfaces. During an interview on 11/05/2025 at 1:52 PM, the Director of Nursing stated staff should wash their hands before and after care and when going from dirty to clean areas. The Director of Nursing stated not performing hand hygiene and proceeding to touch surfaces was cross-contamination and went against infection control guidelines. The facility policy Enhanced Barrier Precautions dated August 2022 included Enhanced Barrier Precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. Enhanced Barrier Precautions are indicated for residents with wounds and/or indwelling medical devices regardless of multi-drug resistant organisms.2. Resident #8 had diagnoses including left above the knee amputation, muscle weakness, and adult failure to thrive. The Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment, the presence of a surgical wound and an unstageable pressure ulcer, and received ulcer/wound care.Review of Resident #8's Comprehensive Care Plan last revised 09/26/2025 included the resident had a wound to their left stump secondary to a recent above knee amputation and an unstageable pressure ulcer to the sacral (tailbone) area. Interventions included, but were not limited to, administer treatments as ordered. The care plan did not included Enhanced Barrier Precautions.During an observation on 11/03/2025 at 9:19 AM, there were no Enhanced Barrier Precautions signs on any resident room doors or Personal Protective Equipment carts in hallways or in close proximity to resident rooms. During an observation and interview on 11/05/2025 at 1:14 PM, Licensed Practical Nurse #1 and Certified Nursing Assistant #4 both put on a pair of gloves only and entered Resident #8's room. Licensed Practical Nurse #1 cleansed the resident's sacral area and applied zinc (a medicated cream) to Resident #8's sacral wound. When interviewed at that time, Licensed Practical Nurse #1 stated the facility did not use Enhanced Barrier Precautions and they would only wear a gown if a wound had heavy drainage or if the resident was on contact precautions for a specific diagnosis. During an interview on 11/05/2025 at 1:34 PM, the Infection Preventionist stated staff should have washed their hands after removing Resident #3's soiled brief so they did not contaminate the surrounding environment, and the staff should not have worn dirty gloves outside of the resident's room. The Infection Preventionist stated the facility used Enhanced Barrier Precautions only when a resident was known to have a multi-drug resistant organism and, to their knowledge, had not received more recent guidance. During an interview on 11/06/2025 at 3:04 PM, the Director of Nursing stated Resident #8 should have been on Enhanced Barrier Precautions because the resident had a pressure ulcer, and seven (7) additional residents had also been identified as requiring Enhanced Barrier Precautions. The Director of Nursing stated Personal Protective Equipment, including a gown and gloves, should be used during high-contact activities to protect residents with open areas in their skin from the potential transfer of organisms during care. 10 NYCRR 415.19(a)(1-4)(b)(1-4)

Based on observations, interviews and record review conducted during an Abbreviated Survey (Intake ID: 2621922, 2656534, NY00382613/820391, and NY00384361/820393) completed on 12/04/2025, for one (1) (Resident #3) of nine (9) residents reviewed, the facility did not ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, Resident #3 was not checked or changed for extended periods, was observed in the dining room with a strong bowel odor for several hours and was later found with a saturated brief and non-disposable incontinence pad inside the brief, with redness noted to the buttocks. Furthermore, the facility did not revise Resident #3's care plan to address their chronic loose stools and increasing incontinence care needs, and staff documentation did not reflect care consistent with the resident's needs or the facility's required frequency of incontinence care.The findings include:The undated facility policy Activities of Daily Living (ADL), Supporting included appropriate care and services would be provided for residents who were unable to carry out activities of daily living independently including care with hygiene and toileting.Resident #3 had diagnoses including altered mental status, muscle weakness, and malignant neoplasm of colon (cancer of the large intestine). The Minimum Data Set (a resident assessment tool) dated 08/27/2025 documented the resident had mild cognitive impairment, was always incontinent of bowel and urine, and required extensive assistance from staff with transfers, toileting hygiene, showering/bathing, and dressing. The Comprehensive Care Plan revised on 09/12/2025 included Resident #3 had an activities of daily living (ADL) self-care deficit and bowel and bladder incontinence. Interventions included but were not limited to: extensive assistance of one (1) staff for toilet use, the resident used disposable briefs and should be changed every two (2) to four (4) hours and as needed.Review of Bladder and Bowel Elimination Reports (results from certified nursing assistant documentation) revealed Resident #3 was incontinent of urine and bowel on 11/04/2025 at 3:07 AM, 10:27 AM and at 8:47 PM. There was no documented evidence Resident #3 was checked, changed, or received incontinence care at any other time on 11/04/2025. Review of Toileting Hygiene Reports (certified nursing assistant documentation related to the level of assistance provided during incontinence care) from 10/01/2025 to 11/05/2025 revealed Resident #3 had documented assistance with incontinence episodes no more than four (4) times daily. There was no documented evidence incontinence care was provided on 11/03/2025 and documented evidence incontinence care was provided one (1) time daily on four (4) days, two (2) times daily on 17 days, and three (3) times daily on 12 days.During an observation on 11/04/2025 at 12:20 PM, Resident #3 was seated in the dining room with their lunch meal placed in front of them and they had a strong odor of bowel incontinence. There were other residents also seated at the table with their meals. During an interview on 11/04/2025 at 3:48 PM, Resident #3 stated they did not remember when their last bowel movement was and did not respond when asked if they were incontinent at that time. During an interview on 11/04/2025 at 3:51 PM with the Director of Nursing and Certified Nursing Assistant #1, the Director of Nursing stated they did not notice any odors from Resident #3. The Director of Nursing directed Certified Nursing Assistant #1 to check and change Resident #3 at that time. During an observation and interview on 11/04/2025 at 3:59 PM, Certified Nursing Assistant #1 and Certified Nursing Assistant #3 assisted Resident #3 to their room for incontinence care. Resident #3 was found to have a bulging brief with a rolled non-disposable incontinence pad, saturated with bowel and urine, inside the brief. Resident #3's buttocks were reddened. When interviewed at that time, Certified Nursing Assistant #1 stated Resident #3 had bowel all over them and needed to be changed. Certified Nursing Assistant #1 stated they did not know how the incontinence pad got inside of Resident #3's brief but it should not have been there. During an interview on 11/05/2025 at 7:03 AM, Certified Nursing Assistant #2 stated Resident #3 was consistently incontinent of bowel and required frequent incontinence care. Certified Nursing Assistant #3 stated staff had tried using two (2) briefs, larger sized briefs, and disposable incontinence pads, but nothing seemed to manage Resident #3's incontinence. Certified Nursing Assistant #3 stated all nursing staff were aware of Resident #3's frequent incontinence needs, but they were not aware of any interdisciplinary discussions about alternative interventions for the resident. There was no documented evidence in the care plan, progress notes, or interdisciplinary notes that alternative interventions were developed or implemented to address Resident #3's frequent loose stools and episodes of incontinence. During an interview on 11/06/2025 at 3:04 PM, the Director of Nursing stated Resident #3 had a history of chronic loose bowels and the resident should not have had a non-disposable incontinence pad inside their brief as it could cause skin issues. The Director of Nursing stated Resident #3's care plan needed to be updated to address her increased incontinence care needs, and staff should check and change Resident #3 more than the standard. The Director of Nursing stated staff should document each time a resident received assistance with incontinence care and if there was no documentation then the care was not provided. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for six (rooms #10, 12, 14, 16, 18, and 19) of 15 resident rooms, the facility did not ensure that the resident environment remained free of accident hazards. Specifically, hot water temperatures exceeding 120 degrees Fahrenheit ( F) were accessible to residents at point of use locations. The findings are: The facility policy titled: 'Water Temperatures, Safety of' included that water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 90 F (120 C), or the maximum allowable temperature per state regulation. Observations on 3/11/24 at 9:44 AM included the in-line temperature gauge for outgoing water from the mixing valve located in the basement boiler room displayed a temperature of 130 F. During an interview at this time, the Director of Environmental Services stated that the hot water temperature should be 120 F or less, and that by the time the water gets to the unit it's usually lower. On 3/11/24 from 10:20 AM to 10:35 AM the following water temperatures were observed from handwashing sinks using an ExTech digital thermometer: 127.1 F in the shared bathroom between resident rooms #10 and# 12, 126.4 F in the shared bathroom between resident rooms #14 and #16, and 132.1 F in the shared bathroom between resident rooms #18 and #19. On 3/11/24 at 10:40 AM the surveyor verified that the ExTech digital thermometer was accurate using the ice-point method. The thermometer read 32.2 F after being placed in a cup of ice water. During an interview on 3/12/24 at 10:01 AM a maintenance staff member stated that the laundry, kitchen, and water to resident rooms all come from the one hot water tank. The maintenance staff member also stated that they were not sure the last time the mixing valve was replaced and a vendor was coming in to replace it. 10NYCRR: 415.12(h)(1), 415.29, 415.29(a), 415.29(f)(6)

Based on observations, interviews, and record review conducted during a Recertification Survey it was determined that for five (rooms # 11, 12, 15, 18, and 19) of 15 resident rooms and one of one shower room, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, floor tiles were cracked and damaged, and hot water in a shower room was not maintained above 90 degrees Fahrenheit ( F). The findings are: The facility policy titled: 'Water Temperatures, Safety of' included that water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 90 F (120 C), or the maximum allowable temperature per state regulation. Observations on 3/11/24 at 9:32 AM included the floor tiles in resident rooms #12 and #15 had multiple chips and cracks throughout the room and at the door thresholds. In resident room [ROOM NUMBER] there were two approximately 12-inch by two-inch sections of the floor tile missing near the door. During an interview at this time the Director of Environmental Services stated that they believed that the flooring was going to be replaced. Observations on 3/11/24 from 10:30 AM to 11:52 AM included the floor tiles in resident rooms #11, #18, and #19 had multiple chips and cracks throughout the rooms and at the door thresholds. During a telephone interview on 3/11/24 at 11:11 AM, the Ombudsman (person who investigates, reports on, and helps resolve complaints usually through recommendations or mediation) stated they have received multiple resident complaints of the lack of hot water during showers and residents not receiving their showers due to the lack of hot water. Observations on 3/12/24 from 9:45 AM to 9:52 AM included the temperature of the hot water coming from the shower in the main bathing/shower room rapidly moved up and down from 66.3 F to 84.8 F to 68.4 F to 78.7 F, and then stabilized at 78 F. A similar observation was made at this time in the hand washing sink in the shower room. Observations on 3/12/24 at 10:01 AM included the in-line temperature gauge at the mixing valve in the basement boiler room displayed temperatures ranging from 62 F to 80 F to 100 F and back down to 85 F over the span of less than a minute. During an interview at this time, a maintenance staff member stated that the laundry, kitchen, and water to resident rooms all come from the one hot water tank. The maintenance staff member also stated that they were not sure the last time the mixing valve was replaced and a vendor was coming in to replace it. During an interview on 3/12/24 at 10:40 AM, CNA #1 stated that sometimes the water in the shower room is too cold so they cannot give the shower. CNA #1 also stated that they would like to give showers when needed, but have to wait. During an interview on 3/12/24 at 1:48 PM, Resident #13 stated they had just received their shower, and the temperature of the water was cold during half of their shower. Additionally, Resident #13 stated that they (facility) said they (facility) had fixed the water temperatures, but they (facility) had not fixed the temperatures that well. 10NYCRR: 415.29, 415.29(f)(6), 415.29(j)(1)

Based on observation, interview, and record review conducted during the Recertification Survey the facility did not ensure that appropriate treatment and services were provided to prevent urinary tract infections for a resident with an indwelling urinary catheter (tube inserted into the bladder to drain urine into a drainage bag) for one (Resident #10) of one resident reviewed. Specifically, Resident #10 had a history of urinary tract infections and was observed on multiple occasions with the urinary catheter drainage bag, catheter drainage port, and catheter tubing lying directly on the floor in the resident's room and in the therapy room. The finding is: The policy and procedure, Foley Catheter Care/Suprapubic Catheter Care, dated 11/7/18 documented the purpose of the procedure was to prevent catheter associated urinary tract infections. Additionally, the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the bladder, use standard precautions (infection prevention practices for all patient care, regardless of infection status) when handling or manipulating the drainage system and be sure the catheter tubing and drainage bag are kept off the floor. Resident #10 had diagnoses which included neuromuscular dysfunction of the bladder (bladder with diminished sensation), urinary retention (inability to voluntarily empty the bladder completely or partially), and a history of urinary tract infections. The Minimum Data Set (MDS - a resident assessment tool) dated 2/11/24 documented Resident #10 was cognitively intact and had an indwelling urinary catheter. The Comprehensive Care Plan documented that Resident #10 had an indwelling urinary catheter (date initiated 11/10/23), staff were to check the tubing for kinks every shift and monitor/record/report signs and symptoms of urinary tract infection. The undated Certified Nurse Assistant (CNA) care plan did not include any interventions for catheter care. The Physician Order, dated 3/14/24, included to change the urinary catheter drainage bag to gravity (maintain below level of bladder) as needed for urine collection and infection control. The Physician Progress Note, dated and signed by Medical Doctor (MD) #1 on 2/29/24, documented frequent urinary tract infections in setting of an indwelling catheter - recently treated for urinary tract infection. During observations on 3/12/24 at 9:10 AM, 11:53 AM, 12:42 PM, and 1:56 PM. Resident #10's urinary catheter drainage bag, catheter drainage port, and catheter tubing were observed lying directly on the floor of the resident's room. During an observation on 3/12/24 at 1:35 PM the catheter tubing was observed lying directly on the floor of the therapy room. During observations on 3/13/24 at 11:27 AM, on 3/14/24 at 9:30 AM and 11:27 AM, and on 3/15/24 at 7:30 AM, Resident #10's urinary catheter drainage bag, catheter drainage port and/or catheter tubing were observed lying directly on the floor of the resident's room. During an interview on 3/24/24 at 9:33 AM Certified Nurse Assistant (CNA) #3 stated the urinary catheter bag, port, and tubing should not directly touch the floor secondary to it increases the risk of infections. During an interview on 3/14/24 at 9:37 AM Licensed Practical Nurse (LPN) #1 stated the floor is considered dirty and the urinary catheter bag, port, and tubing should not directly touch the floor secondary to the increased risk of infections. During an interview on 3/14/24 at 9:42 AM the Registered Nurse (RN) Director of Nursing (DON) stated the floor is considered dirty and the urinary catheter bag, port, and tubing should not directly touch the floor secondary to the increased risk of infections. 10 NYCRR 415.12(d)(1)

Based on interviews and record review conducted during an Abbreviated Survey (#NY00310253 and #NY00311606) completed on 3/27/23, it was determined that for one (first floor) of one resident use floor, the facility did not provide maintenance services necessary to maintain a comfortable interior. Specifically, ambient air temperatures in occupied areas of the facility were below 71 degrees ( ) Fahrenheit (F), the heating system was impaired, and the facility lacked a back-up boiler or secondary heating source. The findings are: 1. Interviews and record review on 2/8/23 from 11:06 a.m. to 2:42 p.m. included the following: a) The Administrator stated that they had not had issues with cold temperatures at the facility until last Friday and Saturday (2/3/23 and 2/4/23) when the artic blast came. The Administrator stated that on Friday (2/3/23) temperatures in the facility were ranging from 63 F-72 F and from 68 F-73 F on Saturday (2/4/23). The Administrator stated that they were aware of the cold temperatures as they were in the building all day Friday when the cold temperatures were happening, that air temperatures in a nursing home should be between 71 F and 82 F, and that when it is windy outside there is issues with temperatures in the building. b) Review of facility log Air Temperatures provided by the Administrator via email included that temperatures were documented to be below 71 F in the locations described as either Thermostat #1, Thermostat #2, Dining Room or room [ROOM NUMBER] in the facility on 1/14/23 (lowest recorded 68 F), 1/26/23 (lowest recorded 68 F), 1/27/23 (lowest recorded 65 F), 1/28/23 (lowest recorded 68 F), 1/29/23 (lowest recorded 68 F), 1/31/23 (lowest recorded 68 F), 2/1/23 (lowest recorded 68 F), 2/2/23 (lowest recorded 68 F), 2/3/23 (lowest recorded 59 F), 2/4/23 (lowest recorded 48 F), 2/5/23 (lowest recorded 68 F), and 2/7/23 (lowest recorded 68 F). Further review of temperature logs included additional temperature recordings listing temperatures were documented to be below 71 F in the facility on 1/24/23 every hour from 6:00 a.m. to 2:00 p.m. (lowest recorded 63 F), on 1/25/23 every hour from 6:00 a.m. to 2:00 p.m. (lowest recorded 59 F), and on 1/27/23 every hour from 10:00 a.m. to 2:00 p.m. (lowest recorded 66 F). Additionally, there was a notation that on 1/24/23 and 1/25/23 that the boiler needed to be reset and on 2/4/23 that a vendor came to fix the pump. c) Review of the facility's Emergency Preparedness procedure for cold emergencies provided by the Administrator via email included that when the temperature goes below 71 F in house, they are to notify the Health Department if it is expected to last more than three hours. d) The Director of Maintenance and Environmental Services (DMES) stated that the regular air temperature logs are readings taken from thermostats in the facility with thermostat #1 located by the nurse's station and thermostat #2 located by the front entrance. The DMES stated that one boiler serves the entire facility, the boiler needs a bladder replaced and there is an issue with the transmitter and the solenoid, but they have not had the issues repaired because in order to fix them they would need to take the boiler off-line, and they wanted to wait for warmer temperatures outside. The DMES stated that when there is a concerning temperature which is below 70 F on the thermostats, they take more detailed room temperatures in occupied areas with an infrared gun and that if the temperature log notates boiler needs to be reset that it is related to the solenoid issue. The DMES stated that the issues with their boiler started either in the beginning of January or end of December and that there is no back-up boiler for the facility. e) The Administrator stated that they believed there was an issue with the solenoid for the boiler and they plan to shut down the boiler in late spring/summer as it needs to be shut off for repair and the facility does not have a back-up boiler. 2. Interviews and record review on 2/9/23 from 9:10 a.m. to 2:26 p.m. included the following: a) Review of facility log Air Temperatures provided by the DMES via email included that temperatures were documented below 71 F in the locations described as either Thermostat #1, Thermostat #2, Dining Room or room [ROOM NUMBER] in the facility on 12/15/22 (lowest recorded 65 F), 12/28/22 (lowest recorded 67 F), 1/7/23 (lowest recorded 68 F), 1/10/23 (lowest recorded 68 F), and 1/11/23 (lowest recorded 67 F). b) The DMES stated that on 12/15/22 they had to reset the boiler and believed that the reset had to do with the solenoid. c) A vendor service report dated 2/4/23 provided by the DMES via email included that the boiler's heating pump #1 was not working and that a new pump and motor assembly with new impeller was installed. 3. Review of an email from a facility vendor dated 2/10/23 included that the crane heating boiler needs to be updated, that the gas valve is obsolete and unreliable, the existing programmer is outdated and has original equipment which could possibly fail, and that they suggest installing updated programmer with diagnostics. 4. During an email interview on 2/10/23 at 1:51 p.m. the surveyor asked the DMES if they had any staff or residents complain about cold temperatures in the building the last couple months. The DMES replied yes and that they address the issue when it arises. 5. During a telephone interview on 3/29/23 at 12:05 p.m. the DMES stated that temperatures were 68 F at 7 a.m. on 2/26/23 and that they reset the boiler and temperatures returned to normal. 6. Review of facility log Air Temperatures provided by the DMES via email on 3/29/23 at 12:22 p.m. included that temperatures were documented to be below 71 F in the locations described as Thermostat #1, Thermostat #2, Dining Room and room [ROOM NUMBER] in the facility on 2/25/23 (lowest recorded 67 F) and 2/26/23 (lowest recorded 66 F). Further review of the log included that on 2/25/23 and 2/26/23 the boiler was reset. 10NYCRR: 415.29, 415.29(b), 415.29(h)1), 415.5(h)(4), 713-1.9(a), 713-1.9(b)

Based on interviews and record review conducted during an Abbreviated Survey (#NY00310253) completed on 3/27/23, it was determined that for one (first floor) of one resident use floor, the facility did not operate in compliance with all applicable State regulations and codes. Specifically, the facility did not report to the New York State Department of Health (NYSDOH) an unintentional loss of heat occurring on five separate days with potential to affect resident care with no back-up system in place. The findings are: Interviews and record review on 2/8/23 from 11:06 a.m. to 2:42 p.m. included the following: a) The Administrator stated that they had not had issues with cold temperatures at the facility until last Friday and Saturday (2/3/23 and 2/4/23) when the arctic blast came. The Administrator further stated that on Friday (2/3/23) temperatures in the facility were ranging from 63 F-72 F and from 68 F-73 F on Saturday (2/4/23). Additionally, the Administrator stated: they were aware of the cold temperatures as they were in the building all day Friday when the cold temperatures were happening but did not report the issue to NYSDOH because they were new in their role and assumed that either their Corporate Maintenance Crew would report it or would tell them to report the situation. The Administrator stated that air temperatures in a nursing home should be between 71 F and 82 F and that when it is windy outside there are issues with temperatures in the building. The Administrator stated that they had gone through the facility in the days leading up to Friday (2/3/23) in preparation for the cold putting plastic up over areas where the cold could come in the building and that staff at the facility were passing out extra blankets and hot soup to residents on Friday (2/4/23). b) Review of facility log titled Air Temperatures provided by the Administrator via email included that temperatures were documented to be below 71 F in the locations described as either Thermostat #1, Thermostat #2, Dining Room or room [ROOM NUMBER] in the facility on 1/27/23 (lowest recorded 65 F), 2/3/23 (lowest recorded 59 F in the a.m. and 61 in the p.m.), and 2/4/23 (lowest recorded 48 F in the a.m. and 54 F in the p.m.). Further review of the log included additional temperature recordings on lined paper showing temperatures were documented to be below 71 F in the facility on 1/24/23 every hour from 6:00 a.m. to 2:00 p.m. (lowest recorded 63 F), on 1/25/23 every hour from 6:00 a.m. to 2:00 p.m. (lowest recorded 59 F), and on 1/27/23 every hour from 10:00 a.m. to 2:00 p.m. (lowest recorded 66 F). Additionally, there was a notation that on 1/24 and 1/25 that the boiler needed to be reset and on 2/4/23 that a vendor came to fix the pump. c) Review of the facility's Emergency Preparedness procedure for cold emergencies provided by the Administrator via email included that when the temperature goes below 71 F in house, they are to serve hot drinks and soups if feasible and they are to notify the Health Department if it is expected to last more than three hours. d) Review of facility form Disaster Drill for Cold Emergency dated 2/2/23 included the scenario that temperatures in the immediate area were going to be below zero for a couple days and that even with a functioning boiler, temperatures may get low inside while trying to meet the demand for heat. The action plan for this event included that staff will continue to dress residents warmly and with layers, will push hot beverages and warm blankets to residents, and that the plan will stay in place until temperatures return to normal. The conclusion for this event was that the action plan was kept in place until temperatures returned to normal 2/5/23. e) The Director of Maintenance and Environmental Services (DMES) stated that the regular air temperature logs are readings taken from thermostats in the facility with thermostat #1 located by the nurse's station and thermostat #2 located by the front entrance. The DMES stated that one boiler serves the entire facility, the boiler needs a bladder replaced and there is an issue with the transmitter and the solenoid, but they have not had the issues repaired because in order to fix them they would need to take the boiler off-line, and they wanted to wait for warmer temperatures outside. The DMES stated that when there is a concerning temperature which is below 70 on the thermostats, they take more detailed room temperatures in occupied areas with an infrared gun and that if the temperature log notates boiler needs to be reset that it is related to the solenoid issue. The DMES stated that the issues with their boiler started either in the beginning of January or end of December and that there is no back-up boiler for the facility. f) The Administrator stated that they believed there was an issue with the solenoid for the boiler and that they did not report the cold temperatures on 1/24/23, 1/25/23, and 1/27/23 to the NYSDOH because they are new and trying to wrap their head around everything. The New York State Incident Reporting Manual includes a Physical Environment section related to physical plant issues/loss of service and that the facility must report planned or unintentional loss of heat lasting or expecting to last more than 4-hours or when there is no back-up system in place. 10NYCRR: 415.29, 415.5(h)(4), 713-1.9(b), NYS Incident Reporting Manual pages 25-26

Based on observations and interviews conducted during the Standard Recertification Survey completed on 6/17/22, it was determined that for one of one main kitchen, the facility did not store, prepare and distribute food in accordance with professional standards for food service safety. Specifically, there was a significant build-up of ice in a reach in freezer, sink plumbing was leaking, a freezer had a torn gasket, and a sink without an indirect drain was being used for food preparation. This is evidenced by the following: 1. Observations during the initial brief tour of the kitchen on 6/14/22 from 8:22 a.m. to approximately 9:22 a.m. revealed the following: a. A 'True' brand 2-door stand-up freezer had a significant accumulation of ice under the evaporator fans. b. The cold-water pipe for the single bay stainless steel prep sink was leaking, and this prep sink was covered with a metal plate. During an interview at this time the Food Service Director stated that they do not use the prep sink and acknowledged the leak dripping from the cold-water pipe. c. There was a small chest freezer with a torn gasket across the front lid of the unit. 2. On 6/15/22 from 9:07 a.m. to 10:25 a.m. the following was observed during a follow-up visit to the kitchen: a. The 2-door 'True' brand freezer had a significant accumulation of ice on the top shelf below the evaporator fans. Icicles were hanging from the top grate and extending down the shelves with ice down the back wall of the freezer. Ice was observed on multiple boxes and plastic packaging of frozen food items. An open box with open packaging of Breaded [NAME] rectangles had ice in the box. A bag of French fries and breaded chicken patties was also opened beneath the icicles under the evaporator fans. The food items were voluntarily discarded by a kitchen worker. Also observed below the ice build-up were two large tubes of ground beef frozen to the bottom of the freezer in about ½-inch of clear ice. b. During an interview, the food service director (FSD) stated that the maintenance director was contacted about the freezer, and they would assess it. The FSD also stated that the leak from the stainless-steel food prep sink was turned off by maintenance. When asked where food was defrosted the FSD stated they use the right bay of the 2- bay sink. The 2-bay sink was observed to be labeled as 'wash', and was not equipped with an indirect drain. 10NYCRR: 415.14(h), 10NYCRR: 14-1.10(1), 14-1.31(a), 14-1.95, 14-1.140(a), 14-1.141, U.S. Food and Drug Administration's (FDA) Food Code, Centers for Disease Control and Prevention's (CDC) food safety guidance

Based on interviews and record reviews conducted during the Recertification Survey completed on 6/17/22, it was determined that the facility did not ensure a written notification, which specifies the duration of the bed-hold policy, was provided to the resident and/or the resident representative at the time of transfer to the hospital. This is evidenced by the following: Resident #123 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In a nursing progress note, dated 4/29/22 at 10:39 a.m., the Director of Nursing documented that Resident #123's blood glucose (bg) was consistently recording as high, that the Nurse Practitioner was notified and instructed to send Resident #123 to the hospital as the facility was unable to control the resident's bg. The resident was transferred to the hospital and did not return to the facility. During an interview on 6/17/22 at 1:05 p.m., the Social Worker (SW) stated that the facility does not provide bed-holds for Medicaid recipients and that only private pay individuals receive a bed-hold notice. The SW stated that admissions staff is responsible for issuing the bed-hold notifications and that Resident #123 was not offered a bed-hold because the resident's family had said they did not want to return. During a combined interview on 6/17/22 at 2:01 p.m., with the Administrator and Vice President of Clinical Operations, the Administrator stated if a resident is a Medicaid recipient, they would not be issued the bed-hold notification. The Vice President of Clinical Operations stated that Medicare and private pay residents are issued the bed-hold policy upon admission and if they are transferred to the hospital then the facility's admission staff would call the resident representative to inquire if they want a bed-hold. The facility was unable to provide documentation that the bed hold policy was provided in writing or verbally to the resident or resident representative. The Admissions representative was not available for an interview. [10 NYCRR 415.3(h)(4)(i)(a)]

Based on interviews and record reviews conducted during the Focused Infection Control COVID-19 survey (Case #NY 521) on 5/26/20, the facility did not ensure compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility did not comply with New York State Executive Order (EO) 202.18, and ensure that resident ' s family and/or their next of kin were notified of either a single confirmed infection of COVID-19 or COVID-19 death within 24 hours from the date of occurrence for two of three reviewed. This is evidenced by the following: The EO #202.18, dated April 16, 2020, documented the following: any skilled nursing facility, nursing home, or adult care facility licensed and regulated by the Commissioner of Health shall notify family members or next of kin if any resident tests positive for COVID-19, or if any resident suffers a COVID-19 related death, within 24 hours of such positive test result or death. An undated letter from the facility's Administrator addressed to families included general information about COVID-19, suspension of visitation in the facility, and alternate means of communication (phone call or digital platform) with residents. The letter revealed that for more information, please follow along our Facebook page for updates. When interviewed on 5/26/20 at 12:00 p.m., the Administrator said the letter was sent by the United States Mail on 3/12/20 to all residents' designated representatives. Review of the Influenza-like Illness, Upper Respiratory Illness Line List Form provided by the facility revealed that COVID-19 cases were identified on 4/30/20 (one resident case), on 5/1/20 (two resident cases), and on 5/13/20 (three resident cases). The Administrator said that two staff members tested positive for COVID-19 on 5/13/20. Review of the facility's Facebook page included a post, dated 3/16/20, that revealed the facility will notify you appropriately if staff or residents are diagnosed with COVID-19. A post on 5/1/20 revealed the facility had identified positive tests for COVID-19 in the facility. There were no numbers provided or who tested positive (residents or staff). There were no posts directing families or designated representatives to the facility's webpage. Review of the facility's webpage included a letter, dated 5/15/20, that revealed that as of 5/15/20, there have been six positive COVID-19 cases among residents. There are currently four residents positive in the facility and four employees. 1. Resident #1 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 5/9/20, revealed that the resident's cognition was severely impaired. When interviewed by telephone on 5/26/20 at 10:54 a.m., the resident's designated representative said they had not received any notification from the facility staff regarding any new COVID-19 cases. They said that they did not receive any phone calls or mailings from the facility. The resident's designated representative said that she learned from the resident's old roommate that there were four other COVID-19 cases in the facility. 2. Resident #2 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 5/12/20, revealed that the resident was cognitively intact. When interviewed by telephone on 5/26/20 at 11:00 a.m., the resident's designated representative said they had not received any notification from the facility staff regarding any new COVID-19 positive cases. They said they were not aware of the number of cases in the facility and had not received any letters or communication from the facility. In an interview on 5/26/20 at 9:35 a.m., the Licensed Practical Nurse Manager stated that she had only contacted the family of the resident tested for COVID-19 with the results. She said she did not communicate with all residents or families regarding new COVID-19 cases. When interviewed on 5/26/20 at 10:42 a.m., at 12:00 p.m., and at 12:50 p.m., the Administrator stated that initially on 3/12/20, the facility sent a letter to all residents' families which included general information and notification to follow along on their Facebook page for updates; the facility would notify them if any staff or residents are diagnosed with COVID-19; and to contact Administration with questions. He said that all families were called on 5/1/20 and that families/designated representatives were reminded that updates are posted on their Facebook page. He said there was no documentation that phone calls were made on 5/1/20. He said an electronic letter was posted on the facility webpage on 5/15/20 that revealed that as of 5/15/20, there have been six positive cases among residents. He said currently there are four residents positive in the facility and four employees. He said that all communication regarding new COVID-19 cases were currently electronic and updated by an outside vendor. He said he sends the vendor a letter with any new COVID-19 cases or deaths and the vendor was responsible to post. He said the vendor was aware the information was time sensitive. He said there was no other means for communicating to families or designated representatives other than the Facebook page or website updates.

Based on observations, interviews, and record reviews conducted during the COVID-19 Infection Control Focus Survey (Case #NY 521), it was determined that the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of COVID-19. The facility staff did not consistently follow infection control precautions for residents on contact and droplet precautions potentially resulting in cross contamination. Specifically, two staff members were observed exiting the rooms of two residents (Residents #1 and #5) that were positive for COVID-19 without removing (doffing) Personal Protective Equipment. This is evidenced by the following: The facility's COVID-19 policy, dated 5/12/20, included to use Personal Protective Equipment (PPE) appropriately. This includes to don (put on) gowns, gloves, mask, eye/face shield before entering a resident's room with COVID-19; doff (take off) gowns and gloves prior to exiting the resident's room; remove the face shield after exiting the room (for extended use, wear gloves to clean and disinfect by carefully wiping the inside and the outside of the face shield using an EPA- registered N-List product, allowing to air dry, and then remove gloves and perform hand hygiene); doff mask after exiting the room (for extended use, wear the same facemask for multiple residents with suspected or confirmed COVID-19 without removing between residents). 1. Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/7/20, revealed that the resident had moderately impaired cognition. In an observation on 5/26/20 at 9:00 a.m., the Certified Nursing Assistant (CNA) exited the resident's room in contaminated PPE (gown, gloves, mask, and face shield). She proceeded walking in her PPE approximately 10 feet down the hallway carrying a red isolation trash bag. She opened the door to the utility room with the same gloves, dropped off the trash, and again opened the utility room door to exit the room with the same gloves. She then proceeded back to the resident's room and removed her gown and gloves in the hallway in front of the resident's room and disposed of the items in a red trash container in the hallway. Without cleaning her hands, the CNA donned gloves, and then took a disinfectant wipe and washed the face shield while it was still on her head. She then removed the face shield and left her facemask in place. When interviewed at that time, the CNA said there was no trash can in the room to dispose of her gown and gloves. She said that she usually puts on a surgical face mask over her N-95 mask and only disposes of the surgical mask. When questioned, she said she did not know if she should remove PPE in the hallway. 2. Resident #1 had [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/9/20, revealed that the resident's cognition was severely impaired. In an observation on 5/26/20 at 9:15 a.m., the Licensed Practical Nurse (LPN) donned PPE and entered Resident #1's room carrying medications. She exited the resident's room in contaminated PPE (gown, gloves, mask, and face shield) and removed her gown and gloves in the hallway outside of the resident's room. She performed hand hygiene, cleaned her shield, and disposed of her N95 mask. When interviewed at that time, the LPN said there was no trash bag in the resident's room. She said that she should have doffed her PPE prior to exiting the resident's room. When interviewed on 5/26/20 at 9:35 a.m., the LPN Manager/Infection Control Nurse said that staff should be removing their gowns and gloves and disposing of them prior to exiting the resident's room. She said that the face shields are being disinfected and sanitized and staff should be changing their mask. She said the facility has plenty of PPE including masks. (10 NYCRR 415.19)

Based on observations and interviews conducted during the Recertification Survey, it was determined that the facility did not safeguard medical record information against loss, destruction or unauthorized use. Specifically, medical records were not secured. This is evidenced by the following: In observations throughout the day on 3/1/20 and 3/2/20, there were three unlocked file cabinets that contained medical records located in an area near the main entrance of the facility that was accessible to anyone. There were also medical records on top of the file cabinets and on the floor near the cabinets. Interviews conducted on 3/2/20 included the following: a. At 8:50 a.m., the Licensed Practical Nurse stated the filing cabinets have been stored in that entry way area for several months. She said the fire panel was alarming one day and several medical records were knocked all over the floor. b. At 8:53 a.m., the Administrator said the receptionist was responsible for the storage and maintenance of the medical records. He observed the stacks of medical records and unlocked file cabinets, and stated it was on his to do list. The Administrator said the medical records should be organized and the file cabinets should be locked. The Administrator stated that anyone could have access to the medical records. c. At 9:32 a.m., the receptionist stated she did not know that the medical records needed to be secured. She said the discharged resident medical records have always been stored in that entry way area by the door. She said there was nowhere else to store the medical records. (10 NYCRR 415.22(c))

Based on observations and interviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not provide food that was palatable, attractive, or at an appetizing temperature. Specifically, the Cook did not follow the menu or the recipe for the main entrée of chicken and biscuits. This is evidenced by the following: The facility provided the lunch menu and recipe for the chicken and biscuits for lunch on 3/1/20. Make one pouch of chicken gravy, add one bag of cooked, diced chicken, and three cups of mixed vegetables and heat until 165 degrees Fahrenheit. Serve over a warm biscuit, split in half. The remaining items for the meal were capri blend vegetables, fruit cocktail, and banana cream pie for dessert. During an observation of the lunch meal on 3/1/20 at 12:34 p.m. and 1:05 p.m. in the main dining room, the residents had been served biscuits and diced chicken with no gravy or vegetables in the chicken and biscuit entrée. Seven of ten residents did not eat the chicken, and three residents said that the chicken was not good. When interviewed at that time, the Licensed Practical Nurse said that she was not sure what was on the plate and proceeded to cut into the food item. She said that was a biscuit, but she had never seen a biscuit look that way. She said there was no gravy over the chicken and biscuits. During an interview on 3/1/20 at 1:00 p.m., with the Cook and Food Service Director, the Cook said that he chopped up the chicken from the freezer, cooked it in oil, and added a little seasoning. The Cook said that he did not use gravy because sometimes the residents complain about it being lumpy. He said he made the biscuits from buttermilk biscuit mix, and maybe he should have added baking powder because the biscuits came out like pancakes. He said that he did not use mixed vegetables in the chicken and biscuit recipe because there were capri blend vegetables on the plate. He said instead of fruit cocktail the residents received chocolate cake. The Food Service Director said that there were biscuits in the freezer to bake and that banana cream pie was supposed to be the dessert. She said that the Cook made a mistake in the scheduled meals and should have followed the recipe. (10 NYCRR 415.14(d)(1)(2))

Based on observations and interviews conducted during the Recertification Survey, it was determined for one of one main kitchen the facility did not store, distribute, or serve food under sanitary conditions. The issues included a defective rinse temperature gauge on the dish washing machine, frozen packages opened and undated, and items stored on the floor in the dry storage room. This is evidenced by the following: During the initial tour of the kitchen on 3/1/20 at 9:20 a.m., there were three racks of bread, three cases of paper and plastic plates, and two cases of V-8 juice stored on the floor in the dried storage room. There were opened and undated frozen items in the freezer including cubed chicken meat patties, hotdogs, cheese raviolis, and undated cooked bacon. In an observation at 12:00 p.m., the rinse temperature gauge was not working. The vendor work order, dated 10/18/19, revealed that the dish washing machine rinse temperature gauge was defective and needed to be replaced. The facility did not have a log that recorded the dish washing machine rinse temperatures. When interviewed on 3/2/20 at 3:36 p.m., the Food Service Director said that items should not be stored on the floor, and opened packages and cooked food should be dated. She said the Cook was responsible for proper food storage. She said the dish washing machine was not functioning correctly. She said the rinse temperature gauge on the dish washing machine was broken. She said the staff did not know if the dish washing machine rinse temperatures were adequate. She said the Dietary Aide reported that the dish washing machine used to register 190 degrees Fahrenheit. She said the last time the vendor came in (10/18/19), the facility knew the gauge was broken, but it was not replaced because it had not been authorized to be fixed. (10 NYCRR 415.14 (h), Subpart 14-1.43(a), 14-1.110, 14-1.113)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 2 of 15 residents reviewed for accuracy of the Minimum Data Set (MDS) Assessment, the facility did not accurately code the MDS Assessment to reflect the resident's status. The issue involved inaccurate coding for an antipsychotic and the need for a translator (Resident #7) and inaccurate coding for weight loss (Resident #1). This is evidenced by the following: 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/11/18, revealed the resident had severely impaired cognition, does not need or want an interpreter, and received an antipsychotic and an antidepressant medication. Review of the Comprehensive Care Plan (CCP) revealed the resident had a communication barrier as her primary language was Spanish. Interventions included the resident preferred to communicate in Spanish and to use alternative communication tools as needed. Review of the (MONTH) (YEAR) Medication Administration Record (MAR), revealed the resident received two antidepressants ([MEDICATION NAME] and [MEDICATION NAME]). During an interview on 3/18/19 at 11:14 a.m., the resident stated, No when asked if she could speak English. Interviews conducted on 3/20/19 included the following: a. At 8:04 a.m., the MDS Coordinator stated she signed as completing the section that included the question regarding a translator; however, she did not complete that section. She said that section was prepopulated but she did not know where that information came from. The MDS Coordinator reviewed the (MONTH) (YEAR) MAR and stated the resident received the antidepressants [MEDICATION NAME] and [MEDICATION NAME]. She stated the antipsychotic was Naldol (used to treat hypertension). The MDS Coordinator said she must have read that wrong. She said the MDS Assessment was inaccurate. b. At 9:00 a.m., the Social Worker (SW) stated that a family member assisted with translating while she conducted the Brief Interview for Mental Status. The SW stated the resident needed an interpreter for anything more than saying hello. 2. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/27/19, revealed that the resident did not have a weight loss of 5 percent in the last month or 10 percent or more in the last six months based on the most recent weight. The resident's weight record revealed that the resident weighed 142 pounds on 9/1/18 and 123.2 pounds on 2/15/19 (a weight loss of 13.24 percent). When interviewed on 3/19/19 at 2:11 p.m., the Registered Dietician (RD) stated she relied on the computer program to trigger and communicate weight loss and it did not trigger. The RD calculated the resident's weight loss and and said it was 10 percent in the last six months. (10 NYCRR 415.11(b))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 2 of 15 residents reviewed for professional standards, the facility did not provide services consistent with professional standards of quality. Specifically, Resident #7's orders for weekly weights were not transcribed correctly, and Resident #25's orders for oxygen saturation levels were not transcribed correctly. This is evidenced by the following: 1. Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/8/19, revealed that the resident had moderately impaired cognition and a weight loss of 5 percent in the last month or 10 percent in the last six months. The Registered Dietician note, dated 3/5/19, included that the resident had weight loss and to order weekly weights for four weeks. A review of the Electronic Medical Record revealed that weekly weights were ordered on [DATE] for every seven days until 4/3/19. The order was transcribed incorrectly (the order type selected revealed that no documentation was required); therefore, the weights did not show on the Treatment Administration Record (TAR) and were not done. There was no documentation of weights after 3/5/19. When interviewed on 3/19/19 at 2:21 p.m., a Licensed Practical Nurse (LPN) Manager stated that when weekly weights are entered as physician orders [REDACTED]. She reviewed the weekly weight order, dated 3/5/19, and stated that no documentation required was selected; therefore, it would not show on the TAR and nursing would not know to obtain weights. 2. Resident #25 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/28/19, revealed the resident was cognitively intact and received oxygen therapy. A physician order, dated 1/5/19, included to monitor oxygen saturations every shift and as needed, and to titrate oxygen to keep saturations greater than 90 percent as needed for shortness of breath. When interviewed on 3/20/19 at 8:49 a.m., the LPN Manager stated the resident's oxygen saturations should be checked every shift. She stated the order was entered into the electronic record incorrectly. She said it was scheduled on the TAR as needed instead of every shift as ordered. (10 NYCRR 415.11(c)(3)(i))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of three residents reviewed for resident rights, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries to notify them of their rights under the regulation. Specifically, Resident #14 did not receive an Advance Beneficiary Notice or denial letter, and Resident #8 did not receive a Notice of Medicare Provider Non-Coverage. This is evidenced by the following: Resident #14 was admitted to the facility on [DATE], was discontinued from Medicare Part A services on 2/4/19, and remained in the facility. There was no evidence that an Advanced Beneficiary or denial letter was given to the resident or legal representative informing them of their potential liability for payment. Resident #8 was admitted to facility on 12/18/18 and was discontinued from Medicare Part A services on 2/1/19. There was no evidence that the resident received a Notice of Medicare Provider Non-Coverage to notify them of their appeal rights under the regulations. Interviews conducted on 3/18/19 included the following: a. At 9:51 a.m., the Minimum Data Set (MDS) Coordinator said that she just started completing liability notices that week. b. At 2:41p.m., the Administrator said that the Director of Therapy used to complete the liability notices but no longer works at the facility. The Administrator said that she has not completed liability notices and was not sure of the process. She said the MDS Coordinator started that week taking over the responsibility of liability notices and had training. The Administrator said that the sister facilities can be contacted if she has any questions. (10 NYCRR 415.3(g)(2)(i))