Every finding on record at Williamsville Suburban, L L C

Based on observation, interview, and record review conducted during a survey the facility did not ensure that food and drink was palatable, attractive and served at appetizing and optimal temperatures for one (1) (second floor South) of one (1) test tray. Specifically, during the lunch meal, food and beverages were served at suboptimal temperatures and were not palatable. Residents #10, 11, 12, 13 and 14 were involved. The findings include: The facility policy and procedure titled Foodborne Illness Prevention and Safe Food Handling dated 01/22/2026 documented to prevent foodborne illness the facility will ensure that all food prepared, stored, handled, and served within the facility was managed in a safe, sanitary, and controlled manner, in accordance with the New York State Department of Health (NYSDOH) regulations and federal requirements. Temperatures shall be verified and documented. Hot foods shall be held at 135 degrees Fahrenheit or above. Cold foods should be held at 41 degrees Fahrenheit or below. The Complaint/Incident Investigation Report, dated 03/03/2026, documented that the meals were cold when they were delivered to Resident #13. During an interview on 07/28/2026 at 2:30 PM, Resident #10 stated their lunch was not tasty, no good, and they sent it back to the kitchen. The food was cold and they did not serve good food in the facility. During an interview on 07/29/2026 at 9:00 AM, Resident #14 stated the quality of the food was terrible. It was served cold at most meals, soggy, and tasteless. They stated it was like the food was taken right out of the refrigerator and severed. The meat was also too tough to cut with a knife. During an observation and interview in the kitchen on 07/29/2026 at 11:36 AM, [NAME] #1 stated they just took the capri blend vegetables (carrots, zucchini-yellow and green, cauliflower) out of the oven and the mashed potatoes were out of the oven for about ten minutes. The meatloaf was taken out of the oven and tempted at 11:38 AM by [NAME] #1 and they stated the meat loaf was at 153.7 degrees Fahrenheit and stated they would return the meat back to the oven for five minutes. At this time the capri blend vegetables were 153 degrees Fahrenheit, the mashed potatoes were 165 degrees Fahrenheit, and the gravy was 177.1 degrees Fahrenheit. During an observation and interview in the Main Kitchen of the South Building on 07/29/2026 at 11:40 AM there was no plate warmer in use at the start of the tray line. [NAME] #1 stated they liked the hot foods to be 165 to 175 degrees Fahrenheit when they were on the steam table for tray line and 155 degrees Fahrenheit to 160 degrees Fahrenheit when the trays were leaving the kitchen which they tried quickly to get the trays delivered and upstairs. At 11:49 AM the meat loaf was removed from the oven, and was tempted at 160 degrees Fahrenheit, and tray line began. Milk cartons and juice cartons were taken out of refrigeration at 11:53 AM and were sitting on top of the line without refrigeration. Coffee was poured into cups at 11:55 AM. At 12:01 PM, it was discovered that the dinner tickets were accidentally distributed on all trays instead of the lunch tickets. [NAME] #1 kept plating the food while others collected and redistributed the correct tickets on the trays. This did not delay service. The first caddy left the kitchen at 12:08 PM for the second floor and the second caddy left the kitchen at 12:13 PM with the test tray. During an observation of the South building, second floor, lunch meal on 07/29/2026, the first caddy arrived to the unit at 12:10 PM and was parked across from the elevator. Staff were noted to remove the first tray at 12:11 PM from the first caddy and deliver hall trays to the residents whose rooms were closest to the elevator. The second caddy arrived on the second floor at 12:15 PM while staff were delivering meals from the first caddy. Tray delivery from the second caddy started at 12:20 PM. The last resident tray was delivered at 12:36 PM. The test tray was sampled at 12:37 PM in the presence of Licensed Practical Nurse #1; the results were as follows: -Meat loaf with gravy: 115.3 degrees Fahrenheit, tasted spicey, dry consistency and cool to the palate.-Mashed potatoes with gravy: 117.3 degrees Fahrenheit, cool to the palate -Capri blend vegetables: carrots, zucchini-yellow and green, cauliflower: 94.8 degrees Fahrenheit, watery, bland, tasteless and cool to the palate. -Lemon Pudding: 77.3 degrees Fahrenheit, tasted warm and very sweet. -Milk: 55.2 degrees Fahrenheit, warm to the palate -Coffee: 107.7 degrees Fahrenheit, bitter, cool to the palate. During an interview on 07/29/2026 at 12:39 PM, Licensed Practical Nurse #1 stated the meat loaf tasted terrible and was cold. The mashed potatoes tasted bland were cool and the vegetables had no taste and were cold and mushy. Licensed Practical Nurse #1 refused to taste the warm milk and coffee. During an interview on 07/29/2026 at 12:50 PM, Resident #11 stated they did not like the meat loaf, and the color was off. The meatloaf was too dark. The edges were burnt. The temperature was cold and it was unappetizing. During an interview on 07/29/2026 at 12:53 PM, Resident #10 stated they took a few bites and sent it back to the kitchen. The meat loaf was hard even with gravy on it. The vegetables were cold, hard, and tasteless. During an interview on 07/29/2026 at 12:55 PM, Resident #12 stated the meat loaf was cold and disgusting and ordered a sandwich instead. During an interview on 07/29/2026 at 12:58 PM, Resident #14 stated the vegetables had no taste and were cold, the carrots were tough to bite into, but the meatloaf was ok. Durning an interview on 07/29/2026 at 2:22 PM, [NAME] #1 stated they were the full time cook and prepared lunch today for the residents. Hot foods like meat and vegetables should be served around 150 to 160 degrees Fahrenheit. They were unsure what temperature hot and cold beverages should be served at. Cold drinks were stored in the cooler till served. On the tray line the cold drinks were not stored over ice. Tray line can take approximately an hour to complete.Durning an interview on 07/29/2026 at 2:24 PM, the Food Service Director stated hot foods should be served at 140 degrees Fahrenheit and cold drinks at 40 degrees Fahrenheit. During tray line cold drinks were not kept over ice to keep them cold. The Food Service Director was unaware of the temperature of the food for lunch today or the test tray. During a telephone interview on 07/30/2026 at 9:55 AM, Registered Dietician #1 stated that hot foods were expected to be served at 165 degrees Fahrenheit and should not go below 140 degrees Fahrenheit and cold foods 35 degrees Fahrenheit or below. Milk should not be served at 55 degrees Fahrenheit and was considered a danger zone. Bacteria could grow and could lead to illness if ingested. During an interview on 07/31/2026 at 11:55 AM, Registered Nurse #1 Nurse Manager stated Residents complained about the food depending on the day. They warmed cold food in the microwave when residents complained. Food borne illness could occur when not served at the proper temperature. During an interview on 07/31/2026, Licensed Practical Nurse #2 stated they received daily complaints from the residents about cold food and having no taste. During an interview on 07/31/2026 at 12:28 PM, the Administrator stated they discussed food concerns monthly during resident council and they had fewer complaints since the Food Service Director took over in March 2026. Sub-optimal food temperatures opened residents up to food borne illness and decreased palatability. During an interview on 07/31/2026 at 1:04 PM, the Director of Nursing stated that optimal food temperatures were important because they would not want the residents to eat spoiled food or get sick. 10 New York State Code Rules and Regulations 415.14 (d)(1)(2)

Based on observation, interview, and record review conducted during complaint investigations (2657322, 26853730) the facility did not ensure that food and drink was palatable, attractive and served at an appetizing temperature for two (2) (North and South) of two (2) buildings and at optimal temperatures for one (1) (second floor South) of one (1) test tray. Specifically, during the lunch meal, food and beverages were served at suboptimal temperatures and were not palatable. Residents #3, #4, #6, #7, #11, #13, and #17 were involved. The findings are:The policy and procedure titled Food Preparation and Service dated 06/26/2018 documented food service employees shall prepare and serve food in a manner that complies with safe food handling practices, and the danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. Therefore, cold foods must be maintained at 40 degrees or below, and hot foods 136 degrees or above.The Complaint/Incident Investigation Report, dated 12/05/2025, documented Resident #3 complained the food in the facility was inedible and cold.The Complaint/Incident Investigation Report, dated 10/31/2025, documented Resident #4 complained the food provided was not edible, so the family brought food in daily to ensure the resident was getting a decent meal.During an interview on 12/18/2025 at 8:48 AM, Resident #13 stated they were still waiting to receive breakfast and were hungry. They stated breakfast was not served usually until after 9:00 AM. They stated the food was usually cold because the staff feed residents in the dining room first. They stated they were not always served a protein and consume their own protein drinks. They stated the frozen vegetables that were served are over cooked. They stated there were not enough staff to reheat food and if you were hungry enough you just eat what was given to you.During an interview and observation on 12/18/2025 at 9:19 AM, Resident #7 stated they were hungry, and breakfast was very late. Resident #7 stated the food was not good and they would not feed it to their dog. They stated the food was slop, unappealing, unseasoned and pissy warm. Additionally, they stated the portions were small. Resident #7 was delivered their tray at 9:25 AM. Meal ticket on tray indicated no milk with meals and they had a half pint carton of one (1) percent milk on their tray. Resident #7 stated their egg sandwich was cold.During an interview, on 12/18/2025 at 10:19 AM, Resident #11 stated the food was always cold no matter what meal. They stated the food was not prepared right, food was either under cooked or over cooked and lacked flavor. They stated they have received rice that was crunchy and vegetables that were mush.During an interview in the Main Kitchen of the South Building on 12/18/2025 at 12:05 PM, [NAME] #1 stated they had taken a temperature of the pork chops before they placed them on the tray line, and they were 165 degrees Fahrenheit. At this time, the Surveyor took a temperature of the pork chops in the steam table, and they ranged from 142.7 to 144.2 degrees Fahrenheit. Also at this time, the mixed vegetables were 179.8 degrees Fahrenheit, the gravy was 133 to 148 degrees Fahrenheit, and the mashed potatoes were 133.7 degrees Fahrenheit. [NAME] #1 stated the mashed potatoes should be 145 to 150 degrees Fahrenheit and returned them to the oven at this time. At 12:15 PM, the gravy was poured over the pork chops. At 12:25 PM, the mashed potatoes were removed from the oven, their temperature was 139 degrees Fahrenheit, and they were placed in the steam table for tray line service, which started at 12:27 PM. The second caddy of lunch trays for the second-floor residents left the Main Kitchen at 12:40 PM with the test tray.During an observation in the Main Kitchen of the South Building on 12/18/2025 at 12:20 PM there was a plate warmer at the start of the tray line and it was full of plates. The plate warmer was not plugged in. During an interview at this time, [NAME] #1 stated they thought the plate warmer did not work and if it did work, they would need an extension cord to use it.During an observation of the South building, second floor, lunch meal on 12/18/2025 at 12:34 PM a food cart was observed across from the elevator. At 12:40 PM a staff member removed a tray from the cart. There were four (4) residents in the dining room. At 12:42 PM a staff member removed another tray from the cart and walked it down to Resident room [ROOM NUMBER]P. At 12:51 PM more staff members were observed removing trays from the cart and walking them down the hallway to resident rooms and a second dietary cart was delivered on the unit.The test tray was sampled at 1:05 PM and the results were as follows:The sampled plate was cool to the touch.-Pork chop with gravy: 99.2 degrees Fahrenheit, tasted bland, chewy, tough. Cool to palate.-Mashed potatoes: 99.1 degrees Fahrenheit, cool to palate-Mixed vegetables: carrots, beans-yellow and green: 101.9 degrees Fahrenheit, soft, lacked flavor, carrots chewy. Cool to palate.-Pudding: 62.5 degrees Fahrenheit, tasted good-Milk: 50.8 degrees Fahrenheit, cool to palate-OJ: 51.1 degrees Fahrenheit, cool to palate-Coffee: 107.7 degrees Fahrenheit, bitter, barely warm to palate. During an observation and interview, on 12/18/2025 at 1:21 PM, Resident #7's meal tray had a pork chop with only a piece taken from it. Resident #7 stated it was too tough, and they didn't like it. They did not receive mashed potatoes and would have liked to. During an interview on 12/19/2025 at 9:59 AM, Certified Nurse Aide #4 stated residents complain that the food is terrible, that it is cold and unappealing. They stated some days the food looks unappetizing. Certified Nurse Aide #4 stated they try their best to accommodate resident's requests for reheating, and for providing condiments. They stated they have expressed resident concerns regarding food to the dietician. Additionally, they stated delivery of trays from the kitchen were usually late because the kitchen was short staffed. During an observation and interview on 12/18/2025 at 1:27 PM, Resident #4 was having lunch in their room, their ticket listed pork chop, scalloped potatoes, Prince [NAME] vegetables, and pudding. On their tray was a paper plate with a pork chop, carrots, scalloped potatoes, and peaches. Resident #4 picked up their pork chop and attempted to bite into it, pulled the pork chop away with difficulty. Resident #4 stated they need to fix this; it was tough to chew and not warm at all. Resident #4 took the pork chop and dragged it around the plate, through the carrots and scalloped potatoes and stated, it needed juice. Resident #4 took another bite of the pork chop and attempted to chew the pork chop, spit out what was in their mouth into their hand and placed it on the plate and stated, cannot chew that. During an interview on 12/18/2025 at 1:15 PM, Certified Nurse Aide #1 stated the food looked unappetizing often, but the residents on the units did not, or could not complain. Certified Nurse Aide #1 stated the residents often got wrong items on their trays and drinks were often missing. They stated they would call down to the kitchen and complain, but they were told by the kitchen that's all they had and to do with it what we may. During an interview on 12/19/2025 at 8:43 AM, Registered Nurse #5 Unit Manager stated they did not have complaints about food from residents because they were not cognitively able to complain. During an interview on 12/19/2025 at 8:44 AM, Resident #6 stated they had the pork chop for lunch the day prior and it was dry and hard. During an interview on 12/19/2025 at 2:09 PM, Resident #17 stated the food in the facility was always cold and the meat was usually too tough. They stated they recently had a meal where they could not tell what the meat was, and they were not able to cut it. Resident #17 stated they have told the staff that the food was not good, but nothing had changed. During an interview on 12/19/2025 at 2:20 PM, Licensed Practical Nurse # 1 stated residents did complain about the food. They complained it did not taste good and that it was cold. They stated it was unsafe to eat foods left out at room temperature too long. They did not know the actual safe serve temperatures or the time, but they knew it could make a resident sick if they ate food that was not kept at the right temperature. During an interview on 12/22/2025 at 9:58 AM, the Food Service Director stated they worked in the facility for 15 days. They stated hot foods should be kept above 140 degrees Fahrenheit and cold foods below 40 degrees. The Food Service Director stated bacteria could grow, and a resident could get sick, if foods were left out of the safe temperature range for very long. They were unsure of the time frame. They stated the staff should be delivering trays to residents within ten (10) minutes of the food leaving the kitchen. The Food Service Director stated they did not have a functioning plate warmer, but they had requested one from administration. They were aware that residents complained about food temperatures. During an interview on 12/22/2025 at 12:04 PM, the Administrator stated they were aware that residents complained about food temperatures. They stated they had put in a request for a new steam table but were waiting for upper level to approve the purchase. The Administrator stated they were not aware the plate warmer was broken. They also stated they expected the dietary staff to have meals out on time and nursing staff to deliver them timely. During an interview on 12/22/2025 at 1:38 PM, The Director of Nursing stated they expected the nursing staff to pass trays immediately when they were delivered to the floor. They stated all staff should help pass trays unless they were proving care at the time of the meal. The Director of Nursing stated that food temperatures were important for the health and quality of life for residents. 10 NYCRR 415.14 (d)(1)(2)

Based on observation, interview, and record review during an Abbreviated survey (Complaint #2637850) the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This affected the Main Kitchen and two (2) (Second Floor and Third Floor) of two (2) unit nourishment refrigerators in the South Building and the Main Kitchen and four (4) (A Wing, B Wing, C Wing, and D Wing) of four (4) unit nourishment refrigerators in the North Building. Specifically, there were issues with personal coats hanging in food and single service item storage areas, soiled and dusty surfaces, broken wall tiles, improper thawing of meats, unnecessary persons in food preparation areas without hairnets, undated/ outdated/ unlabeled refrigerated foods, food labeled Keep Frozen stored in refrigerator for unknown time, soiled bench style can opener, cases of food and single service items stored on the floor, food service workers without hair nets or beard nets while working on tray line, raw meat stored on the top shelf of a walk-in cooler above ready to eat foods, door to the reach-in freezer in disrepair, air temperature inside the reach-in freezer was 20 degrees Fahrenheit, active water leaks from dishwasher, flies in dishwasher area, no test strips for low-temperature dishwashers, thermometers to monitor dishwasher water temperature not functional, floor drain missing grate cover, air temperature of refrigerators and the foods in them were not within safe range, refrigerators missing thermometers, trays of nourishments stored out of refrigeration with temperatures not within safe range, and wiping cloths stored dry on countertop.The findings are: The policy titled Food Receiving and Storage, issued 06/26/2018, documented foods shall be received and stored in a manner that complies with safe food handling practices. Food Services, or other designated staff, will maintain clean food storage areas at all times. Food in designated dry storage areas shall be kept off the floor (at least 18 inches). All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Refrigerated foods must be stored at or below 40 degrees Fahrenheit unless otherwise specified by law. Uncooked and raw animal products and fish will be stored separately in drip-proof containers and below fruits, vegetables and other ready-to-eat foods. Food items and snacks kept on the nursing units must be maintained as indicated: all food items must be placed in the refrigerator located at the nurses' station and labeled with a use by date, all foods belonging to residents must be labeled with resident's name, the item, and the use by date, refrigerators must have working thermometers and be monitored for temperature according to state-specific guidelines, beverages must be dated when opened and discarded after twenty-four (24) hours, other opened containers must be dated and sealed or covered during storage. The policy titled Refrigerators and Freezers, revised 02/27/2020 documented the facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines for all refrigerators on the nursing units and in the Food Services Department. Acceptable temperatures should be 36 to 46 degrees Fahrenheit and less than 0 degrees Fahrenheit for freezers. The Dietary Service Department personnel will surface clean the nourishment refrigerators on the nursing units daily and discard any outdated items. All foods shall be appropriately dated to ensure proper rotation by expiration dates. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once food is opened, and all food/ liquids dated past 24-hours should be discarded. Dietary Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. The policy titled Sanitization, issued 06/26/2018, documented the food service area shall be maintained in a clean and sanitary manner. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners will be kept in good repair. Between uses, cloths and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution, which will be changed at least once per shift. Low-temperature (chemical sanitization) dishwashing machines must be operated with wash temperature of 120 degrees Fahrenheit and final rinse with 50 parts per million (ppm) hypochlorite (chlorine) for at least 10 seconds. Kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The Food Service Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. The policy titled Food Preparation and Service, issued 06/26/2018, documented foods will not be thawed at room temperature. Thawing procedures include thawing in the refrigerator, submerging the item in cold running water, thawing in a microwave and cooking and serving immediately, or thawing as part of a continuous cooking process. The policy titled Preventing Foodborne Illness - Food Handling, issued 06/26/2018, documented food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. Potentially hazardous foods held in the danger zone (41 to 135 degrees Fahrenheit) for more than four (4) hours if being prepared from ingredients at room temperature or six (6) hours if cooked then cooled, will be discarded. Food that has been served to residents without temperature controls (trays, snacks, etc.) will be discarded if not eaten within two (2) hours. The policy titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practice, issued 06/26/2018, documented hair nets or caps and/ or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. The policy titled Foods Brought by Family/ Visitors, revised 02/19/2020 documented food brought into the facility by visitors and family is permitted. Family members and visitors are requested to inform nursing staff of their desire to bring foods into the facility. All food is to be brought to the nursing station. Food brought by family/ visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Perishable foods must be stored in containers in a refrigerator, containers will be labeled with the resident's name, the item, and the use by date. Beverages must be dated when opened and thrown out in three (3) days. Other food items must be dated and sealed or covered during storage and thrown out in three (3) days. The dietary staff will discard perishable foods every 24 hours on or before the use by date. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than two (2) hours will be discarded. 1. Observation in the South Building Main Kitchen on 12/18/2025 between 8:12 AM and 8:50 AM revealed the following:-Personal coats hung from a rack that contained food items and single service items-Visible layer of black dust on the ceiling light fixture, ceiling tile grid, the heat detector, and two (2) pendent sprinkler heads in the dishwash area-Brown splatter on eight (8) ceiling tiles in the dishwash area-Visible dust on the grates of the wall fan in the dishwash area, the fan was on at this time-Visible dust on the grates of the large floor fan in the center area-Bags of pork chops sitting in the left side of the two (2) bay sink, with 1/2 inch standing water at the bottom of the sink-Employee from the Activities department at the two (2) bay sink filling a cup with water without a hair net-Wall below the two (2) bay sink soiled with brown splatter-Four (4) broken and missing wall tiles on the partition wall between the dishwash area and the rear walkway-Walk-in cooler contained an undated bowl of three (3) cups of pudding, four (4) cups of egg salad dated 12/11, an undated bin of four (4) cups of fruit salad, approximately 20 sandwiches individually wrapped on a tray with no date on the sandwiches or the tray, an opened 5 pound bucket of cottage cheese not labeled with the date it was opened, 1/4 pound bologna wrapped in plastic wrap with no date, an opened bag of 2 cups of liquid eggs with no date-Reach-in cooler contained a cut cucumber wrapped in plastic wrap with no date, an opened 5 pound bag of shredded cheese with no date, an opened 2 pound block of Swiss cheese with no date, two (2) opened 1 gallon containers of mayonnaise not labeled with the dates they were opened, ten (10) slices of white American cheese in plastic wrap with no date, an undated bag with two (2) breaded chicken breasts, an undated piece of tin foil with two (2) breaded chicken breasts, an undated container of 5 cups of oatmeal, an undated container of 4 cups of a pureed food, an undated container with three (3) sausage patties, an undated container of 4 pounds of cooked ground beef, approximately 50 commercially prepared pancakes in a box with hand-written date 11/26 and manufacturer instruction on box Keep Frozen, an undated bag of 2 cups of cooked scrambled eggs, an opened undated 5 pound bag of cheese cubes, an undated bag of ten (10) small uncooked biscuits, two (2) opened 1 gallon containers of Italian dressing not labeled with the date opened, an opened 1 gallon container of sweet relish not labeled with the date opened, approximately ten (10) chicken breasts in a box with manufacturer label Uncooked Homestyle Chicken Breasts and Keep Frozen-Bench style can opener had a blade and all surrounding metal surfaces that were heavily soiled with food residue At the time of the observation [NAME] #1 stated the pork chops in the two (2) bay sink were thawing and they were brought out of the freezer about 30 minutes ago. [NAME] #1 stated the bench style can opener was still used, and it had been replaced recently by Maintenance staff. At the time of the observation, the Food Service Director stated the pork chops in the two (2) bay sink should not be thawing in the two (2) bay sink, as the staff were instructed to remove them from the freezer last night and thaw them in the refrigerator. They stated all foods should be dated once they were opened. They stated cheese could be stored in refrigeration for up to one (1) week after opening and mayonnaise could be stored in refrigeration for up to ten (10) days after opening. The Food Service Director stated the pancakes and breaded chicken breasts in the reach-in cooler should be discarded because the manufacturer instructions were to keep frozen, and those items were in the cooler for an unknown amount of time. The Food Service Director stated the bench style can opener was filthy, and they were in the process of ordering a new one. They stated the fans in the South Building Kitchen needed to be cleaned and the fan in the dishwash area was used to dry dishes. At the time of the observation, Dietary Supervisor #1 stated they personally made the tray of sandwiches and placed them in the walk-in cooler last night, which they do not usually do, and the tray needed to be labeled with the date they were made. 2. Observation in the basement of the South Building on 12/18/2025 at 9:00 AM revealed the following:-Four (4) boxes of frozen chicken and frozen vegetables on the floor of the walk-in freezer-Several boxes of single service items on the floor of the Dietary Storage Room-Several cases of food, including canned goods and boxed mashed potato mix, on the floor of the Dietary Storage Room At the time of the observation, the Food Service Director stated nothing should be stored on the floor. 3. Observation in the North Building Main Kitchen on 12/18/2025 between 9:10 AM and 9:45 AM revealed the following:-One (1) staff member working on the tray line without a hair net-Walk-in cooler contained an undated container of mashed potatoes, a tray of eight (8) sandwiches and seven (7) cups of salad with no date on the tray or the individual items, an opened 1 gallon container of cottage cheese not labeled with the date it was opened, two (2) opened 1 gallon containers of mayonnaise not labeled with the dates they were opened, box of raw pork chops on the top shelf above ready-to-eat foods, an undated container of 1 cup of homemade strawberry yogurt, three (3) plates of cottage cheese and grapes with no dates on plastic wrap covering, an undated container of 2 cups of meat in gravy, an undated container of 3 cups of vanilla pudding, ten (10) poured cups of juice some on a tray and some not on a tray with no dates on the cups or the tray-Four (4) boxes of beef sandwich steaks sitting on the counter to the right of the three (3) bay sink, each box was 10 pounds, meat in the top box appeared thawed, meat in the other boxes appeared frozen-Reach-in freezer's left side door in disrepair, the inner panel was disconnected from the door-Thermometer inside the reach-in freezer indicated the air temperature inside was 20 degrees Fahrenheit and the digital thermometer on the bottom indicated the air temperature inside was 19.5 degrees Fahrenheit -Visible dust on the grates and blades of the wall fan in the dishwash area-Active water drip from the sink at the dishwashing machine into a large pan on the floor below, at this time, the pan of dirty water was overflowing onto the floor-Wall below the dishwashing machine was soiled with a layer of grime-Eight (8) live flies observed around the dishwashing machine-Approximately 20 live flies observed under the dishwashing machine near the chemical buckets-Insect light trap located on the wall in the dishwash area was unplugged-Visible layer of black dust on the ceiling tiles, ceiling tile grid, ceiling vent, and pendent sprinkler head in the dishwash area-Personal coats hung from a rack that contained canned goods, coffee, and sugar packets-Case of cereal packs on the floor after tray line service was done-No chlorine test strips for use with low-temperature dishwashing machine-When dishwashing machine was run, water leaked from the rear left corner onto the floor-The 4-inch diameter floor drain to the left of the dishwashing machine had no protective grate At the time of the observation, the Food Service Director stated everyone working on the tray line needed a hairnet. They stated all opened foods in the walk-in cooler needed to be dated and the raw pork chops on the top shelf needed to be stored on the bottom shelf to prevent contamination. The Food Service Director stated the poured juices in the walk-in cooler were poured yesterday. They stated they had spoken to Maintenance staff about the reach-in freezer's door because it won't stay closed, and Maintenance staff had already tried to fix the water drip from the sink at the dishwashing machine. The Food Service Director also stated the case of cereal packs should not be on the floor and the fan in the dishwash area needed to be cleaned. At the time of the observation [NAME] #2 stated the boxes of beef sandwich steaks were taken out of the freezer last night, and as far as they knew, the boxes had been thawing on the counter all night. At the time of the observation, Dietary Aide #1 stated there had always been a problem with flies in the dishwash area, an exterminator treated the area, and a fly light was installed in the dishwash area, but it was never plugged in. At the time of the observation, the Food Service Director stated they had worked in the facility for about 14 days and [NAME] #2 stated they had worked in the facility for about 90 days, and both stated they had not seen chlorine test strips in the facility. Review of the licensed exterminator's Summary of Service dated 11/28/2025 revealed it contained the recommendation, Water leak/ standing water inside underneath dishwashing machine, please remove water and repair leak to prevent unsanitary conditions and attraction by pests. The Summary of Service also contained the recommendation, Fly light keeps getting unplugged, please keep the light plugged in. 4. Observation in the A Wing nourishment refrigerator in the North Building on 12/18/2025 at 8:25 AM revealed the following:- the refrigerator was soiled with a sticky substance on the door-Two (2) open fruit cups, that were not labeled or dated, and without lids-Open bag of burger buns not closed, that were not dated or labeled -Bag of food with a national food-delivery service's label dated 12/9 along with a first name-Opened container of thickened dairy beverage, with a hand-written date 11/13 and manufacturer's expiration date 12/17/2025-1/4 pound lunchmeat in drawer with a store's Sell By date 10/25/25, labeled with a resident's name and room number-A cup of cut-up watermelon with a store's Sell By date 10/25/25, labeled with a resident's name and room number During an interview on 12/18/2025 at 8:30 AM, Licensed Practical Nurse #6 stated food should not be in the refrigerator when it was expired, and/or open and unlabeled. They stated Dietary staff came around to check and clean the refrigerator, but they did not know how often this was done. They stated this refrigerator was for residents' food and expired lunchmeats could make a resident sick. The refrigerator was not locked, residents usually did not go into the refrigerator by themselves, but they could. At this time, Licensed Practical Nurse #6 voluntarily discarded the outdated and unlabeled foods from this refrigerator. 5. A second observation in the A Wing nourishment refrigerator in the North Building on 12/18/2025 at 9:50 AM revealed the following:-Bag of hot dog buns with manufacturer stamp that stated, Fresh Through 11/10, not labeled with a resident's name-One (1) unwrapped roll sitting on the bottom shelf, hard and brittle-No thermometer -Air temperature inside the refrigerator was 50.8 degrees Fahrenheit, as measured by the Surveyor's thermometer-Temperature of vanilla pudding cup in this refrigerator was 48.2 degrees Fahrenheit and temperature of orange juice in this refrigerator was 58.2 degrees Fahrenheit At the time of the observation, the Food Service Director stated they had only worked at the facility for about 14 days, and they were not sure about the nourishment refrigerators on the resident units, but the refrigerator needed to be colder and at this time, they adjusted the dial level. 6. Observation in the D Wing nurses' station in the North Building on 12/18/2025 at 8:37 AM revealed a tray that contained nine (9) cartons of chocolate milk, and three (3) cups of yogurt sitting on the counter. The containers of milk and yogurt felt warm and were not cool to the touch. At the time of the observation, Certified Nurse Aide #1 stated the nourishment refrigerator on D Wing was not in use at this time, because they had dementia patients, and they did not want them going into it. Certified Nurse Aide #1 stated the nourishment tray was brought up and kept at the nurses' station. Dietary staff brought it up early and the items were not refrigerated. They stated Dietary staff brought the current tray up today sometime before 7:00 AM. They stated they were not sure exactly how long the tray was there, but it should be refrigerated. The dairy products could spoil. Certified Nurse Aide #1 also stated Dietary staff should be responsible to keep the nourishments cold and deliver them for the 10:00 AM and 2:00 PM snacks separately, as both the 10:00 AM and 2:00 PM snacks were delivered before 7:00 AM today. 7. Observation in the C Wing nourishment refrigerator in the North Building on 12/18/2025 at 10:00 AM revealed the following: -Bag of four (4) sandwiches labeled with a resident name and room number, but no date-Food spills in the freezer that were yellow, red, and brown At the time of the observation, the Food Service Director stated the freezer needed to be cleaned. At the time of the observation, Certified Nurse Aide #9 stated the sandwiches were brought in for a resident by their family member, all food should be dated, and they would remind the family member to label the food they brought in with the date. 8. Observation in the B Wing nourishment refrigerator in the North Building on 12/18/2025 at 10:10 AM revealed the following:-Opened 12-ounce box of gravy not labeled with the date opened-Three (3) sealed commercially prepared 6-ounce containers of mashed potatoes with a manufacturer stamp that read Use By 12/15/25-Opened container of milk not labeled with the date opened-Bag from a restaurant of food that was not labeled with a resident's name or date-Ice cream in a cup from a restaurant without a cover in the freezer At the time of the observation, Licensed Practical Nurse #5 stated they personally bought the mashed potatoes and gravy for a resident and did not realize the Use By date had passed, and should be thrown out. Licensed Practical Nurse #5 stated they opened the milk container and forgot to date it when it was opened. They stated the bag of restaurant food should be thrown out because they could not be sure what day it was from. 9. Observation in the second-floor nourishment refrigerator in the South Building on 12/18/2025 at 10:30 AM revealed the following:-Opened 14-ounce tube of sour cream not labeled with the date it was opened-Opened 15-ounce container of mayonnaise not labeled with the date it was opened-Opened 16-ounce creamy Caesar dressing not labeled with the date it was opened-One (1) cup of noodle salad in an undated container-Pizza in a brown bag with a resident's name and room number, but no date-Blue plate of food covered with tin foil not labeled with a name or date-Restaurant clam shell container of French fries labeled with a room number, but no date-Restaurant clam shell container with a roast beef sandwich labeled with a room number, but no date-Restaurant Chinese food container labeled with a name and the number 22, but no date-One (1) cup of soup in a plastic container with no name or date-Bag from a restaurant of food with no name or date-On top of the refrigerator was two (2) triangular shaped boxes that each contained a slice of pizza, with no name or date on the boxes-No thermometer-Temperature of an orange juice cup from this refrigerator was 50.5 degrees Fahrenheit and temperature of the soup from this refrigerator was 46.4 degrees Fahrenheit -Sign on this refrigerator read, This refrigerator to be used for residents' food and drinks only -A tray of nourishments, including three (3) pudding cups, two (2) yogurt cups, and several nutritional shakes were sitting on the counter to the left of the refrigerator-Temperature of a pudding cup from the tray was 67.7 degrees Fahrenheit and temperature of a yogurt cup from the tray was 64.0 degrees Fahrenheit At the time of the observation, Unit Secretary #1 stated the nourishment refrigerator should contain only food that belonged to the residents. There used to be a thermometer in this refrigerator. They stated the tray of nourishments on the counter was brought up to the unit this morning. Also, at the time of the observation, Unit Secretary #1 voluntarily discarded the slices of pizza that were on top of the refrigerator. At the time of the observation, the Food Service Director stated the refrigerator needed to be colder and at this time, they adjusted the dial level. 10. Observation in the third-floor nourishment refrigerator in the South Building on 12/18/2025 at 10:50 AM revealed the following:-No thermometer-Air temperature inside refrigerator was 62.0 degrees Fahrenheit, as measured by the Surveyor's thermometer-Temperature of a pudding cup in this refrigerator was 66.5 degrees Fahrenheit and temperature of chocolate milk in this refrigerator was 47.9 degrees Fahrenheit 11. Observation in the South Building Main Kitchen on 12/18/2025 at 12:05 PM revealed the following:-Two (2) staff members working on the tray line without beard nets, their facial hair ranged from 1/2 to 3/4 of an inch long-Rags being used to wipe surfaces on and around the tray line appeared yellowed with tan soils and was stored on the counter dry, not in sanitizing solution-Two (2) staff members entered the kitchen about two (2) minutes apart to fill cups at the ice machine, neither staff member was wearing a hair net At the time of the observation [NAME] #1 stated the facility did not provide beard nets, and removed the hair net from their head and placed it over their beard. At the time of the observation, Dietary Aide #2 stated they were never provided a beard net. At the time of the observation, Food Service Supervisor #1 stated staff from departments other than dietary came into the kitchen to use the ice machine. Food Service Supervisor #1 also stated the facility had no beard nets, but the workers with beards should be wearing them. 12. Observation in the South Building Main Kitchen on 12/18/2025 at 2:05 PM revealed the following:-No chlorine test strips for use with low-temperature dishwashing machine-As the dishwashing machine was running, the thermometer stayed between 40- and 60-degrees Fahrenheit before, during, and after the cycle At the time of the observation, Dietary Aide #2 stated they did not have any test strips. At the time of the observation, Food Service Supervisor #1 stated they could not locate any test strips. 13. Observation in the North Building Main Kitchen on 12/18/2025 at 2:22 PM revealed the following:-No chlorine test strips for use with low-temperature dishwashing machine-As the dishwashing machine was running, the thermometer closer to the floor was covered in a hard film and could not be read, and the thermometer on the machine read 100 degrees Fahrenheit, neither of the thermometers moved before, during, or after the cycle During an interview on 12/18/2025 at 2:35 PM, the Food Service Director stated without chlorine test strips, they did not know whether the sanitizer level was acceptable. During an interview on 12/19/2025 at 8:50 AM, the Maintenance Director stated they were not made aware of any problems with the thermometers on the dishwashing machines. 14. Observation in the North Building Main Kitchen on 12/19/2025 at 8:30 AM revealed one (1) staff member was working on the tray line without a hair net. During an interview on 12/19/2025 at 10:45 AM, the Food Service Director stated there was not currently a kitchen cleaning schedule, as they found an old kitchen cleaning schedule, but it needed to be reviewed and updated before use. The Food Service Director stated Dietary staff should maintain the nourishment refrigerators on the resident units, including daily restocking, checking for undated or outdated items, and cleaning as needed. They stated as a general rule, unopened foods could be used until the manufacturer's Best By date. Once foods were opened, they needed to be labeled with the date and used within three (3) days, except for cheese, salad dressings, and mayonnaise, which could be kept longer. They stated sanitizing cloths should be kept soaking in a sanitizer, meats should be thawed in a refrigerator or under running water, and coats should be stored in designated areas with coat hooks. During an interview on 12/19/2025 at 2:45 PM, the Administrator stated kitchen cleanliness had improved with the onboarding of a new Food Service Director, was headed in the right direction, but was not where it needed to be yet. 10 NYCRR 415.14(h)Subpart 14-1: 14-1.40, 14-1.42, 14-1.43, 14-1.44, 14-1.72,14-1.86, 14-1.110, 14-1.115, 14-1.117, 14-1.140, 14-1.160, 14-1.171, 14-1.177, 14-1.180

Based on observation, interview, and record review conducted during an Abbreviated Survey (Complaint #'s 2637850, 2657322, 2676432, 2680267) the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (2) (North Building and South Building) of two (2) resident buildings. Specifically, there were torn and stained privacy curtains in resident rooms; walls, floors, and baseboards that were soiled, discolored and/or in disrepair. Shower rooms with soiled furnishings and loose toilet seats, stored unlabeled opened personal care items; soiled and in disrepair floors, broken blinds, wall board in disrepair and separating from the wall, stained ceiling tiles and a rusty ceiling tile grid. Additionally, soiled linens were observed on floors of shower room and in resident rooms.The findings are:The undated facility document titled General Housekeeping Procedure documented the purpose was to prevent the spread of bacteria and infection from one person to the next: to assure the highest level of cleanliness and sanitation possible. Daily procedure for cleaning resident rooms, lobbies, corridors and bathrooms consisted of dusting all vertical and horizontal surfaces, cleaning of cubicle curtains, spot clean and vacuum carpets, dust mop, wet mop, and spot mop tiles. Shower rooms were cleaned to maintain cleanliness, sanitation, and optimum levels of safety, to control the spread of infection and bacteria and to minimize unpleasant odors. Daily procedure consisted of inspecting area; pick up and large pieces of trash, linen, clothing, etc. Clean shower stall, shower curtains, partitions, toilets, sink, and mirror. Procedure for cleaning window shades consisted of periodic dusting, vacuuming, and washing. Report any damage or any recommendations for replacements to supervisor immediately. Daily cleaning would be inspected by the Director of Housekeeping to ensure all necessary cleanliness and sanitation levels had been achieved.1a. Intermittent observations and interviews in the South Building revealed the following:Observation on the second floor on 12/18/2025 at 9:00 AM revealed resident room [ROOM NUMBER]W had a privacy curtain with brown, maroon colored stain/ debris.Observation on the second floor on 12/18/2025 at 9:34 AM revealed the tiled hallway floor appeared dull with dirt ingrained into it. The second-floor shower room had used, unlabeled personal care items in the shower stall, including a hairbrush and an 8-ounce bottle of shampoo/ body wash. The shower stall floor was wet with grey lint debris and yellowish/ brown colored water on floor outside shower stall. The toilet in the bathroom present in the shower room had grey stained ring in the toilet bowl and brown debris on the toilet rim and the underside of the toilet seat.Observation on the second floor on 12/18/2025 t 9:44 AM revealed the privacy curtain in Resident room [ROOM NUMBER] was torn.Observation on the second floor on 12/18/2025 at 10:24 AM revealed the hallway wall outside of Resident room [ROOM NUMBER] was soiled and had trails of dried liquid going down the wall.Observation and interview on 12/18/2025 at 9:00 AM, Resident #13 stated ambiance was lacking in the facility and updates were needed. They stated the lack of sanitation was visible and that it bothered them. They stated the baseboards in the facility were dirty with dirt build up present. They stated their privacy curtain was stained with blood and was unsanitary. They stated they reported it almost immediately upon being admitted and nothing had been done.Observation in the third-floor shower room in the South Building on 12/18/2025 at 1:10 PM revealed two (2) areas of dried gray debris on the floor tile under the sink.A second observation of the second-floor shower room in the South Building was made on 12/18/2025 at 1:23 PM. The perimeter of the floor in the toilet area was discolored gray. The toilet seat was up, and there was feces on the bottom of the toilet seat and on the toilet bowl rim.During an interview on 12/18/2025 at 3:05 PM, the Housekeeping Supervisor stated shower rooms should be cleaned daily by housekeeping staff, and if they see something was dirty throughout the day, it should be touched up. The Housekeeping Supervisor stated they had tried to bleach the area of floor tile around the toilet in the second-floor shower room in the South Building and it came a little cleaner. They stated if housekeeping staff could not completely clean something, they would notify maintenance staff.Another observation of the second-floor shower room in the South Building was made on 12/19/2025 at 9:25 AM. The perimeter of the floor in the toilet area remained discolored gray. The toilet seat was loose and swayed 4 inches left to right. There was a dark brown coating on the grout around the base of the toilet and an area of black staining on the floor tile in front of the toilet. Additional observation revealed the ceiling tile at the entrance to the shower room had dark brown splatter and the ceiling tile grid (which holds ceiling tiles in place) in the shower stall was coated with rust.During an interview on 12/19/2025 at 9:40 AM, Housekeeping Aide #2 stated they swept and mopped the shower room every day. They stated they had tried to get out the gray discoloration in the floor tile, grout, and caulk in the perimeter of the toilet area of the second-floor shower room in the South Building, but it did not work. They stated the caulk may have to be taken out and re-done. Housekeeping Aide #2 stated they had never noticed the stain on the ceiling tile at the entrance to the room before and they were not sure what it was, but feces could not be ruled out. They also stated they had never noticed the rust on the ceiling tile grid in the shower stall before.During an interview on 12/19/2025 at 9:59 AM, Certified Nurse Aide #4 stated the quality of the environment was poor. They stated resident privacy curtains were raggedy, the baseboards in the hallway were dirty, the hallway floors were grimy, dull and needed to be replaced. They stated the walls were not wiped down and maintenance just painted over dirt. Certified Nurse Aide #4 stated it was important for the residents' environment to be sanitary for infection control, clean for a homelike environment; and to be visually pleasing to everyone. During an interview on 12/19/2025 at 10:18 AM, Certified Nurse Aide #4 stated the privacy curtain in Resident room [ROOM NUMBER] W was old, dirty looking and torn. Stated the debris could be blood or poop. They stated it was unsanitary and needed to be cleaned for infection control purposes.During observation and interview on 12/19/2025 at 10:27 AM, Registered Nurse #4 stated the privacy curtain in Resident room [ROOM NUMBER]W was dirty, and nasty looking. They stated it appeared to have either old blood, fecal matter, or food stains on it. They stated privacy curtains should be clean for infection control purposes. They stated housekeeping and/or maintenance were responsible to clean and maintain the privacy curtains and that any staff member could notify housekeeping if a privacy curtain was dirty.During an interview on 12/19/2025 at 10:36 AM, Licensed Practical Nurse #1 stated the hallway floors did not appear homelike and the baseboards in the hallway looked dirty and needed some elbow grease. They stated having a clean, homelike environment was important for the healing process and infection control.During an interview on 12/19/2025 at 2:15 PM, Registered Nurse #3 Supervisor stated everyone was responsible for maintaining the cleanliness of the unit for infection control purposes. They stated the hallway floor was worn, past the point of being stripped and waxed, and needed to be replaced.1b. Intermittent observations and interviews in the North Building revealed the following:Observation on 12/18/2025 at 9:45 AM revealed soiled washcloths on the floor of the D Wing shower room, dried brown feces on the chair and toilet in the shower room bathroom.Observation on 12/18/2025 at 12:49 PM revealed a soiled fitted sheet, top sheet, and blankets were on the floor in Resident #4's bathroom.Observation in the A Wing shower room in the North Building on 12/18/2025 at 3:00 PM revealed two (2) sets of window blinds in the toilet area had broken and missing slats. In the shower stall, two (2) areas of protective wall covering were partially disconnected from the wall. In the shower stall, there were two (2) areas of broken and missing floor tiles, one (1) area was 10 inches in diameter and the other area around the floor drain was 6 inches in diameter.During an interview on 12/19/2025 at 8:50 AM, the Maintenance Director stated they were unaware of the broken floor tiles in the A Wing shower room in the North Building, and all cracked and broken tiles needed to be replaced. They stated it needed to be a smooth surface for resident use. The Maintenance Director stated staff could inform the maintenance department about any issues that needed their attention either through the facility's automated maintenance work order system or by telling a member of the maintenance department directly.During an interview on 12/19/2025 at 8:50 AM, the Maintenance Supervisor stated they were unaware of the broken floor tiles in the shower stall in the A Wing shower room in the North Building.During an interview on 12/19/2025 at 9:05 AM, Housekeeping Aide #1 stated they had worked at the facility for three (3) months and the floor tile in the A Wing shower room shower stall had been like that the whole time they worked here. Housekeeping Aide #1 also stated the floor tile was all broken up when they swept it, and they told their supervisor, the former Housekeeping Director. They also stated, all of the nurses know about it, though.Observation on 12/19/2025 at 8:26 AM revealed the garbage can was overflowing in the Nourishment Room on D Wing, dried brown debris dripping down Resident #4s door; two soiled washcloths on floor of shower room on D Wing and the dried brown substance remained on chair in bathroom in shower room.During an observation and interview on 12/19/2025 at 8:29 AM, Certified Nurse Aide #10 stated the aides were responsible for picking up any linens from shower room after giving a shower, and the soiled linen should not have been on the shower room floor. Certified Nurse Aide #10 stated the dried brown debris on the toilet and chair in shower bathroom was feces, it should not be there, someone could sit in it; it was an infection control issue.During an observation and interview on 12/19/2025 at 8:37 AM, Registered Nurse Unit Manager #6 stated the linen on Resident #4's bathroom floor and on the shower room floor should not be there. Certified nurse aides were responsible for picking up the soiled linen after they stripped the beds and gave showers. Registered Nurse #6 Unit Manager stated the dried brown debris on the toilet and chair in the shower bathroom was an infection control issue and should be cleaned daily. They stated these observations were not homelike.During an interview on 12/19/2025 at 11:30 AM, the Housekeeping Supervisor stated housekeeping aides utilized worksheets titled Daily Resident Room Cleaning Checklist, which were specific to resident rooms, and included a line for the supervisor's signature. The Housekeeping Supervisor stated Housekeeping Aides used this sheet daily, but they could not locate any completed sheets at this time.During an interview on 12/19/2025 at 1:37 PM, the Housekeeping Supervisor stated an audit of privacy curtains inside resident rooms was conducted last week. As a result of the audit, new privacy curtains were ordered. They stated if a privacy curtain was dirty, it could be washed, but if it was in bad condition, it would be replaced. The Housekeeping Supervisor stated they were notified when something needed their attention by certified nurse aides or housekeeping aides telling them. They stated wall baseboards were cleaned regularly, but if they had wax buildup on them, that would be beyond regular cleaning. he Housekeeping Supervisor stated they personally were involved in stripping and waxing floors, but on days with limited staffing, they were pulled in different directions, and other tasks took priority above stripping and waxing floors. The Housekeeping Supervisor stated a Housekeeping Aide cleaned the D Wing shower room in the North Building daily, and they had not personally seen it, but if a chair in the toilet area of the D Wing shower room had feces on it or if soiled linen was on the floor, that would not be homelike. They stated, If I saw that coming to visit my family members, I would be upset. Additionally, the Housekeeping Supervisor stated the facility's stripping and buffing floor machines worked, but not at 100 percent, as the machines were damaged while being using earlier this month. They stated the Administrator was made aware of the condition of the floor machines.During an interview on 12/19/2025 at 2:30 PM, the Housekeeping Supervisor stated the floor in front of the second floor Nurses' Station in the South Building and the wall baseboards in the corridor of the second floor were gray-tone due to a buildup of wax and dirt, and regular mopping would not get that out. Additionally, at this time, the Housekeeping Supervisor looked at the privacy curtain in the center of Resident room [ROOM NUMBER]. The curtain had a 1 1/2 inch diameter red stain with smaller light tan stains and a tear that was 5 inches long at the top mesh. The Housekeeping Supervisor stated the large stain could be blood and the smaller stains were likely coffee, and the curtain needed to be washed. They stated the tear in the mesh would likely get further damaged in the wash, and if that happened, it would have to be replaced.During an interview on 12/19/2025 at 2:45 PM, the Administrator stated the Housekeeping Supervisor told them earlier this week that the floor machines had some functions that were not up to 100 percent. The Administrator stated they advised the Housekeeping Supervisor to contact the leasing company, as the machines might still be under a maintenance contract, but they still needed to follow up on this with the Housekeeping Supervisor. The Administrator also stated the first and second floors of the South Building were waxed in October, but an older mop head was used, which left streaks, and a new strip and wax was needed in those areas. Additionally, the Administrator stated a homelike environment was important for the residents, and clean, shiny floors and clean resident areas made for a homelike environment.10 NYCRR 415.5(h)(1)(2)

Based on observation, interview, and record review during an Abbreviated survey (Complaint #2637850) the facility did not dispose of garbage and refuse properly. Specifically, two (2) (South Building and North Building) of two (2) resident buildings had waste that was not properly contained outside in closed dumpsters. Garbage and loose debris were observed on the ground around the dumpsters, which created potential feeding and harborage areas for pests. The findings are: The policy and procedure titled Food-Related Garbage and Rubbish Disposal, issued 06/26/2018, documented garbage and rubbish containing food wastes will be stored in a manner that is inaccessible to vermin, storage areas will be kept clean at all times, and outside dumpsters will be kept closed and free of surrounding litter. 1a. Observation on 12/18/2025 at 9:05 AM revealed there were two (2) garbage dumpsters located outside of the South Building. Both dumpsters contained bagged garbage, and both had open lids and sliding doors. A second observation of the South Building's exterior garbage storage area on 12/18/2025 at 1:46 PM. The garbage dumpster on the left was full of bagged garbage and both sliding doors were open. Garbage was observed on the ground in this area, including paper plates, plastic utensils, four (4) empty milk cartons, used disposable gloves, a paper bag, a plastic cup, a lighter, a used sanitary pad, ripped cardboard, and a 2-foot-long inflated plastic bag used as shipping material. A third observation of the South Building's exterior garbage storage area on 12/19/2025 at 8:20 AM revealed the garbage dumpster on the left was 75 to 100 percent full and both sliding doors were open. 1b. Observation on 12/18/2025 at 2:26 PM revealed there were two (2) garbage dumpsters located outside of the North Building. Both dumpsters were greater than 100 percent full and both dumpsters had open lids. The dumpster on the left had several long two by four (2x4) pieces of wood sticking out of the top, 3 (three) feet above the top rim of the dumpster. Garbage was observed on the ground in this area, including cardboard boxes, a water bottle, five (5) empty milk cartons, ripped paper plates, plastic utensils, multiple drink lids, a broken ceiling tile, two (2) juice cups, and a soda can. During an interview on 12/18/2025 at 2:40 PM, the Maintenance Director stated garbage pickup occurred on Monday, Wednesday, and Friday. They stated they cleaned the area around the garbage dumpsters at the North Building earlier today and the items currently on the ground were not there earlier today. They also stated the lids of the dumpsters should sit flush on the top rim of the dumpsters. At this time, the lids were closed, and they sat up to 12 (twelve) inches above the top rim of the dumpsters. The Maintenance Director stated staff should know to use the dumpsters at the South Building when these dumpsters were full. During a second observation on 12/19/2025 at 8:32 AM, both garbage dumpsters at the North Building were greater than 100 percent full, and bagged garbage was greater than 12 (twelve) inches above the top rim. The lids were open on both garbage dumpsters. The items observed on the ground in this area on 12/18/2025 remained. There was also one (1) bag of garbage on the ground at the rear door of the facility, near the basement steps. During an interview on 12/19/2025 at 8:43 AM, the Housekeeping Director stated they had only personally worked at this facility for a few days, but in their experience, garbage dumpsters should be able to be closed, and they should be kept closed. They stated the bag of garbage at the rear door of the facility should not have been left on the ground. During an interview on 12/19/2025 at 8:50 AM, the Maintenance Director stated when they arrived at the facility at 6:00 AM this morning, they personally closed the lids and sliding doors to the dumpsters at the South Building. Also at this time, the Maintenance Director observed that the lids to the garbage dumpsters at the North Building were open, the Maintenance Director shut them, and the lids sat on top of the garbage bags, 24 (twenty-four) to 36 (thirty-six) inches above the top rim of the dumpsters. The Maintenance Director stated cleaning the area around the dumpsters was a Maintenance department task, but the Maintenance department had asked the Dietary department for help with this task in the past because the items on the ground appeared to be mostly food related. They stated the area around the garbage dumpsters was currently messy and they would ask the contractors who picked up the garbage to move the dumpsters in order for staff to be able to clean around and under them. The Maintenance Director stated they believed the overflowing garbage dumpsters at the North Building was likely due to big boxes at the bottom taking up space. During an interview on 12/19/2025 at 10:15 AM, the Administrator stated doors and lids to garbage dumpsters should always be shut and the area around garbage dumpsters should be kept clean. The Administrator stated the ground around the North Building dumpsters needed to be cleaned and that was a Maintenance department task.10NYCRR 415.14(h)14-1.150

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #2655726) the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for two (2) (Residents #8 and #9) of five (5) residents reviewed. Specifically, Resident #8 was not provided with morning care and Resident #9 was not provided with timely incontinent care. The findings are:The facility policy and procedure titled Activities of Daily Living dated 11/18/2024 documented the facility will ensure a resident is given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. The facility will provide care and services for hygiene-bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain grooming, and personal hygiene.The facility policy and procedure titled Quality of Life-Dignity dated 2/2021, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing their self-esteem and self-worth. The policy and procedure titled Giving a Bed bath (AM/PM Care) dated 03/01/2017, documented the purpose of that procedure was to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. The following equipment and supplies will be necessary when performing this procedure: wash basin, soap, body lotion, deodorant, and comb/hairbrush. 1. Resident #8 had diagnoses of macular degeneration (loss of the central field of vision because of deposits of the retina), congestive heart failure (a chronic condition where the heart is too weak to pump blood), type two (2) diabetes mellitus (disease affecting blood sugar). There was no comprehensive resident assessment completed. Nursing admission assessment dated [DATE] documented Resident #8 was oriented and was unable to read newsprint with or without assistive devices. The Baseline Care Plan created 12/15/2025, documented Resident #8 self-care with two (2) assistances, total dependence with staff performance. Cognition was alert/cognitively intact, communicated verbally, vision impaired, and was at risk for incontinence. During an observation and interview on 12/18/2025, Resident #8 stated they were admitted to the facility on Monday (12/15/2025) and had not received or been helped with bathing/washing up since they arrived. They stated it made them feel horrible and further stated they were starting to smell. There was no wash basin or supplies for personal hygiene present in Resident #8's room and bathroom. The resident looked untidy and there was dry, flaking skin was observed on bedsheets.During an observation and interview on 12/18/2025 at 12:35 PM, wash basins containing spray cleaner, moisturizer, deodorant and hairbrush in package was sitting on dresser in Resident #8's room. Resident #1 remained in bed. Resident #8 stated they were supposed to have therapy before 11:00 AM, and morning care still had not been completed.During an observation on 12/18/2025 at 2:14 PM, Certified Nurse Aide #2 and Certified Nurse Aide #5 provided Resident #8 morning care, including changing of bedsheets and gown. During an interview on 12/18/2025 at 2:50 PM, Certified Nurse Aide #2 stated residents only receive showers/bed baths once a week. They stated they provided Resident #8 a bed bath today per Resident #8's and family request due to not being cleaned up since they arrived. Certified Nurse Aide #2 stated it was their first time washing Resident #8 up since they arrived, and they were the resident's assigned aide on 12/17/2025. They stated morning care should be done every day for sanitation and dignity. During an interview on 12/18/2015 at 3:01 PM, Licensed Practical Nurse #2 stated basic care; washing of face, armpits and peri-area, should be completed at least daily to maintain skin integrity and human dignity. They stated they did not know until today when the resident/family reported to them that Resident #8 had not been provided basic care since Monday. Licensed Practical Nurse #2 stated that it was not acceptable. They stated personal care items, wash basin, soap, deodorant, comb, should already be present in a resident's room upon admission. During an interview on 12/19/2025 at 2:15 PM, Registered Nurse #3 Supervisor stated morning care should be provided daily to maintain dignity, infection control and skin integrity. They stated it was not acceptable for a resident not to be offered or provided basic morning care including washing of face, hands and changing of clothing. During an interview on 12/22/2025 at 1:38 PM, the Director of Nursing stated Certified Nurse Aides were responsible and should be providing basic activities of daily living every day. They stated basic activities of daily living would include washing face, brushing teeth, washing armpits and private parts. The Director of Nursing stated providing activities of daily living was important to maintain skin integrity, general health, and dignity. 2. Resident #9 had diagnoses that included hemiplegia (paralysis on one side of body) and hemiparesis (weakness of one side of body) following cerebral infarction (stroke) affecting left side, adjustment disorder, and absence of right leg above knee. The Minimum Data Set (resident assessment tool) dated 08/15/2025 documented the resident was cognitively intact, was usually understood, and usually understands others. Resident #9 was dependent on staff for toileting hygiene, bed mobility and had frequent urinary incontinency. he Care plan Report dated 08/12/2025 documented Resident #9 had a self-care deficit and documented toileting needs per occupational therapy recommendations. The undated Care Profile (a guide used by staff to provide care) documented Resident #9 was oriented and independent with decision making. Resident #9 always required two (2) caregivers and had toileting schedule documented as upon demand. Activity of Daily Living Assessment (11/12/2025) documented toileting hygiene as dependent with two (2) helpers; one (1) helper to assist with positioning, one (1) helper to assist with peri care and brief management. During an observation and interview on 12/22/2025 at 9:38 AM, Resident #9 was in bed and stated they were incontinent and had told Certified Nurse Aide #7 they needed to be changed over an hour ago. Resident #9 stated they had not been given any care or incontinent care yet that morning. At 10:09 AM Resident #9 activated their call bell to request incontinent care again. During a continual observation on 12/22/2025 from 10:09 AM - 10:35 AM, Resident #9's call bell remained activated.During an observation and interview on 12/22/2025 at 10:35 AM, Certified Nurse Aide #6 entered Resident #9's room, turned off their call bell and exited Resident #9's room. Certified Nurse Aide #6 stated they worked full time on unit and were somewhat familiar with Resident #9. They stated Resident #9 does not need to be changed that often and usually has their call bell on to be boosted. Certified Nurse Aide #6 stated everybody, nurses, and aides, were responsible to answer call bells timely because there could be an emergency. They stated a call bell should be answered right away if you see or hear it, but sometimes it takes longer, five (5) minutes when aides are in other rooms giving care; and there are only three (3) aides on the unit. During an observation on 12/22/2025 at 10:42 AM, Certified Nurse Aide #7 and Certified Nurse Aide #8 entered Resident #9's room and completed fecal incontinent care on Resident #9. During an interview on 12/22/2025 at 11:05 AM, Certified Nurse Aide #7 stated they were assigned, responsible for Resident #9. They stated they boosted and shut Resident #9's window that morning at 8:00 AM and that Resident #9 requested to be changed. Certified Nurse Aide #7 stated they did not provide requested incontinent care to Resident #9 at that time. They stated, Just started down the line and started getting people up. They stated Resident #9 should not have had to wait to be changed but they were in the middle of getting their get up's (residents who needed to be out of bed) ready for the day. Certified Nurse Aide #7 stated they try and complete care when requested right then and there but Resident #9 required two (2) assist to be changed and they were assigned 12-13 residents. Additionally, Certified Nurse Aide #7 stated it was important that timely care was provided because of health conditions and skin breakdown. During an interview on 12/22/2025 at 11:28 AM, Licensed Practical Nurse #3 stated if a resident requested to be changed, the aides know they should change the resident right away to prevent skin breakdown. During an interview on 12/22/2025 at 1:38 PM, the Director of Nursing stated they would have expected timely, as soon as possible, incontinent care to have been provided to Resident #9, to prevent skin breakdown and dignity issues. 10 NYCRR 415.12 (a) (3)

Based on observation, interview, and record review conducted during an Abbreviated Survey (Complaint #2680267) completed on 12/22/2025, the facility did not ensure that all residents receive treatment and care in accordance with professional standards of practice for two (2) (Resident #7 and #8) of two (2) residents reviewed. Specifically, there was lack of ongoing evidence of skin assessments and lack of evidence the treatment was completed as ordered (#7) and there was a delay in obtaining an order for completing dressing changes and lack of evidence flushes were completed as ordered (#8). The findings are: The policy titled Wound Care dated 12/01/2017, documented the purpose was to provide guidelines for the care of wounds to promote healing. Documentation should be recorded in the resident's medical record: any change in the resident's condition, all assessment data (wound bed color, size, drainage, etc.) obtained when inspecting the wound, any problems or complaints made by the resident related to the procedure and the signature and title of the person recording the data. The policy titled Dressing, Sterile dated 12/01/2017, documented the purpose was to provide guidelines for the application of sterile dressings. Verify that there is a Physician's order for this procedure. Assess the wound and surrounding skin for edema, redness, drainage. The following information should be recorded in the resident's medical record: the date and time the dressing was changed, assessment data, any problems or complaints made by the resident related to the procedure, complications related to the wound, and the signature and title of the person recording the data. The policy titled Central Venous Catheter Flushing undated, documented Central Venous Catheters included Peripherally Inserted Central Catheters (PICC). The policy documented specific flush orders must be documented; flushing is performed to ensure and maintain catheter patency. Documentation in the medical record includes but is not limited to date and time, prescribed flushing agents, and site assessment. The facility was unable to provide a policy specifically for PICC (peripheral inserted central catheter) line dressing change per the Administrator on 12/22/2025. 1. Resident #7 had diagnoses that included cerebral infarction (stroke), congestive heart failure (a chronic condition where the heart is too weak to pump blood), and type two (2) diabetes mellitus (disease affecting blood sugar). The Minimum Data Set (resident assessment tool) dated 12/02/2025 documented the resident understood, understands and was unable to complete the interview for mental status. Resident #7 did not exhibit any rejection of care, was dependent on staff for toileting hygiene, transfers and was always incontinent of urine and bowel. Resident #7 was at risk of developing pressure ulcers and had three (3) Stage two (2) pressure ulcers present upon admission. The Careplan Report dated 11/28/2025 documented Resident #7 had the potential for altered nutrition with intervention to monitor skin status and goal for skin to improve through next review. There was no care plan development r/t impaired skin integrity. The Resident Care Profile (a guide used by staff to provide care) completed 11/26/2025 documented Resident #7 skin care: skin check with routine care each shift. Review of Weekly Skin Tracker/Quality Assurance Report completed by Registered Nurse Supervisor #3 on 11/26/2025 at 10:13 PM documented Resident #7 had three (3) blisters acquired out of facility to sacrum/coccyx each measuring 0.2 centimeters round. Current treatment normal saline, pat dry, dry clean dressing. Further review revealed there were no Weekly Skin Tracker assessments completed between 11/27/2025 and 12/18/2025. Review of Physician's Order form as of 12/22/2025 documented Resident #7 had treatment order started on 11/26/2025 to cleanse sacrum with normal saline, pat dry, apply dry clean dressing daily on the day shift and as needed. Review of Monthly TAR (Treatment Administration Record) from November 2025 and December 2025, documented the ordered treatment for Resident #7's sacrum was checked as completed six (6) out of twenty-two (22) days between 11/26/25 and 12/17/2025. Review of Progress Notes dated 11/26/2025-12/18/2025 documented:-11/26/2025 at 9:36 PM by Registered Nurse #3, Supervisor, Resident #7 with three (3) intact blisters to sacrum (MD to assess).-11/28/2025 at 9:12 AM, Nutrition Assessment, skin integrity: three (3) intact blisters to sacrum per nursing note 11/26-11/29/2025-12/18/2025 there were no additional progress notes documenting and/or addressing Resident #7's blisters to their sacrum. Review of untitled medical provider notes dated 11/26/2025, 11/28/2025, 12/01/2025, 12/08/2025, and 12/10/2025 revealed there was no documented evidence of any skin conditions and/or pressure ulcers. During an interview and observation on 12/18/2025 at 1:21 PM, Resident #7 stated they wash themselves up in the bathroom on non-shower days. They denied receiving any assist other than staff providing washcloths and towels to wash up. Resident #7 ambulated to bathroom independently with roller walker while surveyor was present. Resident #7 showed the surveyor while in bathroom two dried scabbed areas to their left upper inner buttock without a dressing. First scabbed area was round, approximately the size of a nickel (2 centimeters) and the second scabbed area located below the first area was irregular in shape approximately .5 centimeters in length by 1.5 centimeters wide. There was no drainage, redness, or s/s of infection observed. Skin was clean. There were no intact blisters observed. During an interview and observation on 12/18/2025 at 1:33 PM, Licensed Practical Nurse #1 stated Resident #7 had three (3) little dots near their coccyx (tailbone) that was being treated with zinc or A and D. They stated they were not sure but thought the treatment was completed on the day shift. Upon reviewing Resident #7's Treatment Administration Record in the electronic medical record, at their medication cart, Licensed Practical Nurse #1 stated the wound doctor was at the facility yesterday and must have changed Resident #7's treatment. Licensed Practical Nurse #1 stated treatment was to cleanse sacrum with normal saline, pat dry and apply a dry clean dressing. Additionally, they stated the nurse manager or whoever was overseeing wounds completes the measurements and enters them into the computer. During an observation on 12/18/2025 at 1:42 PM, Licensed Practical Nurse #1 completed ordered treatment to Resident #7's left upper inner buttock. Licensed Practical Nurse #1 stated the two areas present to Resident #7's left inner buttock were superficial and dry and looked the same. During a follow up interview on 12/19/2025 at 10:36 AM, Licensed Practical Nurse #1 stated they had believed Resident #7 was being followed by the wound doctor weekly because Resident #7 had a treatment ordered. They stated blank boxes on the treatment administration sheet indicated that the treatment was not done, or it was not signed it was completed. They stated Resident #7's treatment should be signed out to let everyone know it has been done. During an interview on 12/19/2025 at 2:15 PM, Registered Nurse Supervisor #3 stated they were not aware of the wound round process. They stated they were responsible for documenting wounds on the admission assessment forms and if no treatment was provided from the hospital, a simple treatment was initiated until the resident was seen by a medical provider. They stated the unit manager, or a nurse would notify the wound provider of any new wounds. Registered Nurse Supervisor #3 stated they completed Resident #7's admission assessment and that Resident #7 had three (3) small intact fluid filled blisters to their sacral/coccyx area. They stated they initiated a treatment to the area and expected that Resident #7 would have been seen by the wound care provider. Registered Nurse Supervisor #3 stated they had not seen Resident #7's skin since their admission. Registered Nurse Supervisor #3 stated it was important for treatments to be completed as ordered so wounds improved, and did not get worse. They stated that the Licensed Practical Nurses on the medication carts were responsible for completing treatments. Additionally, they stated a treatment not signed for indicated it was not completed. During an interview on 12/22/2025 at 1:38 PM, the Director of Nursing stated wound rounds were to be completed weekly by the wound provider, Assistant Director of Nursing, and a Nurse Manager. The Director of Nursing stated they were not familiar with Resident #7 and would have to investigate their wounds/blisters. They stated if Resident #7 had blisters they should have been seen every week or a best there should be a note from a medical provider. They stated Resident #7 was not followed by the wound consultant. They stated it was important for wounds to be monitored, assessed for decline or healing. Additionally, they stated they expected treatments to be completed as ordered. During a telephone interview on 12/22/2025 at 2:26 PM, Nurse Practitioner #2 stated if a resident was admitted with any skin concerns/wounds, they would expect a Registered Nurse to assess them and then have the resident seen by the wound consultant. They stated it was important for skin to be reassessed for further breakdown. Nurse Practitioner #2 stated they were not aware that Resident #7 had any skin concerns, blisters, or scabs present and should have been. They stated they would have expected Resident #7's treatment to be completed as ordered. 2. Resident #8 had macular degeneration (loss of the central field of vision because of deposits of the retina), congestive heart failure (a chronic condition where the heart is too weak to pump blood), and type two (2) diabetes mellitus (disease affecting blood sugar). No comprehensive resident assessment completed. Nursing admission Assessment created 12/15/2025 documented Resident #8 was oriented and was unable to read newsprint with or without assistive devices. The Baseline Care Plan created 12/15/2025, documented Resident #8 was total dependence with staff performance of two (2) assist for self-care, and transfers. Cognition was alert/cognitively intact, communicated verbally, vision impaired and had double lumen PICC (peripheral inserted central catheter) to right upper extremity, had a foley catheter and was at risk for incontinence. During an observation on 12/18/2025 at 9:46 AM, Resident #8 had a PICC (peripheral inserted central catheter) line to their right anterior upper arm with a dressing dated 12/8, edges of clear dressing were rolled. Review of Nursing admission Assessment created 12/15/2025 at 2:35 PM, documented presence of a double lumen (two separate internal channels/tubes) PICC (peripheral inserted central catheter) to Resident #8's right upper extremity. Review of Physician's Order Form as of 12/22/2025 documented treatment order starting 12/15/2025 to flush PICC (peripheral inserted central catheter) line every eight (8) hours with five (5) milliliters of 0.9 percent Normal Saline, then five (5) milliliters of Heparin for maintenance. On 12/19/2025 orders initiated for treatment to change PICC (peripheral inserted central catheter) line dressing every week and as needed, measure arm circumference and external catheter length (one time a week); and to monitor PICC (peripheral inserted central catheter) line for signs/symptoms of infection every shift. Review of orders dated 12/15/2025 through 12/18/2025 revealed no orders upon admission to monitor and change Resident #8's PICC (peripheral inserted central catheter) line dressing. Review of Monthly TAR (Treatment Administration Record) between 12/01/2025 and 12/19/2025 documented an order to flush the PICC (peripheral inserted central catheter) line with ten (10) units of heparin protocol-maintenance, flush line every eight (8) hours with five (5) milliliters of 0.9 percent normal saline, then five (5) milliliters of heparin every eight (8) hours. Scheduled to be completed at 6:00 AM, 2:00 PM and 10:00 PM. Treatment Administration Record documented order was completed on 12/15/2025 at 10:00 PM and on 12/17/2025 and 12/18/2025 at 2:00 PM. Order was checked as done/completed only 3 out of 11 scheduled times between 12/15/2025 at 10:00 PM through 12/19/2025 at 6:00 AM. There was no evidence that the peripheral inserted central catheter dressing was changed, length of external catheter or arm circumference was completed on the treatment administration record since admission. Review of Progress Notes as of 12/19/2025 at 3:03 PM, revealed there was one (1) progress note dated 12/17/2025 at 5:33 PM by Registered Nurse Supervisor #3 that PICC (peripheral inserted central catheter) was flushed as ordered with ease, blood return, dressing dry, clean, intact, no signs/symptoms of infection. During an interview on 12/19/2025 at 2:15 PM, Registered Nurse #3 Supervisor, stated Register Nurses were responsible for the assessment and care of PICC (peripheral inserted central catheter) lines. They stated it was important for the PICC (peripheral inserted central catheter) line to be monitored for signs and symptoms of infection, flushed to maintain patency, checked for blood return, and to ensure dressing was clean, dry and intact. Registered Nurse Supervisor #3 stated a PICC (peripheral inserted central catheter) line dressing change should be completed every week and as needed to maintain the site, to keep clean and inspect insertion site for signs/symptoms of infection. They stated the initial nursing assessment of Resident #8's PICC (peripheral inserted central catheter) line was completed by them on 12/15/2025. Registered Nurse #3, Supervisor, stated the exposed external catheter of the PICC (peripheral inserted central catheter) line should have been measured upon admission and they should have noticed that the dressing had not been changed since 12/8 but had not, missed it. During an interview on 12/22/2025 at 1:38 PM, the Director of Nursing stated Registered Nurses were responsible for PICC (peripheral inserted central catheter) line care according to orders for flushing, and dressing changes to prevent infection and maintain functioning. They stated orders for maintaining, caring for PICC (peripheral inserted central catheter) lines should be obtained upon admission. During a telephone interview on 12/22/2025 at 2:26 PM, Nurse Practitioner #2 stated Resident #8's peripheral inserted central catheter line increased their risk for infection. Nurse Practitioner #2 stated they would expect peripheral inserted central catheter policies to be followed. They stated PICC (peripheral inserted central catheter) lines should be checked at least daily; dressing should be clean, dry, intact, and changed as needed by a Registered Nurse to reduce the risk of infection. They stated they would expect Resident #8's PICC (peripheral inserted central catheter) line to be flushed as ordered, once a shift to maintain patency. 10 NYCRR 415.12

Based on interviews and record review conducted during an Abbreviated survey during a Complaint Investigation (#2657322) the facility did not ensure that each resident received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well-being for one (1) (Resident #4) of one (1) resident reviewed. Specifically, Resident #4 with a history of expressing sadness and making negative statements was not provided a Psychiatry consult, consistent with prior Psychiatry recommendations. The finding is:The policy titled Behavior Assessment, Intervention and Monitoring dated 11/01/2019, documented the facility would provide and residents would receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services would be provided by qualified staff who had the competencies and skills necessary to provide appropriate services to the residents.During an interview on 12/19/2025 at 1:15 PM, the Administrator stated the facility had no policy related to following provider recommendations/orders or psychiatry consult recommendations. Resident #4 had diagnoses including Alzheimer's disease (progressive brain disorder that slowly destroys memory, thinking, reasoning skills, and abilities to perform activities of daily living), depression, and hearing loss. The Minimum Data Set (a resident assessment tool) dated 10/02/2025 documented Resident #4 was severely cognitively impaired, was usually understood, usually understands by others.The Comprehensive Care Plan dated 04/09/2025 documented Resident #4 was at risk for injury, with diagnoses of Alzheimer's and delirium due to known physiological condition. Interventions included Psychiatry/ Psychology consults as ordered. Resident #4 was at risk for altered mood state related to expressed sadness/anger/feeling empty with interventions to encourage/provide opportunities to verbalize feelings, explore positive strategies with resident, and recognize use of positive coping strategies. Additionally, the comprehensive care plan documented Resident #4 had the potential for side effects as related to being on psychotropic drug for depression and having expressed sadness. Interventions included but were not limited to assess mood, behavior patterns, and sudden change in Affect, attempt to re-direct behavior through diversional activities, positive reinforcement, behavior management programs, and Psychiatry evaluation/consultation as ordered. Review of nursing progress note dated 09/23/2025 at 3:30 PM, Registered Nurse #1 (former) Unit Manager documented Psychoactive medication use of recommendations. Most recent psych consult recommended to follow up in two (2) weeks. Unable to locate consult in chart. Please consider ordering. Will update psych on this. Nurse Practitioner #1 aware.Review of e-mail thread dated 10/22/2025 at 4:24 PM, Assistant Administrator received an e-mail from Account Executive from facilities psychiatry service documenting they were actively looking for a replacement for their psych services. If there were any emergencies, to reach out to their Medical Director who could conduct a telehealth visit. On 10/23/2025 at 11:02 AM, Assistant Administrator replied giving contact information for new Administrator. Review of nursing progress note dated 10/27/2025 at 10:55 PM, Registered Nurse #2 Nursing Supervisor documented Resident #4's family was very concerned and had brought to their attention that Resident #4 was making negative (suicidal) statements, and they requested a psychiatric evaluation. Registered Nurse #2 Nursing Supervisor initiated thirty (30) minute checks and Resident #4's door was to always remain open. Nurse Practitioner #1 was updated and came onto unit, spoke with Resident #4's family and addressed other concerns they had as well.Review of Record of Grievance/ Concern form dated 11/04/2025, Resident #4's family documented they had concerns regarding negative statements made by Resident #4. A family meeting was scheduled for 11/18/2025.Review of untitled facility document dated October 2025 to December 2025 documenting Resident #4's active and discontinued physicians' orders revealed there was no documented evidence that a psych consult had been ordered.During an interview on 12/18/2025 at 12:10 PM, Registered Nurse #2 Nursing Supervisor stated they spoke with Resident #4's family on 10/27/2025 about their concerns, implemented 30-minute checks, told staff to always keep Resident #4s door open, and updated Nurse Practitioner #1 on the families concerns and requests, and documented everything that they did.During an interview on 12/18/2025 at 1:19 PM, Registered Nurse #6 Unit Manager stated they started in the beginning of October and had received the grievance form from Resident #4's family in late October and brought it up in morning report. Resident #4 was added to the list to be seen by the psych provider.During an interview on 12/19/2025 at 9:34 AM, the Administrator and Assistant Administrator stated their current psych provider started about 3 weeks ago. Their previous psych provider was an outside contract and were available as needed but were difficult to get a hold of.During an interview on 12/19/2025 at 10:05 AM, the Director of Nursing stated there were not any previous psych consults on file for Resident #4. They stated there had been a request for an appointment for Resident #4 but could not say if an appointment was ever made.During a follow up interview on 12/19/2025 at 10:21 AM, Registered Nurse #6 Unit Manager stated providers put all their own orders in and consult with the Unit Managers if any new orders or recommendations were made after their visit with the residents. Registered Nurse #6 Unit Manager stated there was a meeting with Resident #4's family and they were made aware of their concerns and requests. They stated Nurse Practitioner #1 saw Resident #4 after their concerns were brought up. Nurse Practitioner #1 evaluated Resident #4 and started a new medication for them, but the provider never put an order in for Resident #4 to see a psych provider. During an interview on 12/19/2025 at 10:51 AM, Director of Social Work stated they were not aware that Resident #4 had negative statements and was seen by Nurse Practitioner #1 who made a recommendation for a psych consult until the family meeting on 11/18/2025. They stated Resident #4's social worker was new and did not understand the protocol for that type of situation, did not communicate to them Resident #4 had made negative statements. Director of Social Work stated when a resident was having negative thoughts they should be assessed by nursing, the social worker should do an assessment, then they should be seen by a provider who would make any recommendations to see a psych provider.During a telephone interview on 12/19/2025 at 11:15 AM, Registered Nurse #1 (former) Unit Manager stated they left the facility at the end of September, but prior to that family had brought up concerns about Resident #4's mental health. They stated Resident #4 was seen by the psych provider in the facility prior, and the progress note written on 09/23/2025 was regarding a follow up appointment recommended by the previous psych provider. The previous psych provider stopped showing up, so there was a period the facility did not have a psych provider. There were also changes in social workers, so there was a possibility there had been a delay in treatment due to that.During an interview on 12/19/2025 at 11:30 AM, the Administrator stated they started at the end of September 2025 and the psych providers stopped coming in around that time. There was a turnover with finding a new psych provider, so they reached out to the agency they used for psych with their concerns.During a follow up observation and interview on 12/19/2025 at 12:19 PM, the Administrator stated the Account Executive reached out at the end of October 2025 and the facility they were looking for a replacement for a psych provider for them. The Administrator stated if they were aware of Resident #4's negative statements, they would have sent a referral to an outside psych provider in the interim or sent them out to the hospital to be evaluated, if that was warranted. Additionally, the Administrator stated they did not see any social work notes in Resident #4's progress notes following up on the negative statements, and they would have expected an evaluation to have been completed. There was a good chunk of time recently that the facility only had one social worker, so things were not communicated correctly, and some things were missed. The Administrator reviewed Nurse Practitioner #1's note from 10/28/2025, stated Nurse Practitioner #1 made a recommendation for Resident #4 to see a psych provider; they would have expected Nurse Practitioner #1 to have put an order in for a psych consult so that nursing could follow up on it. They stated they were not sure why Resident #4 had seen psych prior without an order in place.During an interview on 12/19/2025 at 1:17 PM, the Director of Nursing stated the providers saw residents and put in any new orders or changes to orders themselves. They expected the providers to update Unit Managers on the new orders or recommendations. The Director of Nursing stated they would have expected social work to do a follow up evaluation on Resident #4 after being made aware of their negative statements, and have nursing send them out to the hospital if they could not be seen by psych in a timely manner. Additionally, the Director of Nursing stated they started working in the facility in September, they did not know why there was never an order placed previously for Resident #4 to have a psych consult.During a telephone interview on 12/19/2025 at 1:57 PM, Nurse Practitioner #1 stated they assessed Resident #4 after they were made aware of the families concerns about the negative statements. They stated the facility did not have a psych provider in house at the time of the family's request, so they did not put an order into the system, but did write a recommendation for Resident #4 to see a psych provider so that when the facility had one, Resident #4 could be seen. Nurse Practitioner #1 stated they were unaware Resident #4 had been seen by the prior psych provider and would have expected the facility to follow through with the previous recommendation to see psych in two (2) weeks if that was the previous recommendation in September 2025. They stated there should have been an order in place already if Resident #4 was being seen by psych. They added, It was an issue they came across at the facility often. Additionally, Nurse Practitioner #1 stated they started Resident #4 on Namenda (medication used to treat Alzheimer's symptoms) because they felt there was a progression of their disease, and they ordered a urinalysis to check for a urinary tract infection. They stated they did not feel Resident #4 was a harm to themselves or others, or else they would have taken more action right away.During a telephone interview on 12/19/2025 at 2:11 PM, Resident #4 family stated they were concerned with Resident #4's mental health and had requested them to be seen by a psych provider, the facility never got back to them on the request.10 NYCRR 415.12(f)(1)

Based on observation, interview, and record review completed during an Abbreviated Survey (#2655726) the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases and infections for two (2) (Resident #8 and Resident #9) of five residents reviewed for infection control. Specifically, Resident #8 was on enhanced barrier precautions (interventions designed to reduce transmission of multi-drug-resistant organisms, including gown and glove use during high contact resident care activities) and staff did not wear proper personal protective equipment (gowns) during hands-on care while bathing, performing catheter care, changing brief, and changing linens; Certified Nurse Aide #7 did not change their gloves and perform hand hygiene prior to handing clean brief, bed remote after performing fecal incontinent care (Resident #9). The findings are:An undated policy titled Enhanced Barrier Precautions, documented Enhanced Barrier Precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. Enhanced Barrier Precautions employ targeted gown and glove use during high contact resident care activities. Gloves and gown are applied prior to performing the high contact resident care activity. Examples of high-contact resident care activities requiring the use of gown and gloves include bathing; providing hygiene; changing linens; changing briefs; device care (urinary catheter) and wound care. Enhanced Barrier Precautions are indicated for residents with wounds and/or indwelling medical devices regardless of multi-drug-resistant organism colonization. The policy titled Handwashing/Hand Hygiene revised 04/01/2020, documented hand hygiene the primary means to prevent the spread of infections. Wash hands with soap and water for the following situations: when hands are visible soiled, and after contact with a resident with infectious diarrhea. Use an alcohol-based hand rub; or soap and water for the following situations included: before and after direct contact with residents, before moving from a contaminated body site to a clean body site during resident care, after contact with blood or bodily fluids, after contact with objects in the immediate vicinity of the resident, and after removing gloves. Enhanced Barrier Precautions signs documented staff must wear gloves and a gown for the following High-Contact Resident Care Activities: Dressing; Bathing/Showering; Transferring; Changing Linens; Providing Hygiene; Changing briefs or assisting with toileting; Device care or use: central line, urinary catheter, feeding tube, tracheostomy; and Wound Care: any skin opening requiring a dressing. 1.Resident #8 had macular degeneration (loss of the central field of vision because of deposits of the retina), congestive heart failure (a chronic condition where the heart is too weak to pump blood), obesity (excessive amount of body fat) and type two (2) diabetes mellitus (disease affecting blood sugar). No comprehensive resident assessment was completed. Nursing admission assessment dated [DATE] documented Resident #8 was oriented and was unable to read newsprint with or without assistive devices, had a double lumen PICC (peripheral inserted central catheter) to right upper extremity, a foley catheter (insertion of tube to drain urine) and a surgical wound.The Baseline Care Plan dated 12/15/2025, documented Resident #8 was total dependence with staff performance of two (2) assist for self-care, bed mobility, and transfers. The resident was alert/cognitively intact, communicated verbally, their vision was impaired/blind, they had a double lumen PICC (peripheral inserted central catheter) to their right upper extremity, a foley catheter, was at risk for incontinence and had a wound requiring a wound vac.During an observation on 12/18/2025 at 2:14 PM, a sign for enhanced barrier precautions was posted for Resident #8 outside their room and directed staff to utilize gowns and gloves for hands on care. Certified Nurse Aides #2 and #5, were observed at the resident's bedside wearing gloves, but no gowns while providing hands on care including handling of linen for washing and drying the resident during a bed bath, turning and positioning resident in bed, handling soiled bed linen and Certified Nurse Aide #2, performed foley catheter care. Resident had a dressing intact to their left calf and a peripheral inserted central catheter to their right upper arm.During an interview on 12/18/2025 at 2:45 PM, Certified Nurse Aide #5 stated they should have worn a gown while assisting Certified Nurse Aide #2 with providing hands on care to Resident #8 because they were on enhanced barrier precautions. They stated it was important to follow enhanced barrier precautions for infection control. Certified Nurse Aide #5 stated they were rushing to help Certified Nurse Aide #2 and forgot to apply a gown. They stated they should have been wearing a gown for infection control, to protect them and the resident.During an interview on 12/18/2025 at 2:50 PM, Certified Nurse Aide #2 stated they should have put all that stuff on gown, mask, shoe covers because they touched Resident #8 foley catheter. Certified Nurse Aide #2 was unable to tell surveyor what enhanced barrier precautions were or how to distinguish between different precautions (droplet, airborne, contact) and what personal protective equipment was to be used based on precautions indicated. During an interview on 12/18/2025 at 3:01 PM, Licensed Practical Nurse #2 stated a gown, and gloves were always to be worn when a resident was on enhanced barrier precautions for infection control. They stated Resident #8 was on enhanced barrier precautions because they had a foley catheter and a PICC (peripheral inserted central catheter) present. They stated the nurses were responsible to ensure the aides followed precautions posted. During an interview on 12/19/2025 at 2:15 PM, Registered Nurse #3, Supervisor, stated residents that have a foley catheter, a PICC (peripheral inserted central catheter), or wounds should be on enhanced barrier precautions and gown, gloves, and mask should be worn when performing hands on care. They stated Certified Nurse Aides #2 and #5 should have been wearing gowns while performing care on Resident #8 to protect themselves and the resident.2. Resident #9 had diagnoses that included hemiplegia (paralysis on one side of body) and hemiparesis (weakness of one side of body) following cerebral infarction (stroke) affecting left side, adjustment disorder, and absence of right leg above knee. The Minimum Data Set (a resident assessment tool) dated 08/15/2025 documented the resident usually understood, usually understands, and was cognitively intact. Resident #9 was dependent for toileting hygiene, bed mobility and had frequent urinary incontinence. The Careplan Report dated 08/12/2025, documented the resident had a self-care deficit, interventions included toileting per occupational therapy recommendations. The undated Care Profile (a guide used by staff to provide care) dated 12/22/2025, documented Resident #9 was oriented, independent with decision making, required two (2) caregivers at all times and toileting schedule upon demand. The Activity of Daily Living assessment dated [DATE], documented for toileting hygiene the resident was dependent with two (2) helpers; one (1) helper to assist with positioning, one (1) helper to assist with peri care and brief management. During an observation on 12/22/2025 at 10:42 AM, Certified Nurse Aides #7 and #8 applied gloves, Certified Nurse Aide #7 provided fecal incontinence care for Resident #9 removing a large amount of soft feces. Certified Nurse Aide #7 did not remove their gloves and perform hand hygiene prior to applying a clean brief, applying barrier cream to the resident's skin, handling clean bed linens and adjusting the bed height with the remote control. During an interview on 12/22/2025 at 11:05 AM, Certified Nurse Aide #7 stated they were just responsible to wash their hands before and after incontinent care. They stated if their gloves were dirty, they should be removed and hands washed. Certified Nurse Aide #7 stated they should not have touched anything clean wearing the same gloves they performed incontinent care with due to cross contamination, for infection control. During an interview on 12/22/2025 at 11:18 AM, Licensed Practical Nurse #4, Unit A Nurse Manager, stated gloves should be changed, hands washed or sanitized after performing fecal incontinent care. They stated dirty and clean material should not mix for infection control.During an interview on 12/22/2025 at 11:28 AM, Licensed Practical Nurse #3 stated gloves should be removed and hands washed as soon as possible after completing fecal incontinence care to prevent the spread of infection and cross contamination. During an interview on 12/22/2025 at 1:38 PM, the Director of Nursing stated they expect staff to follow enhanced barrier precautions and wear the appropriate personal protective equipment when providing care to prevent the spread on infection. They stated gloves should be removed and hand hygiene should be performed between handling something dirty and then clean to prevent cross contamination. 10 NYCRR 415.19(a)(1)(b)(4)

Based on observation, interview, and record review conducted during an Abbreviated Survey (Complaint #2637850) the facility did not ensure that, in accordance with professional standards and practices, they maintained medical records on all residents that were complete and accurately documented. Specifically, the controlled substance inventory records, for the nurses shift to shift counts, were not consistently signed off by two nurses on four (4) (South building second floor, and North building B, C and D units) of six (6) units observed.The findings are:The undated policy and procedure titled 4.0 Schedule II Controlled Substance Medication documented an inventory count of all controlled medications stored on each nursing unit shall be performed at each change of shift by both the incoming and outgoing nurse. Both nurses are responsible for the count and must sign the inventory count form.The form titled Controlled Substance Inventory Record dated 10/04/2016 documented all controlled substances are to be counted at the beginning and ending of each shift. Two signatures; that of the nurse coming on duty and that of the nurse going off duty, are to appear in the signature column. The nurse signing in is responsible for the security of all controls on that shift. That sheet is to be completed and returned to the HIM (unknown) office on Monday of each week.Review of the Controlled Substance Inventory Sheets revealed there were several blank spaces (149) in the signature column on the sheets from the South building, second floor (side one (1) and two (2)), and the North building Unit B, unit C and unit D between 12/1/2025-12/19/2025. During an interview on 12/19/2025 at 10:36 AM, Licensed Practical Nurse #1 reviewed the narcotic inventory record and stated the record was incomplete as there were missing signatures. The process for logging the narcotics was for both the oncoming and outgoing nurse to count the medication together prior to the exchange of the narcotic keys; reviewing the medication itself alongside the inventory record verifying its accuracy. Both nurses sign the inventory record verifying the medication count was accurate. A blank would indicate that someone did not complete the medication count and sign for their shift. If the count was off, the off-going nurse would need to check the cart, and they would call the supervisor together. Licensed Practical Nurse #1 stated they would not accept the keys if the count was off. During an interview on 12/19/2025 at 12:52 PM, Licensed Practical Nurse #7 stated they always signed in and out on the Controlled Substance Inventory Sheet. They stated a blank on the form could have been from the nurse getting distracted or they forgot to sign. Licensed Practical Nurse #7 reviewed the inventory sheet and stated there were incomplete because they were missing signatures. They stated it was important to know who had access to the narcotics.During an interview on 12/19/2025 at 12:57 PM, Registered Nurse #6 Unit Manager, stated the nurses were supposed to count off with each other and sign off on the Controlled Substance Inventory Sheet before handing off the keys. When they take the keys, they were saying the medication count was correct and verifying with their signature. If there were blanks, they may have forgotten to sign but they may not have counted. Registered Nurse Unit Manager #6 reviewed the narcotic inventory sheets and stated they were incomplete as they were missing signatures.During an interview on 12/19/2025 at 1:22 PM, the Director of Nursing stated the nurses should be standing next to each other, both counting the controlled medications and signing each time. If the nurse didn't sign off, they would be responsible for a missing medication. There was no good reason for the nurses not signing off. There was not a staffing issue. The Director of Nursing stated there needed to be some re-education to all the nurses. They expected there to be a signature for every shift, even if the nurse was working a double.During an interview on 12/19/2025 at 2:15 PM, Registered Nurse #3, nursing supervisor, stated the narcotics should be counted with both nurses present. The signatures were important for accountability. They stated the nurses were not always signing the sheets like they should.During an interview on 12/19/2025 at 2:59 PM, Licensed Practical Nurse #5 stated they always signed between shifts on the count sheet. They did not know why some were blank but thought it might be from different staff floating to help the unit. They stated that the nurse that was leaving was responsible for any missing narcotics, so the oncoming nurse should not take the keys without counting.During an interview on 12/19/2025 at 1:01 PM, Licensed Practical Nurse #8 stated they worked a double on 12/18/2025, and they counted and verified medication but did not sign between the double shifts. 10 NYCRR 415.22(a)(1-2)

Based on observation, and interview conducted during an Abbreviated survey (Complaint #NY00365545 and #NY00373162) the facility did not ensure that there were housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Second Floor) of two resident floors in the South Campus and one (C Wing) of four resident wings in North Campus. Specifically, there were dirty and sticky floors; stain ceiling tiles; window blinds with missing or damaged slats; residue (substance/film) on the surface in shared bathroom sink; room labeled detailed- full clean with debris on floor, in drawers, on bed frame, and bathroom sink; bedpans, wash basins on floors in shared bathrooms (Second Floor-South Campus); window blinds with missing or damaged slats; soiled, damaged fall mat; soiled wall and toilet seats in resident rooms (C-Wing). The findings are: The policy titled Cleaning and Disinfecting Resident's Rooms dated 11/1/2017, documented that resident rooms housekeeping surfaces such as floors and tabletops will be cleaned on a regular basis; environmental surfaces shall be disinfected or cleaned on a regular basis or when visibly soiled; and walls, blinds, and window curtains will be cleaned when these surfaces are visibly contaminated or soiled. Terminal room cleaning is done when the resident is transferred, discharged , or expires. Clean all high-touch furniture items (bedside tables, overbed tables, chairs and beds). Clean all high-touch personal use items (lights, phones, call bells, bedrails, etc.). The policy titled Cleaning and Disinfecting Environmental Surfaces dated 3/10/2020, documented that environmental surfaces shall be cleaned on a regular basis, when spills occur, and when the surfaces are visibly soiled. The policy titled Quality of Life-Home Environment dated 6/1/2017, documented residents are provided with safe, clean, comfortable and homelike environment. The facility staff and management shall maximize, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment. The job description of a Housekeeper documented they were to implement required housekeeping procedures in an efficient, cost-effective manner meeting all federal, state, and local requirements while providing a safe environment for residents. Specific Job Function: maintain resident rooms by cleaning restroom, walls, baseboards, moving furniture to dry and wet mop floors, dust and clean all furniture and fixtures in resident rooms and terminal cleaning of resident room upon transfer, discharge, or death. 1. South Campus building observations on 5/6/25 between 9:40 AM to 11:35 AM revealed the following on the second floor: -Resident room [ROOM NUMBER]- there was food debris, sugar packets along the wall baseboard behind bed and under nightstand; the room floor was dirty and dull; two unlabeled bedpans and one wash basin under sink in shared bathroom. - Resident room [ROOM NUMBER]- tissues, paper and food debris on the floor and under the bed in room; floor dirty, dull and tacky. -Resident room [ROOM NUMBER]- a paper was posted outside the room on the name plate and documented Detail-full clean, date May 5-25 by Housekeeping Aide #1. The floor was dull, dirty with bright pink debris present; the call bell cord was dirty with black debris and a piece of cloth white tape wrapped around it. The bed control cord with scrunched up dirty appearing plastic. The bed frame was soiled with dried liquid and gray dust like matter. There was toilet paper wrapped behind sink faucet, fecal matter in the toilet; and debris, linens in closet and drawers in room. -Resident Rooms #222, 223, 227- the window blinds had missing or damaged slats. room [ROOM NUMBER] had no blind over left side of window. -Resident room [ROOM NUMBER]- had unlabeled bed pans on floor in a shared bathroom under the sink; thick grayish colored residue in the bathroom sink; brown/yellow bowing and stained ceiling tile in bathroom over toilet with additional surrounding stained ceiling tiles. South Campus building observations on 5/7/25 between 8:45 AM to 9:49 AM revealed the following on the second floor: -Resident room [ROOM NUMBER]- the floor was dirty and dull; two unlabeled bedpans, one wash basin remained under sink in shared bathroom. -Resident room [ROOM NUMBER]- the floor was dirty, dull and tacky. -Resident room [ROOM NUMBER]- the unlabeled bed pans on floor in shared bathroom under the sink; thick grayish colored residue/physical scum in bathroom sink; brown/yellow bowing, stained ceiling tile in bathroom over toilet with surrounding stained ceiling tiles all remained. -Resident Rooms #222, 223, 227- had blinds with missing or damaged slats. Resident room [ROOM NUMBER] had no blind over left side of window. During an interview on 5/6/25 at 10:11 AM, Housekeeping Aide #1 stated housekeeping was responsible for thoroughly cleaning the resident's rooms every day. They stated they were responsible for cleaning the resident's bathroom which included cleaning inside and around toilets, cleaning sinks, emptying garbage, sweeping and mopping the floor. They stated if they noticed anything in disrepair, they would notify maintenance. During an interview and observation on 5/6/25 at 10:15 AM, the Housekeeping Supervisor stated the Housekeeping Aides should clean the rooms like their family member was in there. They stated all touch surfaces should be wiped, garbage should be removed, surfaces dusted, bathroom sink, toilets cleaned, floors swept and mopped every day. The Housekeeping Supervisor stated a room that was labeled as detailed meant the room had been cleaned and was ready for the next admission. Upon observing the handwritten sign posted on the name plate room [ROOM NUMBER], the Housekeeping Supervisor stated the room should be ready for a new admission. The Housekeeping Supervisor observed the inside of the room and stated there was nail polish on the floor; the plastic on the bed control cord was very dirty and should have been removed; the call bell cord should have been wiped clean and be free of debris for infection control purposes. They stated nothing should have been left in the room, and everything should have been wiped cleaned with no debris left behind. Additionally, they stated the floors were dull and needed to be buffed. During a follow up interview on 5/6/25 at 10:30 AM, Housekeeping Aide #1 stated they completed the detail on room [ROOM NUMBER] on 5/5/25 at 12:30 PM. They stated they had three other rooms to detail yesterday (5/5/25), and added room [ROOM NUMBER] would not be acceptable to their family because it was dirty. They stated staff utilize unoccupied resident rooms, bathrooms after they were cleaned and stash linen in the drawers. During an interview on 5/6/25 at 10:44 AM, Resident #2 stated their room was not homelike. They stated the floor in their room was disgusting, dirty as hell and the blinds didn't fit the window. They stated they have only seen a housekeeper once since they have been there. During a follow up interview on 5/6/25 at 11:04 AM, the Housekeeping Supervisor stated there should not be food debris, sugar packets on resident floors, behind beds or dressers, and under beds. They stated floors with debris present were not clean and could attract bugs or rodents. During an interview on 5/6/25 at 11:09 AM, Certified Nurse Aide #1 stated the floors on the second floor needed some attention. They stated the floors were not desirable and they do not shine. They stated floors should be cleaner for infection control purposes, and to be more environmentally pleasing to people coming into facility. Additionally, they stated when they notice window blinds in disrepair, they notify the nurse or unit clerk. During an interview on 5/6/25 at 11:17 AM, Registered Nurse #1 stated unclean floors were an infection control concern. They stated unclean (sticky, cluttered, debris) on floors were a concern for residents and families. They stated residents should live in a clean space. During an interview on 5/6/25 at 11:20 AM, Licensed Practical Nurse #4, Rehabilitation Nurse Manager, stated they had concerns with the floors not looking clean, and looking dull on the second floor. They stated they have brought this concern up to the Housekeeping Supervisors and during morning report. They stated they expected rooms to be clean, so they were nice and presentable to the residents. Additionally, they stated they have told staff not to go into rooms that have been detailed but that housekeeping should still check all the rooms every day. During an observation of Resident room [ROOM NUMBER]'s bathroom and interview on 5/7/25 at 9:11 AM, Certified Nurse Aide #3 stated bedpans and wash basin should not be on the floor; they were not labeled and did not know who they belonged to. They stated bedpans and wash basins should be labeled to prevent cross contamination and stored separately in the resident's bottom drawer. During an observation of Resident room [ROOM NUMBER] bathroom and interview on 5/7/25 at 9:15 AM, Certified Nurse Aide #1 stated the unlabeled bedpans on the bathroom floor should be put in the garbage. Bedpans should be labeled and not stored on the floor for infection control purposes. They stated the residue in the sink was an environmental issue and would not be homelike in their home. Additionally, they stated the ceiling tile needed to be replaced because it was stained and not homelike. During an observation of Resident room [ROOM NUMBER]'s bathroom and interview on 5/7/25 at 9:24 AM, Registered Nurse #1 stated the bedpans on the floors in the bathrooms were an infection control concern and should not be stored there. They stated the ceiling tile looked like it could come down on someone's head and was a safety issue and the sink was dirty and was not homelike. During an observation and interview of Resident room [ROOM NUMBER] bathroom on 5/7/25 at 9:35 AM, the Housekeeping Supervisor stated the dirty condition of the bathroom sink made them pissed. They stated they wouldn't brush their teeth in that sink. They stated there should not be build up in the sink, it should be cleaned every day for infection control purposes and to prevent dirt buildup. Additionally, they stated the ceiling tile was dangerous, it could fall on staff or a resident and there could be mold on it. During an interview on 5/7/25 at 9:45 AM, Maintenance Assistant stated the stained ceiling tile in the bathroom of room [ROOM NUMBER] was from water damage. They stated stained ceiling tiles were not homelike and not environmental clean. During an interview on 5/7/25 at 9:49 AM, the Director of Housekeeping and Laundry stated they expected housekeeping staff to do a fine job and follow policy when cleaning resident rooms every day. They stated this was the resident's home and their environment should be clean. Additionally, they stated they have had staff issues and have had to wait for cleaning supplies. During an interview on 5/7/25 at 10:06 AM, the Director of Maintenance stated they would expect nurses, nurse managers to report things to maintenance if there was an issue in a resident room. They stated they were aware of the condition of the window blinds in resident rooms, and if they had any blinds available, they would replace them. They stated there were no window blinds available and there were issues with purchasing. They stated there should be blinds on windows for privacy and for a homelike environment. Additionally, they stated ceiling tiles are part of the homelike environment and should not be stained. They stated they were made aware of stained ceiling tiles through walking rounds and reports from staff. 2. North Campus C-Wing observations on 5/6/25 between 12:15 PM to 1:37 PM revealed the following: -Resident room [ROOM NUMBER]- the window blinds had damaged slats; and there was a urine odor to the room. -Resident room [ROOM NUMBER]- there was a fall safety mat in disrepair with foam exposed, edges curling/peeling up and was soiled; there was buildup of tan/brown dried substance on the close wall; the toilet seat in bathroom was dirty with brown splatter. North Campus C-Wing observations on 5/7/25 between 10:17 AM to 11:03 AM revealed the following: -Resident room [ROOM NUMBER]- the window blinds had damaged slats. -Resident room [ROOM NUMBER]- the toilet seat in bathroom remained soiled with brown splatter. During an interview on 5/6/25 at 12:16 PM, Resident #4 stated this place is a (expletive) hole, smells and was not homelike. At 1:26 PM, Resident #4 stated it bothered them that blinds were damaged because it let too much sunlight in. During an interview on 5/6/25 at 12:51 PM, Licensed Practical Nurse #2 stated the cleanliness of the building was terrible. The building was old, run down, and the substance on floors cannot be removed. They stated the staff try their best to make it homelike. Additionally, they stated if a staff member sees a mess, they should clean it up or make housekeeping aware. During an observation and interview on 5/6/25 at 1:12 PM, Certified Nurse Aide #8 stated the tan/brown debris in room [ROOM NUMBER] on the closet wall looked like poop or chocolate. They stated housekeeping was responsible for wiping down the walls. Certified Nurse Aide #8 stated the floor mat should be replaced because someone could trip over the curling corner and that foam should not be exposed. They stated it was not sanitary or homelike to for the walls and floors to be dirty. During an observation and interview on 5/6/25 at 1:19 PM, Licensed Practical Nurse #3 stated there was chocolate or poop on the wall and the floor mat in room [ROOM NUMBER] needed to be removed. They stated the floor mat edge was curled up posing a tripping hazard, and the exposed foam on the mat could not be cleaned properly. They stated this was not homelike and needed to be cleaned for infection control purposes. During an observation and interview on 5/6/25 at 1:30 PM, Licensed Practical Nurse #1, C-Wing Nurse Manager, stated they did not know what the tan/brown substance was on the wall in room [ROOM NUMBER] but it needed to be cleaned. They stated it was important to maintain cleanliness to prevent the spread of germs and because this was the resident's home. Additionally, Licensed Practical Nurse #1, C-Wing Nurse Manager, stated the floor mat in room [ROOM NUMBER] was dirty, and it needed to be replaced. They stated it was unsanitary and not homelike. During an interview on 5/7/25 at 10:30 AM, Licensed Practical Nurse #3 stated the toilet seats should be clean for infection control purposes. During an observation and interview of Resident room [ROOM NUMBER]'s bathroom on 5/7/25 at 10:41 AM, Certified Nurse Aide #5 stated the brown debris on the toilet seat looked like poop, was degrading, unsanitary, and needed to be cleaned. They stated it was everyone's job, if aides see it, they should wipe it clean and let housekeeping know. During an observation and interview of Resident room [ROOM NUMBER] bathroom on 5/7/25 at 10:54 AM, Housekeeping Aide #2 lifted the toilet seat and revealed brown splatter under the toilet seat. Housekeeping Aide #2 stated it had been a while since they worked C-Wing and that the housekeepers were responsible and should be cleaning the toilets every day for infection control purposes. During an interview on 5/7/25 at 11:03 AM, Licensed Practical Nurse #1, C-Wing Nurse Manager, stated they expected nursing staff to wipe down and sanitize toilet seats when they notice there were dirty and then have housekeeping follow behind. During an interview on 5/7/25 at 2:05 PM, the Director of Nursing stated they expected wash basins, bed pans to be labeled and put away after use. They stated they should not be stored on the floor for infection control purposes. They stated they expected that resident rooms to be thoroughly cleaned by housekeeping between residents. The Director of Nursing stated if staff noticed any environmental concerns, they would expect them to notify the nurse manager or maintenance, so the concern was addressed. During an interview on 5/7/25 at 2:20 PM, the Assistant Administrator stated they expected the policy to be followed for daily cleaning of resident rooms and that maintenance was notified of concerns. 10 NYCRR 415.5(h)(1)(2)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00365545) completed 5/7/2025, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (Residents #1) of three residents reviewed. Specifically, Resident #1 was unshaven with facial hair longer than ¼ inch. The finding is: The facility policy and procedure titled Activities of Daily Living dated 11/18/24, documented the facility will ensure a resident is given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living. The facility will provide care and services for hygiene-bathing, dressing, grooming and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain grooming, and personal hygiene. The facility policy and procedure titled Quality of Life-Dignity dated 2/2021, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing their self-esteem and self-worth. Residents shall be groomed as they wish to be groomed (hair styles, nails, facial hair, etc.). Resident #1 had diagnoses which included dementia, cerebral infarction (stroke), and seizure disorder. Review of a Minimum Data Set (a resident assessment tool) dated 12/3/24 documented the resident had severe cognitive impairment and required supervision or touch assist for personal hygiene. Review of a Minimum Data Set, dated [DATE] documented resident sometimes understood, sometimes understands, had severe cognitive impairment and required partial/moderate assistance for personal hygiene. Resident #1 had no rejection of care. Review of the comprehensive care plan initiated on 11/29/24 documented Resident #1 required extensive assist of one with self-care and had a deficit in activities of daily living. An intervention dated 2/18/25 documented personal hygiene was to be done per occupational therapy recommendations. Review of Occupational Therapy Evaluation and Plan of Treatment certification period 2/18/25-3/19/25, documented Resident #1 required partial/moderate assistance with personal hygiene. Review of Resident #1's Progress Notes dated 11/30/24 - 3/1/25 revealed no evidence that the resident refused to be shaved. There were no progress notes from 3/2/25 to 5/6/25. A Bath and Shower Sheet documented Resident #1 received a shower on 5/2/25 and 5/6/25 with no documented indication whether the resident was shaved. No documented evidence that the resident refused to be shaved. During intermittent observations on 5/6/25 at 12:41 PM, and 1:37 PM, and on 5/7/25 at 10:20 AM, Resident #1 had facial hair present longer ¼ inch and appeared unkempt. During an interview and observation on 5/7/25 at 10:22 AM-10:26 AM, Certified Nurse Aide #5 stated shaving usually occurred on the resident's shower days or as needed. Certified Nurse Aide #5 stated Resident #1 should be shaved on their shower days Friday mornings and Tuesday evening, and sometimes Resident #1's family member would also shave them. Upon observing Resident #1, Certified Nurse Aide #5 stated they could use a shave and looked scruffy. Certified Nurse Aide #5 stated it was important for residents to be shaved to feel clean, decent and for dignity. During an interview on 5/7/25 at 10:30 AM, Licensed Practical Nurse #3 stated the nursing staff focuses on shaving of the residents on their shower days. They stated shaving if needed should be done daily for dignity. During an interview on 5/7/25 at 10:32 AM, assigned Certified Nurse Aide #4 stated residents were shaved twice a week on shower days or when needed for hygiene purposes. They stated Resident #1 always needed to be shaved; their hair grew fast. They stated Resident #1 was already out of bed upon the start of their shift today. During an interview on 5/7/25 at 11:03 AM, Licensed Practical Nurse #1, Nurse Manager, stated shaving was part of the resident's shower and Resident #1 should have been shaved yesterday for appearance and dignity. They stated Resident #1 was scheduled for their shower on Tuesday evening and the nurse should have verified Resident #1 was shaved. They stated if a resident refused to be shaved it should be documented. Licensed Practical Nurse #1, Unit Manager, stated they have personally shaved Resident #1 and that it was difficult to do with the facility razors. During a telephone interview on 5/7/25 at 12:21 PM, Licensed Practical Nurse #5 stated Resident #1 received their shower yesterday evening and that if Resident #1 needed to be shaved the Certified Nurse Aide should have shaved them as it was part of grooming and for dignity. Licensed Practical Nurse #5 stated they checked Resident #1's skin last evening but did not believe they were shaved and did not know why. During a telephone interview on 5/7/25 at 12:28 PM, Certified Nurse Aide #7 stated they gave Resident #1 their shower yesterday evening and forgot to shave them. They stated it was important for residents to be shaved so they felt and looked good. They stated shaving was a part of grooming and dignity. During an interview on 5/7/25 at 2:05 PM, the Director of Nursing stated shaving should be completed by the certified nurse aides or nurses on the resident's shower day or whenever necessary to maintain the resident's dignity. 10NYCRR 415.12(a)(3)

Based on interview, observation and record review conducted during a Complaint investigation (Complaint #NY00353284, #NY00329150) during the standard survey completed on 10/28/24, the facility did not ensure that there was sufficient nursing staff on a 24-hour basis to provide care for all residents. Specifically, one of one facility reviewed for sufficient staffing the facility did not meet their assessed minimum staffing levels for Certified Nurse Aides on 8/24/2024, 9/8/2024, 9/16/2024, 9/22/24, 10/5/2024, 10/6/2024, and 10/20/2024 to meet the needs of the residents. The finding is: Refer to F 677 Activities of daily living care for dependent residents. The policy and procedure titled Nursing Department Staffing dated 2/17/2021 documented the facility provides adequate staffing to meet needed care and services for our resident population. It documented that Certified Nurse Aides are available on each shift to provide the needed care and services of each resident as outlined in the resident's comprehensive care plan. The policy and procedure titled Resident Rights dated 3/1/2017 documented that residents have the right to have communication with and access to people and services, both inside and outside the facility. The resident council meeting minutes dated 7/31/2024 documented that residents were concerned about low staffing and how it impacted their care and treatments. The resident council meeting minutes dated 9/19/2024 documented that multiple residents stated that nursing staff was shorthanded and affected how residents were treated. The resident council meeting minutes dated 10/17/2024 documented the residents were concerned that being short staffed affected personal hygiene and showers were not a priority. The resident census analysis report for August 2024 documented that on 8/25/2024 there were 169 residents in the facility. The resident census report for September 2024 documented that on 9/8/2024 and 9/16/24 there were 167 residents in the facility; and on 9/22/2024 there were 171 residents in the facility. The resident census analysis report for October 2024 documented that there were 172 residents in the facility on 10/5/2024, 10/6/2024, and 10/20/2024. The facility assessment dated [DATE] documented minimum staffing levels for Certified Nurse Aides were 12 aides on the day shift (7:00 AM to 3:00 PM), 10 aides on the evening shift (3:00 PM to 11:00 PM), and five aides on the night shift (11:00 PM to 7:00 AM) for a facility census of 171 residents. The facility nursing daily staffing sheets documented the following: 8/25/2024 - 10 Certified Nurse Aides on the day shift (down 2). 9/08/2024 - 9 Certified Nurse Aides on the day shift (down 3) and 8 Certified Nurse Aides on the evening shift (down 2). 9/16/2024 - 11 Certified Nurse Aides on the day shift (down 1). 9/22/2024 - 5 Certified Nurse Aides on the day shift (down 7). 10/5/2024 - 10 Certified Nurse Aides on the day shift (down 2). 10/6/2024 - 10 Certified Nurse Aides on the day shift (down 2). 10/20/2024 - 8 Certified Nurse Aides on the day shift (down 4) and 9 Certified Nurse Aides on the evening shift (down 1). During an interview on 10/21/2024 at 10:03 AM, Resident #70 stated that over the weekend there were two Certified Nurse Aides working on the day shift. They stated that they wanted to get out of bed at 10:00 AM but did not get out of bed until 2:30 PM. Resident #70 stated that sometimes they don't get out of bed at all because there was not enough staff During an interview and observation on 10/22/2024 at 10:21 AM, Resident #71 stated that the staff were too busy to clean their fingernails or shave them. They stated they were embarrassed about the chin hairs, their nails were ugly and would like them cleaned. Resident #71 was observed with long, white whiskers on their chin and long nails with brown debris underneath. During an interview on 10/22/2024 at 11:16 AM, the Staffing Coordinator stated they have trouble staffing the facility on the weekends. They stated they try to get staff to come and work shifts but that doesn't always happen. During an interview on 10/24/2024 at 10:57 AM, Certified Nurse Aide #3 stated they cannot get showers or nails done when there were only two aides working on a shift. They stated they try to get showers completed by the next day but that was not always possible. During an interview on 10/25/2024 at 9:31 AM, Licensed Practical Nurse #1 stated they cannot get their charting done on residents when there were not enough Certified Nurse Aides working. They stated they have to help the Certified Nurse Aides transfer patients and other things which take away from their nursing duties. During an interview on 10/25/2024 at 11:03 AM, Registered Nurse Nursing Supervisor #1 stated that it was very difficult for them to be on a medication cart and be a supervisor at the same time. If they have to do an assessment on a resident, they have to leave the floor and the Certified Nurse Aides have to watch the floor until they come back. Then the other floor nurse must cover the floor they were working on as well. During an interview on 10/25/2024 at 11:04 AM, Certified Nurse Aide #4 stated they work double shifts because the facility was short staffed. They stated the weekends were terrible. They stated they can't get people out of bed if they only have two aides working on a unit. During an interview on 10/25/24 at 11:18 AM, Registered Nurse Nursing Supervisor #2 stated they cannot do what they need to do in providing care for the residents. They stated if they were on a medication cart, watching a floor, and being a supervisor at the same time, a 16-hour shift turns into 18 hours just to complete everything they need to complete. During an interview on 10/25/24 at 1:12 PM, the Assistant Director of Activities stated there were times when residents miss activities because there wasn't enough staff to change the resident's brief or to toilet the residents. They stated residents come in late or miss activities a couple of times a week because there wasn't enough staff to take care of them. During an interview on 10/25/2024 at 1:23 PM, the Director of Nursing #1 stated they do not have enough staff to take care of the residents' needs on a daily basis. They stated that they have been trying to get staffing for the facility, but it has been very difficult. During an interview on 10/28/2024 at 9:20 AM, the Interim Administrator stated the issue of not having enough Certified Nurse Aides was that personal hygiene and care was getting missed for the residents. This included showers, nail care, and shaving. They stated they have been working getting more staff. During an interview on 10/28/2024 at 10:48 AM, Licensed Practical Nurse Unit Manager #2 stated they cannot get resident care done with only two Certified Nurse Aides working on a shift. They stated that resident showers may be shortened with no nail care or shaving done on the residents. 10NYCRR 415.13(a)(1)(i-iii)

Based on interview and record review conducted during a Standard survey completed on 10/28/24, the facility did not implement an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one of one infection control program reviewed. Specifically, the facility did not provide documentation showing that antibiotics were being monitored and tracked to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This involved Resident #84. The finding is: The policy and procedure titled Antibiotic Stewardship - Review & Surveillance of Antibiotic Use & Outcomes, dated 8/2018, documented that Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form, and all clinical infections treated with antibiotics will undergo review by the Infection Preventionist. All Antibiotic starts will be reviewed by the Infection Preventionist within 48 hours to determine if continued therapy is justified, justified with needed intervention, or not justified. Resident #84 had diagnoses including chronic pain syndrome, stage 4 pressure ulcer of the sacral region (wound on the lower back, above the buttocks, that includes full thickness skin loss that extends into muscle, bone, or supporting structures), and osteomyelitis (bone infection) of the sacral region. The minimum data set (a resident assessment tool) dated 7/12/24, documented Resident #84 was moderately cognitively impaired, was always understood, always understands, had a wound infection and was on an antibiotic medication. The comprehensive care plan, revised 9/16/24, documented Resident #84 had an infection. Interventions included to observe for side effects from antibiotic therapy and report to the provider. Review of Resident #84's Physician's Order Form dated 10/23/24, revealed they had multiple antibiotics ordered including Cefdinir oral capsule 300 milligrams every 12 hours for pressure ulcer from 6/7/24-9/12/24, and 9/13/24-9/17/24. Bactrim DS oral tablet 800-160 milligrams, 1 tablet by mouth every 12 hours for cellulitis, from 7/23/24-8/3/24. Ertapenem sodium injection 1 gram intravenously daily for urinary tract infection, from 9/17/24-9/17/24. Review of the Antibiotic Stewardship binder contained no documentation that the facility had an effective antibiotic stewardship program. There was no tracking of antibiotics used in the facility for the months of July 2024 - October 2024. During an interview on 10/28/24 at 8:49 AM, Licensed Practical Nurse #6, stated they used to keep track of the antibiotics on their unit, but since recently returning from a leave, they did not know if there was a process in place. They used to track them on a list and give it to the Director of Nursing at the beginning of each month, but no one had been tracking them recently. During an interview on 10/28/24 at 9:30 AM, the Corporate Infection Preventionist stated they oversaw the Antibiotic Stewardship program in the facility. The Director of Nursing, that recently left, used to be responsible for it. They were in the process of training the new Director of Nursing and Assistant Director of Nursing to take over the responsibility. They stated they used the McGeer criteria (a standardized set of guidelines for identifying infections in long term care facilities) as their guide for antibiotic stewardship. They stated that recently they had been running a report from their electronic medical record to track antibiotic use. They were unable to provide the monthly documentation to support their process. They stated the previous Director of Nursing left in early September; however, they were unable to locate the tracking documentation from July 2024 - current. The Corporate Infection Preventionist also stated the unit managers should have lists of residents on antibiotics for their units, however they were unable to provide that documentation. During an interview on 10/28/24 at 10:13 AM, the Director of Nursing #1 stated they were not yet involved in the antibiotic stewardship program, but they started the infection preventionist training to take it over. They stated it was important to track and monitor antibiotic use, so residents didn't develop a resistant infection and to monitor for side effects, lab values, or cultures, and make sure they were on the correct antibiotic. During an interview on 10/28/24 at 12:24 PM, the Pharmacy Consultant stated their role in antibiotic monitoring was to check if the order had an accurate duration and diagnosis for the treatment. They were not directly involved in the antibiotic stewardship process. During an interview on 10/28/24 at 12:47 PM, the Interim Administrator stated that having an effective antibiotic stewardship was very important. The purpose of the Antibiotic Stewardship program was to make sure they didn't overuse antibiotics and to make sure the residents were on the appropriate antibiotic. They should track whether it's been effective, and if the resident has responded appropriately. They can also use the information to track trends like which units are having more infections and then can use that to educate staff or monitor more closely. The Acting Administrator stated that the system they currently had was not an effective process and they needed to be more consistent. During an interview on 10/28/24 at 1:11 PM, The [NAME] President of Clinical Services stated they were unable to locate the antibiotic tracking sheets from the last few months. 10 NYCRR 415.19(a)(1,3)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/28/24, 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 one (Resident #84) of three residents reviewed for infection control practices during care. Specifically, Certified Nurse Aide's #2, 4, 5, and 6 did not wear appropriate personal protective equipment (PPE) during care activities for a resident on enhanced barrier precautions who had an indwelling catheter (tube inserted into the bladder to drain urine) and a stage IV pressure ulcer. The findings are: The undated policy and procedure titled Enhanced Barrier Precautions documented 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 employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gowns are applied prior to performing the high contact care activity. Examples of high-contact care activities requiring the use of a gown and gloves for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toileting, urinary catheter care and wound care. Enhanced Barrier Precautions remain in place for the duration of the resident's stay or the discontinuation of the medical device that places them at increased risk. Staff are trained prior to caring for residents on Enhanced Barrier Precautions. Signs are posted in the door or wall outside the resident room. Resident #84 had diagnoses which included stage IV pressure ulcer (the most severe type of pressure ulcer and involves full-thickness tissue loss with exposed bone, tendon, or muscle), obstructive uropathy (blockage of urinary flow) and urinary tract infection. The Minimum Data Set (MDS- an assessment tool) dated 10/4/24 documented Resident #84 had moderate cognitive impairment. #84 had an indwelling foley catheter and a stage IV pressure ulcer. The undated resident care profile (guide used by staff to provide care) documented Resident #84 was dependent on 2 staff members for toileting needs and transferred with a mechanical lift. Resident #84 had a pressure ulcer of the sacral region. There was no documentation the resident had an indwelling foley catheter. Enhanced Barrier Precautions were included as special instructions under Infection Control. The comprehensive care plan revised on 9/16/24 documented that Resident #84 had a foley catheter, monitor for infection, maintain precautions as needed, and impaired skin integrity related to a pressure ulcer of the sacral region. During an observation on 10/21/24 at 10:20 AM outside Resident 84's room an orange sign was posted and indicated Enhanced Barrier Precautions with the directive to wear gloves and a gown for high contact care activities. The high contact activities included dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use which included urinary catheter, and wound care: any skin opening that required a dressing. Additional observation revealed a clear plastic bin outside of Resident #84's room with 3 drawers that contained gowns, facial masks, and surgical gowns. During a mechanical lift transfer observation on 10/23/24 at 12:50 PM Certified Nurse Aide's #5 & #6 each donned (put on) a pair of gloves. Certified Nurse Aide's #5 & #6 lifted Resident #84 out of their wheelchair using a mechanical lift. During the transfer Certified Nurse Aide #5 removed Resident #84's foley catheter drainage bag from the privacy bag and held the catheter tubing during the transfer and lowered Resident #84 onto the bed. Certified Nurse Aide's #5 & #6 rolled Resident #84 over and removed Resident #84's incontinence brief. Resident #84 had a large dressing affixed to their sacrum. Certified Nurse Aide #5 removed the catheter tubing through the pant leg and placed the foley drainage bag onto the bed frame. Certified Nurse Aide's #5 then changed their gloves, completed hand hygiene and gathered supplies for fecal incontinence care. There were no gowns worn during this care observation by either staff member. During an observation on 10/23/24 at 1:02 PM Certified Nurse Aide #5 donned a clean pair of gloves and performed fecal incontinence care as Certified Nurse Aide #6 assisted with bed mobility. Certified Nurse Aide #2 entered Resident #84's room at 1:08 PM, donned a pair of gloves and assisted Certified Nurse Aide #5 with fecal incontinence care. Certified Nurse Aide #6 continued to assist with bed mobility. Certified Nurse Aide #4 then entered Resident #84's room at 1:11 PM donned a pair of gloves and finished fecal incontinence care with Certified Nurse Aide's #2, 5 & 6 then completed hand hygiene and left Resident #84's room. No gowns were worn by any of the staff during this care observation. During an observation on 10/23/24 at 1:15 PM, Certified Nurse Aide #5 donned a pair of gloves and emptied 750 milliliters of yellow urine into a graduate (container), then emptied the container into the toilet in Resident #84's bathroom. During an interview on 10/23/24 at 1:19 PM, Certified Nurse Aide #2 stated enhanced barrier precautions included wearing gowns, gloves, and masks when providing direct care for residents with foley catheters and wounds to reduce the risks of infection. We all should have had on gowns, masks, and gloves. During an interview on 10/23/24 at 1:20 PM, Certified Nurse Aide #6 viewed the orange enhanced barrier precaution sign outside Resident #84's room and stated that they should have worn a gown and mask in addition to wearing gloves. During an interview on 10/23/24 at 1:22 PM, Certified Nurse Aide #4 stated they should have had additional personal protective equipment on due to Resident #84's urinary catheter and wound. During an interview on 10/23/24 at 1:33 PM, Certified Nurse Aide #5 enhanced barrier precautions were used during direct care for residents who were at a higher risk of infection such as pressure ulcers and foley catheters. Certified Nurse Aide # 5 stated they should have worn a gown and mask during care for Resident #84 to avoid cross contamination. During an interview on 10/23/24 at 2:30 PM, Licensed Practical Nurse #7 stated the additional protection was a reminder to the staff and protected the residents and others from transmission of germs. I should have enforced them to follow the enhanced barrier precautions. During an interview on 10/28/24 at 8:49 AM, Licensed Practical Nurse #6, Unit Manager stated gowns, gloves, and masks were located outside of resident rooms who required enhanced barrier precautions. Certified Nurse Aides were expected to acknowledge the postings outside the resident's room by wearing the appropriate personal protective equipment. Licensed Practical Nurse #7 should have ensured that Certified Nurse Aide # 2, 4, 5, & 6 had worn a gown, glove, and a mask during the high contact care activity. During an interview on 10/28/24 at 10:41 AM, Director of Nursing #1 stated residents with foley catheters and wounds were susceptible to infection. Certified Nurse Aides #2, 4, 5, & 6 should have worn a gown and masks in addition to gloves for infection control purposes. During an interview on 10/28/24 at 12:05 PM, the Corporate Quality Assurance/Infection Preventionist stated they would expect the staff to wear gloves, gown, and a mask for residents on enhanced barrier precautions. During an interview on 10/28/24 at 1:28 PM, the Interim Administrator stated staff were educated on the policy, signage, expectations and were expected to follow it. NYCRR10 415.19(b)(4)

Based on interview and record review conducted during a Complaint investigation (#NY00332426) during a standard survey completed on 10/28/24, the facility did not ensure that all alleged violations involving abuse, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made to the facility's Administrator and the State Survey Agency for one (Resident #62) of five residents reviewed. Specifically Resident #62 was found to have an injury of unknown source to their forehead, and it was not reported within the required timeframe. The finding is: The policy and procedure titled Abuse, Neglect and Exploitation of Residents, reviewed 2/29/24, documented that if abuse is suspected, personnel will report their observation to their supervisor immediately and without delay, and the Administrator, Director of Nursing or designee will notify the appropriate state agencies per state regulations. 1. Resident #62 had diagnoses including unspecified dementia, status post fractured hip, and disorientation (a mental state of confusion about time, place, or one's identity). The Minimum Data Set (a resident assessment tool) dated 1/26/24, documented Resident #62 was severely cognitively impaired, rarely or never understood and rarely or never understands. They were dependent on staff for toileting and transfers, and incontinent of bowel and bladder. The comprehensive care plan dated 5/19/23 documented Resident #62 was a risk for injury, with a Hoyer lift (mechanical lift) and required two staff members for transfers. Review of the ACTS (ASPEN Complaint/ Incidents Tracking System) Complaint/Incident Investigation Report submitted on 1/29/24 at 11:14 AM, revealed Resident #62 was found to have a 1.0 centimeter x 1.5 centimeter closed hematoma (a collection of blood under the skin, caused from a broken blood vessel) to their forehead on 1/26/24 around 9:00 PM, and the origin was unknown. Review of the facility investigation, dated 2/2/24, revealed Resident #62 was found to have the 1.0 centimeter x 1.5 centimeter hematoma to their forehead when being cared for by two Certified Nurse Aides. The resident had no recent falls, and no reported resident to resident altercations or other incidents. Neurological checks were monitored and remained within normal limits. No mental harm was found. Staff stated they noticed the area during care, and none observed prior. Staff statements were dated 1/26/24. Actions taken following the investigation included staff re-education regarding safety during care, transfers, and the monitoring of residents for any change in condition. Review of Resident #62's progress notes from 1/26/24-1/29/24 revealed the following: 1/26/24 at 10:49 PM Licensed Practical Nurse #4 documented the Certified Nurse Aide (#10) notified them of a bump on Resident #62's forehead. The supervisor was notified, neurological checks were initiated and within normal limits, and the resident had no pain or discomfort. 1/27/24 at 5:30 AM Nursing Supervisor, Registered Nurse #3, documented there were no delayed injuries at this time. 1/29/24 at 1:25 PM Assistant Director of Nursing #2 documented there were no delayed injuries from incident on 1/26/24. Forehead hematoma with ecchymosis (bruising) noted. Will continue to monitor the resident. During an interview on 10/24/24, Certified Nurse Aide #1 stated they did not recall the incident with Resident #62 from January but Resident #62 could have hit their head during a Hoyer transfer but Resident #62 did not have the ability to self-transfer on their own. During a telephone interview on 10/24/24, Licensed Practical Nurse #4 stated they did not recall the incident with Resident #62 from January. The progress note dated 1/26/24 at 10:49 PM was reviewed with LPN #4 and stated based on their documentation they notified the supervisor of the injury after checking on the resident. However, stated they were unsure when the supervisor assessed the resident. During a telephone interview on 10/25/24 at 10:23 AM, Assistant Director of Nursing #2 stated they did not specifically remember the incident with Resident #62 in January. They stated that injuries of unknown origin needed to be reported within two hours. The supervisor should have called them or the Director of Nursing immediately. They might have needed to assess the resident and they could have reported it on time. During an interview on 10/25/24 at 10:59 AM, Director of Nursing #1 (current Director) stated they were not employed by the facility at the time of the incident with Resident #62, but it was important for all injuries of unknown origin to be reported to the Director of Nursing immediately. An injury of unknown origin could be abuse, and it needed to be investigated as soon as possible. During a telephone interview on 10/25/24 at 12:03 PM, Director of Nursing #2 (Director at time of occurrence) stated they should have been notified by Nursing Supervisor (RN #3) as soon as they assessed the resident. Director of Nursing #2 stated they were notified on Monday 1/29/24 of the injury, and that's when it was reported to the department of health. An injury of unknown origin should have been reported to the state within two hours because injuries of unknown origin could be suspicious of abuse. During an interview on 10/25/24 at 12:39 PM, the Interim Administrator stated the injury should have been reported to the Director of Nursing immediately so they could start the investigation. They might have found that it was not an unknown at all. All injuries of unknown origin need to be reported to the state within two hours. The staff were all aware of the importance of reporting immediately. 10 NYCRR 415.4 (b)

Based on observation, interview, and record review conducted during a Standard survey completed on 10/28/24, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (Residents #71 and #127) of five residents reviewed. Specifically, issues involved unkempt long, dirty, jagged fingernails (#71, #127). In addition, Resident #71 had presence of unwanted facial hair. Additionally, the 3rd floor Bath & Shower Sheet dated 10/23/24 for #71 was inaccurately documented, that care had been provided. The findings are: The policy and procedure titled Activities of Daily Living created 2/13/23 documented a resident who was unable to carry out activities of daily living would receive the necessary services to maintain good grooming and personal hygiene. The policy and procedure titled Care of Fingernails issued 6/26/18 documented nail care was to include daily cleaning and regular trimming on resident assigned bath/shower days and unless otherwise permitted, nails of diabetic residents or residents with circulatory problems were to be trimmed only by licensed nurses. If a resident did not receive a bath/shower or refused on the scheduled bath/shower day, nail care was to still be provided on the scheduled bath/shower day. Finally, the nurse supervisor was to be notified if the resident refused care. 1. Resident #71 had diagnoses including hemiplegia (paralysis on one side of body), dysphagia (difficulty swallowing), and diabetes mellitus. The Minimum Data Set, dated dated dated [DATE] documented Resident #71 was moderately cognitively impaired, was understood and understands. The Minimum Data Set documented Resident #71 was substantial/maximal assistance for personal hygiene. The certified nurse aide care profile (a guide used by staff to provide care) dated 8/18/24 documented scheduled bath days were twice weekly on the 7:00 AM to 3:00 PM shift on Wednesdays and Saturdays. The comprehensive care plan revised on 8/23/23 documented Resident #71 was diabetic and the plan documented to trim fingernails weekly. The 3rd floor shower/bath scheduled verified as current by Licensed Practical Nurse #6 Unit Manager documented Resident #71's scheduled baths/showers were scheduled for Wednesday and Saturday during the 7:00 AM to 3:00 PM shift. A physician's order dated 8/23/23 revealed an active physician's order to trim fingernails weekly. During an observation and interview on 10/22/24 at 10:21 AM, Resident #71's fingernails were jagged, and dirty with dried brown debris. The resident also was unkempt and had one-inch white whiskers on their face, chin, and neck. Resident #71 stated their nails were ugly and would like them cleaned and that they were embarrassed to have such long whiskers. Resident #71 stated they haven't had a bath or shower in 2 weeks. Observation on 10/23/24 at 12:03 PM revealed Resident #71's fingernails were jagged, dirty and had dried brown debris. Resident #71's whiskers remained on their face, chin and neck and they stated they did not receive their scheduled shower this morning. Review of the nursing progress notes dated 10/1/24 through 10/23/24 revealed there was no documented evidence that nail care was provided, that Resident #84 was bathed, or refused showers and nail care. Review of the 3rd floor Bath & Shower Sheets dated 10/2/24, 10/9/24, and 10/16/24 revealed there was no documented evidence the resident's nails were trimmed and cleaned or had been shaved. Further review of the 3rd floor Bath & Shower Sheets dated 10/23/24 revealed Certified Nurse Aide #4 documented Resident #71's fingernails were cleaned and trimmed, and Resident #71 was shaved. Review of the Treatment Administration Record from 10/1/24 through 10/23/24 documented an active physician order to trim fingernails weekly. The Treatment Administration Record documented that Resident #71's fingernails were trimmed on 10/9/24 and blank on 10/2/24, 10/16/24, and 10/23/24. Further observation and interview on 10/24/24 at 10:13 AM Resident #71 stated the staff were too busy. No one had offered them their shower on 10/23/24. Resident #71 had jagged fingernails dirty with dried brown debris and facial and neck whiskers. The resident stated they hoped to be shaved and have their nails cleaned. During an interview on 10/25/24 at 8:45 AM, Certified Nurse Aide #4 stated they did not give Resident #71 a shower on 10/23/24. There was no sling. Certified Nurse Aides were responsible for providing nail care and shaving unless the resident had a diagnosis of diabetes, then the nurse would be responsible for nail care. I should have informed the nurse the shower was not done or grabbed a sling from laundry. During an interview on 10/25/24 at 10:30 AM, Licensed Practical Nurse #8 stated they were unaware if Resident #71 had their shower on 10/23/24. Certified Nurse Aide #4 never notified them to complete a skin check. Therefore, likely the shower was not given. Resident #71 was diabetic and Licensed Practical Nurse #8 stated they did not clean or trim Resident #71's nails. During an interview on 10/25/24 at 10:33 AM, Licensed Practical Nurse #6, Unit Manager stated they expected proper care daily which included cleaning fingernails, and shaving. 2. Resident #127 had diagnoses of diabetes mellitus type 2 and dementia with mood disturbance. The Minimum Data Set, dated dated dated [DATE] documented Resident #127 was severely cognitively impaired and was dependent on staff to perform personal hygiene. The comprehenisve care plan and the certified nurse aide care profile (a guide used by staff to provide care) the dated 9/26/24 did not include instructions for staff regarding nail care. During an observation on 10/22/24 at 9:56 AM, Resident #127 had long yellow fingernails and were dirty with dark brown debris. During follow-up observations on 10/23/24 at 9:16 AM, 10/25/24 at 10:23 AM, and 10/28/24 at 10:13 AM, Resident #127's nails were long and yellow with no dark brown debris under them. During an interview on 10/28/24 at 11:04 AM, Certified Nurse Aide #8, stated they only cleaned under Resident #127's nails and did not clip them, as Resident #127 was diabetic and nurses would need to clip their nails. During an interview on 10/28/24 at 10:15 AM, Licensed Practical Nurse #2 Unit Manager D-wing stated they were the only licensed nurse on the unit for this shift and were also responsible for passing medications scheduled during this day shift. At this time, Licensed Practical Nurse #2 reviewed the month's Bath & Shower Sheets for Resident #127, stated they were to receive a bath or shower on Wednesday during the AM shift and on Saturday during the PM shift. They stated the most recent Wednesday AM check was documented on 10/9/24 and only documented that skin was checked. None of the other categories (nails) were checked off, and there was no Saturday evening check documented during October 2024. They stated they had not been made aware of any bath/shower refusals by Resident #127. During an interview on 10/28/24 at 11:15 AM, Assistance Director of Nurses (ADON) #1, stated Resident #127's fingernails were too long and needed to be clipped. They stated that any resident with a diagnosis of diabetes was to have their nails trimmed by a Licensed Nurse, not a Certified Nurse Aide. They stated it was expected that facility staff notify their supervisor when residents refused baths or showers. They were not aware of any refusals by Resident #127. 10NYCRR 415.12(a)(3)

Based on observation, interview, and record review conducted the Standard survey completed on 10/28/24, the facility did not ensure that residents who had an indwelling (foley) catheter (tube inserted into the bladder to drain urine) received the appropriate care and services to manage catheters for one (Resident #84) of one resident reviewed. Specifically, Resident #84 was symptomatic for a urinary tract infection, and the foley catheter drainage bag was not draining to gravity below their bladder. The finding is: The policy and procedure titled Catheter Care: Urinary revised on 4/30/24 documented the purpose of this procedure is to prevent catheter-associated urinary tract infections. The position of 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 urinary bladder. Resident #84 had diagnoses which included anxiety, stage IV pressure ulcer (most severe type of pressure ulcer and involves full-thickness tissue loss that exposes bone, tendon, or muscle), and urinary tract infection. The Minimum Data Set (MDS- an assessment tool) dated 10/4/24 documented Resident #84 had moderate cognitive impairment, was understood, understands. Resident #84 had an indwelling foley catheter. The undated resident care profile (tool used by staff to provide care) documented Resident #84 was dependent for toileting needs and to offer toileting every 2-3 hours. There was no documentation the resident had an indwelling foley catheter. The comprehensive care plan dated 4/12/24 documented Resident #84 had a foley catheter with a history of urinary tract infections, and to monitor for signs and symptoms of infection. Review of the nursing progress notes dated 10/22/24, revealed Resident #84 complained of burning on 10/21/24. The nurse practitioner was notified. The foley catheter was changed, an order was obtained for a urinalysis (a laboratory test that provides important clinical information on kidney function). The urine sample was collected and sent on 10/22/24. During observation and interview on 10/23/24 at 9:22 AM and 10:06 AM, Resident #84 was in their wheelchair next to the bed. An empty blue privacy bag was hanging off the bottom of the wheelchair. The foley catheter drainage bag was lying flat and was empty on Resident #84's lap. There was visible yellow urine with white mucous shreds contained throughout the catheter tubing. At 10:06 AM Resident #84 stated that's where they left it when they got me up. Resident #84 stated they had a burning sensation. Further observation and interview on 10/23/24 at 10:10 AM, Certified Nursing Assistant #5 stated they got Resident #84 into the wheelchair at 8:00 AM and was sidetracked, left the room, leaving the bag on Resident #84's lap. The foley drainage bag should have been placed in the privacy bag and should be below the bladder to prevent infections. During an interview on 10/23/24 at 12:48 PM, Licensed Practical Nurse #7 stated foley drainage bags were positioned below the bladder and drained to gravity. Resident #84 had complained of burning and a urine had been collected on 10/22/24. Review of the Physicians' Order Form as of 10/23/24 revealed a physician's order for a Urinalysis to be collected on 10/22/24. Review of the Bacteriology preliminary report dated 10/23/24 revealed a urinalysis collected on 10/22/24 had a colony count greater than 100,000 colony forming units/milliliters Escherichia Coli and was signed by Licensed Practical Nurse #6, Unit Manager on 10/24/24. During an interview on 10/24/24 at 10:39 AM, Nurse Practitioner #1 stated they'd expect foley drainage bags be positioned below the bladder to avoid the risk of urinary tract infections. During an interview on 10/28/24 at 9:17 AM, Licensed Practical Nurse #6 Unit Manager stated Resident #84 was on antibiotics for a urinary tract infection. Certified Nursing Assistant #5 should have placed the drainage bag in the privacy bag under the wheelchair and not on Resident #84's lap to prevent discomfort or the backflow of urine into the bladder. During an interview on 10/28/24 at 10:45 AM, the Director of Nursing stated foley drainage bags should never be placed on someone's lap. The urine flow would back into the bladder and for someone with a urinary tract infection, could make the infection worse. During an interview on 10/28/24 at 12:05 PM, Corporate Quality Assurance/Infection Preventionist stated foley drainage bags left on the lap was an infection control issue, and lead to urinary tract infections. 10NYCRR 415.12 (d) (2)

Based on observation, interview, and record review conducted during a Standard Survey completed on 10/28/24, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs for one (A Wing North Building) of three medication rooms observed for medication storage. Specifically, three bottles of liquid Lorazepam (a Schedule IV controlled substance-sedative/antianxiety medication) were stored in a removable locked box inside a small refrigerator that was not permanently affixed, which was located in a room with an unlockable door. This involved Resident #32. The finding is: The policy and procedure titled Controlled Substances with effective date 12/1/17 documented that refrigerated controlled substances must be stored in a refrigerator that has a locked, affixed narcotic box inside of the refrigerator with a separate lock on the outside of the refrigerator. The refrigerator must be affixed to the floor or wall. The refrigerator and interior narcotic container must remain locked at all times. During a medication storage room observation on 10/23/24 at 3:42 PM, Licensed Practical Nurse #9 unlocked the refrigerator in the medication room and removed a small, locked metal box that was not in an affixed compartment. The small metal box contained three bottles of Lorazepam concentrate 2 milligrams per milliliter for Resident #32. Bottle #1 for Resident #32 had 27 milliliters remaining; bottle #2 for Resident #32 was unopened and had 30 milliliters remaining; bottle #3 for Resident #32 was unopened and had 30 milliliters remaining. Further observation revealed the medication refrigerator was not affixed to the wall or counter and was in a room with an unlockable door. During an interview on 10/23/24 at 3:42 PM, Licensed Practical Nurse #9 stated they had not been using the locked compartment inside the medication refrigerator because there was no key. They stated they were not sure if the locked box needed to be affixed. During an interview on 10/23/24 at 4:44 PM, the [NAME] President of Clinical Services stated that they were unaware that the medication refrigerator on the A wing was not affixed or secured and should have been. They stated they did not know how long it had been unsecured or why and they would have maintenance address the issue immediately. During an interview on 10/24/24 at 9:52 AM, Licensed Practical Nurse Unit Manager #5 stated they had not been aware the medication refrigerator was not secured and was unsure why the affixed locked compartment in the refrigerator was not being used to store controlled substances. They stated when the residents transferred over from B wing in June the medication refrigerator was already in place on the unit. Licensed Practical Nurse Unit Manager #5 stated they believed the nurse was not aware they had a key to the affixed locked compartment for the medication refrigerator. During an interview on 10/24/24 at 10:14 AM, Licensed Practical Nurse #9 stated they were not aware they had a key on their key ring for the affixed locked compartment in the medication refrigerator. During an interview on 10/28/24 at 9:46 AM, the Director of Nursing #1 stated they were unaware that the medication refrigerator on the A wing was not secured and did not know why the affixed locked compartment in the refrigerator was not being used for controlled substances. The Director of Nursing #1 stated they would have expected both the medication refrigerator and narcotic box to be affixed and secured to ensure no one could remove and walk out with medications. During an interview on 10/28/24 at 10:25 AM, the Interim Administrator stated they would expect all medication refrigerators to be secured, not removable and would expect that controlled substances were stored in a locked box that was affixed to the refrigerator. They stated this would be important as someone could walk away with the controlled substances if not securely stored. 10 NYCRR 415.18 (e)(1)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/28/24, the facility did not provide or obtain dental services to meet the resident's needs for one (Resident #84) of one resident reviewed. Specifically, there was no follow up to recommendations for a crown for a chipped tooth. In addition, the care plan was not revised to include Resident #84's chipped tooth. The finding is: The policy and procedure titled Dental Services with a revised date 1/28/20 documented routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. The Director of Nursing, or his/her designee, is responsible for notifying Social Services of a resident's need for dental services and coordinate appointments with Medical Records/Unit Clerks. Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary whenever an outside appointment is requested. The Medical Records Department/Unit Clerks will schedule and track resident dental appointments as per the required and recommended visits in the medical appointment tickler tracking system document. The policy and procedure titled Quality of Life - Dignity dated 9/1/17 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing his/her self-esteem and self-worth. Resident #84 had diagnoses which included anxiety, stage IV (4) pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), and urinary tract infection. The Minimum Data Set (a resident assessment tool) dated 10/4/24 documented Resident #84 had moderate cognitive impairment, was understood, understands, and had no mouth or facial pain, or difficulty chewing. The undated resident care profile (used by staff to guide care) documented Resident #84 was dependent on staff for oral hygiene. The comprehensive care plan dated 4/12/24 documented that Resident #84 had poor dentition. The plan included dental consults annually and as needed, and to monitor for pain or problems with chewing. The comprehensive care plan documented to examine the oral cavity and assess for lesions, broken or missing teeth on admission, annually and as needed. Resident #84's chipped front tooth was not reflected on the plan of care. During observation and interview on 10/21/24 at 10:20 AM, Resident #84 stated they had a cracked tooth and hadn't seen the dentist. The tooth wasn't painful, they were self-conscious about it, and wished it was fixed. Resident #84's right front tooth was visibly chipped. Review of the Dental Orders and Progress Notes Form dated 7/29/24 documented Resident #84 was seen by the facility dentist for an initial visit and had obvious broken natural teeth. Tooth #8 was chipped. The tooth would need a crown and Resident #84 would have to follow up with an outside dentist as this service was not provided by the facility dentist. The dental progress note was signed by the medical provider on 8/6/24. Review of the nursing progress notes from 7/29/24 through 8/10/24 revealed no documented evidence the dental recommendations were addressed, or an appointment had been arranged. During an interview on 10/25/24 at 11:31 AM, Licensed Practical Nurse #6, Unit Manager stated dental consults were placed in medical records mailbox by the dentist. Medical records staff distributed the consults to the units. Unit managers addressed recommendations with the medical provider and Unit Clerks were responsible to schedule the outside appointments. Licensed Practical Nurse #6, Unit Manager stated Resident #84's dental consult was signed by the medical provider on 8/6/24 and Licensed Practical Nurse #10, Unit Manager should have followed up on the recommendations. There were no nursing progress notes that reflected Resident #84 had been seen by the dentist on 7/29/24. The process was not working because this was obviously missed. Resident #84's care plan should have reflected the chipped tooth for monitoring potential weight loss, pain or difficulty chewing. During an interview on 10/25/24 at 11:32 AM, Unit Clerk #2 stated the dental consult was given to Licensed Practical Nurse #10, Unit Manager and could not recall that an outside appointment was made and must have been overlooked. Typically, it was the responsibility of unit managers or unit clerks. During a telephone interview on 10/25/24 at 12:51 PM, Director of Nursing #2 stated dental consults went directly to medical records. Medical records distributed the consults to the unit managers who reviewed them for recommendations. Unit clerk #2 was responsible for arranging follow up appointments once the medical provider agreed. During an interview on 10/25/24 at 1:17 PM, the Director of Medical Records stated dental consults were given to medical records staff after a resident had been seen. Medical records staff then distributed them to the units for the unit manager to address any recommendations with the provider. Unit managers would inform the unit clerk if an outside appointment needed to be scheduled. Unit Clerk #2 should have made the appointment. During an interview on 10/25/24 at 1:25 PM, the Interim Administrator stated Licensed Practical Nurse #10, Unit Manager was unavailable for interview until further notice. During an interview on 10/28/24 at 1:28 PM, the Interim Administrator stated Licensed Practical Nurse #10, Unit Manager should have reviewed Resident #84's dental consult for recommendations and Unit Clerk #2 should have scheduled the appointment. There needed to be an extra step in the process to ensure the appointments were really scheduled or why it was missed. 10 NYCRR 415.17(c)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00331630), the facility did not ensure residents had the right to be free from physical abuse for one (Resident #1) of three residents reviewed. Specifically, on 1/16/2024 resident to resident physical abuse occurred between Resident #1 and Resident #2. Resident #2 grabbed Resident #1's arm and aggressively threw Resident #1 down to the floor. Resident #1 experienced pain; sustained a compression fracture (small breaks in the spine) of T2 (the upper aspect of thoracic region (middle section of spine) and fractures (break) of the left elbow and hip. Resident #1 was subsequently transferred to the hospital. This resulted in actual harm to Resident #1 that is not immediate jeopardy. The finding is: The policy and procedure titled Abuse, Neglect and Exploitation of Residents with a review date of 2/23 documented that each resident has the right to be free from physical abuse. Residents will not be subjected to abuse by anyone, including but not limited to other residents. The definition of physical abuse was the inappropriate physical contact with a resident which harms or was likely to harm the resident. This included but was not limited to, hitting, slapping, pinching, spitting at, and kicking. Resident #1 had diagnoses which included advanced dementia, depression, and anxiety. The Minimum Data Set (a resident assessment tool) dated 1/5/2024 documented Resident #1 had severe cognitive impairment, was rarely understood, and rarely understands. The resident ambulated independently and wandered daily. The comprehensive care plan identified as current by covering Licensed Practical Nurse Unit Manager #3 dated 8/1/2023 documented Resident #1 was at risk for resident altercations related to wandering into peer's room. The goal documented the resident would be safe and free from harm by peers. Interventions included to keep Resident #1 away from other resident(s) exhibiting physical/verbal behavioral symptoms directed towards others; protect from potential harm; and redirect/refocus attention by offering alternatives. Resident #2 had diagnoses which included psychosis (when people lose some contact with reality), aphasia (absence or difficulty with speech), and mood disorder. The Minimum Data Set, dated dated dated [DATE] documented Resident #2 had severe cognitive impairment, was usually understood, and usually understands. The resident had no physical behavioral symptoms directed towards others. Required partial/moderate assistance with bed to chair transfers and wheelchair mobility. The comprehensive care plan identified as current by covering Licensed Practical Nurse Unit Manager #3 dated 1/17/2022 documented Resident #2 had impaired social interactions with resident-to-resident altercation (aggressor) dated 8/17/2022. Interventions included to encourage participation in activities, psychological services as needed and private room due to aggressive behavior. Resident #2 could be physically/verbally aggressive and throws themselves onto the floor when upset. During an observation of the North 2nd Floor D Wing hallway video surveillance footage on 2/8/2024 at 8:50 AM in the presence of the Administrator revealed the following: On 1/16/2024 at 5:00 PM Licensed Practical Nurse #1 stood in the hallway at the medication cart and was engaged in a medication pass. Resident #1 came into view from the right and ambulated independently toward the nurse and the medication cart. Resident #2 came into view from the left. Resident #2 came swiftly down the hallway headed directly towards Resident #1 using their left hand on handrail and feet to self-propel their wheelchair. Resident #2 released the handrail and with their left hand forcefully grabbed ahold of Resident #1's right arm and threw them to the floor. Resident #1 bumped their head on the wall as they fell to the floor. During an interview on 2/8/2024 at 8:55 AM, the Administrator stated there was no additional surveillance footage prior to the incident. The Administrator stated based on the video surveillance footage the altercation between Resident #1 and Resident #2 was physical abuse. The Full Quality Assurance Report referred to by the Director of Nursing as the accident/incident report dated 1/16/2024 completed by Assistant Director of Nursing #1 documented Resident #1 ambulated in the hallway and was in a witnessed altercation with Resident #2. Assistant Director of Nursing #1 had documented that they were notified that Resident #1 ambulated into Resident #2's room, then walked out. Resident #2 grabbed Resident #1 and pulled Resident #1 to the floor. Resident #1 bumped their head against the wall and grimaced in pain. The nursing progress notes dated 1/16/2024 at 11:34 PM completed by Assistant Director of Nursing #2 documented Resident #1 was transferred to the hospital for evaluation at 10:30 PM. The Hospital History and Physical dated 1/17/2024 documented the computerized tomography scan (CT- a medical imaging technique used to obtain detailed internal images of the body) showed a compression fracture of T2 (thoracic spine #2). X-rays documented fractures of the left elbow and hip. Resident #1's family opted for palliative (conservative) measures. The Nursing Home Investigative Report submitted by the Director of Nursing on 1/25/2024 printed on 1/25/2024 documented there was reasonable cause to believe that abuse, neglect, or mistreatment occurred. During an interview on 2/8/2024 at 9:06 AM, Licensed Practical Nurse #1 stated on 1/16/2024 they looked up from the medication cart and saw Resident #1 walking towards them. Resident #2 was loudly yelling Ahh and intentionally grabbed Resident #1's right arm aggressively and yanked Resident #1 down to the floor. Licensed Practical Nurse #1 stated they were unaware of what precipitated Resident #2's aggression. Resident #1 wandered daily in and out of other resident rooms and was easily redirected. The altercation on 1/16/2024 was physical abuse, resulted in fractures, and caused harm to Resident #1. During a telephone interview on 2/8/2024 at 10:47 AM, Certified Nurse Aide #2 stated Resident #1 wandered daily in the hallway and into other resident rooms. Was always on the go and was harmless. They stated they would redirect, encourage engagement in the activities, and offered snacks. Certified Nurse Aide #2 stated Resident #2's behaviors included temper tantrums, throwing their remote control and throwing themselves on the floor to get attention. During an interview on 2/8/2024 at 12:08 PM, Assistant Director of Nursing #1 stated when Resident #2 grabbed Resident #1 by the arm, yanked them down which resulted in a fall was physical abuse. Resident #1 sustained fractures and had pain upon assessment. Any fracture would be harmful. During a telephone interview on 2/8/2024 at 2:46 PM, Medical Provider #2 stated Resident #2 hurt Resident #1. The incident was physical abuse which caused a cascade of events. Resident #2 pulled Resident #1 down to the floor, caused the fractures and then Resident #1's condition declined. The injuries were harmful to Resident #1. During a telephone interview on 2/9/2024 at 8:53 AM, Certified Nurse Aide #3 stated they were assigned to Resident #1 and #2 on 1/16/24. It was chaotic, I turned around and Resident #1 was on the floor. Resident #1 must have entered Resident #2's room which made them aggressive. During an interview on 2/9/2024 at 11:31 AM, the Director of Nursing stated physical abuse occurred when one of the party's understood the repercussions. During an interview on 2/9/2024 at 11:49 AM, the Administrator stated Resident #2 intended to cause Resident #1's fall and their actions led to serious bodily injury and harm to Resident #1. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interview conducted during a Complaint Investigation (Complaint #NY 965) completed during an Abbreviated survey on 10/5/21, the facility failed to ensure that the drug regimen of each resident was reviewed at least once a month by a licensed pharmacist and that the pharmacist reported irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon. for one (Resident #1) of three residents reviewed. Specifically, the attending physician did not act timely in response to the Pharmacy Consultant recommendations regarding Resident #1's multiple pain medications, the resident experienced adverse consequences which subsequently resulted in the resident being admitted to the hospital with a diagnosis (dx) of opioid overdose. This resulted in actual harm that is not immediate jeopardy. The finding is: Review of the policy and procedure (P/P) titled Medication Regimen Reviews, dated 5/21/18, documented the primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medications appropriately and prevent or minimize adverse consequences related to medication therapy. The Consultant Pharmacist will provide a written report to Physicians for each resident with an identified irregularity. If the situation is serious enough to represent a risk to a person's life, health, or safety, the Consultant Pharmacist will contact the Physician directly to report the information to the Physician and will document such contacts. 1. Resident #1 was admitted with diagnoses including [CONDITION(S)] (infection of the bone), diabetes mellitus, and hypertension (high blood pressure). The Minimum Data Set (MDS- a resident assessment tool) dated 9/10/21 documented the resident was understood and understands. Review of the Consultant Pharmacist Note To Attending Physician/Prescriber dated 9/13/21 for Resident #1 documented the admission medication regimen was completed for Resident #1 and the following irregularities were documented: a. There is a nursing note from 9/12/21 to d/c (discontinue) [MEDICATION(S)] (opioid-narcotic pain medication) and start [MEDICATION(S)] ER (opioid-narcotic pain medication) 30mg (milligrams) TID (three times a day) but Resident #1 was started on [MEDICATION(S)] (opioid-narcotic pain medication) 10mg q (every) 6 h (hours) instead which is a much higher milligram [MEDICATION(S)] equivalent. Please clarify it. b. This resident is on multiple scheduled opioids. Please consider discontinuing resident's prn (as needed) [MEDICATION(S)] (antianxiety medication) as it interacts with their opioids and consider adding the prn [MEDICATION(S)] (medication used for the emergency treatment of opioid overdose) to their orders per the 9/10/21 hospital discharge summary. Under Physician/Prescriber Response, other was checked with the following documented, signed and dated 9/15/21 by the Director of Nursing (DON): verbally reviewed with physician via PC (personal cell) on 9/15/21 d/t (due to) status, taken to hospital for evaluation. Will f/u (follow up) if/when resident returns. Review of the Consultant Pharmacist e-mail sent 9/13/21 at 8:32 AM documented the Note To Attending Physician/Prescriber dated 9/13/21 for Resident #1 was attached and sent to Resident #1's attending Physician, DON, Unit Manager and Administrator. There was no documented evidence of a Consultant Pharmacist follow up phone call to the physician. The signed and dated Physician's Order Form from 9/10/21 to 9/15/21 documented the following: -[MEDICATION(S)] 5mg q 8 h as needed with a start date of 9/11/21 for behavior. -[MEDICATION(S)] HCL ER 30mg give 0.5 tablets q 12 h with start date 9/10/21 and end date 9/12/21 for pain management. -[MEDICATION(S)] HCL 10mg by mouth q 6 h with a start date of 9/13/21 for pain. -Oxycodone HCL (opioid-narcotic pain medication) 20mg q 8 h with a start date of 9/10/21 for pain management. -There were no orders obtained for [MEDICATION(S)]. Review of the Monthly Medication Administration Record (MAR)/ Treatment Administration Record (TAR) dated between 9/1/21 and 9/30/21 documented the following: -[MEDICATION(S)] 5mg q 8 h prn was marked as given on 9/13/21 and 9/14/21 one time on each day. -[MEDICATION(S)] HCL 10mg q 6 h on 9/13/21 was marked as given at 12:00 PM and 6:00 PM, on 9/14/21 was marked as given at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM and on 9/15/21 was marked as given at 12:00 AM and 6 AM. -Oxycodone HCL 20mg q 8 h was marked as not received 9/13/21 to 9/15/21. However, review of the Controlled Subs dated 9/30/21 documented four Oxycodone tab 5mg were taken from the automated dispensing medication device on 9/15/21 at 1:08 AM for Resident #1 and was signed out by Registered Nurse (RN) #3 and witnessed by RN #2. Review of the Progress Notes Report dated 9/10/21 through 9/15/21 documented the following: 9/12/21 at 11:54 AM Licensed Practical Nurse (LPN) #2 documented, physician in to see. New order to discontinue [MEDICATION(S)]- give [MEDICATION(S)] ER 30mg po q 8 h. 9/13/21 at 8:19 AM Pharmacist Consultant documented Admission MRR (medication regimen review): admit recommendation. 9/14/21 at 3:49 PM Physician documented Resident #1's Admission History and Physical. 9/15/21 at 8:57 AM LPN #6 documented Resident #1 was hard to arouse. Fasting sugar 205, blood pressure was faint and unable to obtained. Per Physician assessment, Resident #1 to be sent to the hospital. 9/15/21 at 8:43 PM Resident #1 admitted to the hospital with [CONDITION(S)], altered mental status and opiate overdose. Review of the hospital Discharge Summary dated 9/23/21 documented Resident #1 was admitted on [DATE]. Discharge diagnosis: Opioid overdose and unresponsive. Further review of the hospital discharge summary hospital course revealed a diagnosis of metabolic [CONDITION(S)] secondary to opioid overdose. Originally the patient was thought to be septic due to urinary tract infection ([CONDITION(S)]), but [CONDITION(S)] resolved with [MEDICATION(S)] bolus/drip and the antibiotics were discontinued. Additionally, the urine toxicology screen was positive for Benzodiazepine. Instructions included to monitor and avoid multiple narcotics. During a phone interview on 10/1/21 at 1:58 PM, the Consultant Pharmacist stated, when they make recommendations, they place them in the box on the units for the physicians to sign, When I made recommendations for Resident #1, I e-mailed the DON, Administrator, Nurse Manager and attending Physician that day (9/13/21) because the resident was a new admission and this particular recommendation ideally should have been reviewed by the physician that day. The dose the resident was being given could have caused an overdose and increased risk of respiratory depression. The Consultant stated using the conversion of standards if the resident received the oxycodone and [MEDICATION(S)] ER this would have provided 270mg [MEDICATION(S)] equivalent. By receiving the oxycodone and [MEDICATION(S)] this would have provided 410mg [MEDICATION(S)] equivalent, which is a much higher dose. The Consultant Pharmacist stated they did not follow up phone with a phone call to the attending Physician regarding their recommendations. During a telephone interview on 10/1/21 at 2:49 PM, the attending Physician #1 stated pharmacy recommendations were received inconsistently and there was not a direct flow for receiving the Pharmacy recommendations. I do not recall receiving an e-mail on 9/13/21 from the Pharmacy Consultant regarding Resident #1. As soon as I receive recommendations, 99% of the time I follow up on them. The medication [MEDICATION(S)] 10mg q 6 h was probably substituted for the [MEDICATION(S)] ER 30mg TID because the facility probably did not have the medication that was ordered, and they needed to substitute something for it. The facility has had problems with receiving medications that are ordered or frequently running out of medications which may cause a hazard. I do not know why I did not order the [MEDICATION(S)] upon admission. When ordering opioids, you need to take in account the opioid conversion. Using multiple opioids and if given too many you could cause an overdose. During an interview on 10/1/21 at 2:57 PM, the DON stated the Consultant Pharmacist sends an e-mail chain to the DON, Administrator, all Physicians, and all Unit Managers (UM). The attending Physician for Resident #1 comes into the facility 3-4 x's a week and the UM was responsible to follow up with the physicians. The morning of 9/15/21, Resident #1 was very drowsy and had a definite change in their mannerism. I spoke to the physician on 9/15/21 regarding the pharmacy recommendations and documented it on the recommendation sheet. During a telephone interview on 10/4/21 at 11:02 AM, the Medical Director stated, I would expect all the physicians to review the recommendations as soon as they receive them. The possible outcome for a resident who was on multiple opioid medications could possibly be an overdose, but that was not very common. During an interview on 10/4/21 at 11:30 AM, the Administrator would expect the physicians to follow-up on any Pharmacy Consultant recommendations. 415.18 (c)(2)

Based on interview and record review conducted during a Complaint Investigation (Complaint #NY 253) during the Standard survey completed on [DATE], the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #36) of four residents reviewed for quality of care related to hospitalization . Specifically, there was an approximate one and a half hour delay sending the resident to the hospital as ordered by the Physician. The resident expired in the facility. This resulted in actual harm that is not immediate jeopardy. The findings are: 1. Resident #36 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident had moderately impaired decision making ability, was understood, usually understands, and had short and long term memory impairment. Review of the Advanced Directives section in the medical record revealed a Do Not Resuscitate (DNR - to with hold emergency lifesaving measure in the event an individual stop breathing or heart stops) consent form was signed by the resident on [DATE]. Further review revealed that the resident signed a Health Care Proxy (HCP) which included instructions that she did not want artificial hydration or artificial nutrition. Review of an Interval Exam Note, signed by the Physician, dated [DATE] revealed the resident had a DNR and a HCP. The Physician documented that the HCP was not activated. Review of a Progress Note, signed by the Nurse Practitioner (NP), dated [DATE] revealed the resident was being treated for [REDACTED]. The NP also documented there was communication with the resident's Health Care Agent. Additional review of the NP Progress Note revealed a section entitled "Advance Care Plan". The Advance Care Plan documented that the resident had capacity as of [DATE] and included the following: - "Medical Care and Treatment Directives per discussion: Patient is a DNR". - "Care and Treatment Requested": Antibiotics Oral, Antibiotics intramuscular (IM), Laboratory Studies, and Diagnostic Testing - "Care and Treatment NOT to be initiated": Intubation (insertion of a tube into the airway to facilitate ventilation: Tube Feeding, hospitalization other than for critical symptom management, pacemaker insertion, major surgery other than critical symptom management. - "Care and Treatment that is Undecided": Blood [MEDICAL CONDITION], Antibiotics IV (intravenous). Review of the Comprehensive Care Plan (CCP) dated [DATE] revealed the resident was alert and oriented ",[DATE]" and had memory deficits and moderately impaired decision making skills. The CCP documented that the resident's Advanced Directives included a DNR and a HCP. Review of Nurses' Notes dated [DATE] to [DATE] revealed the resident was started on [MEDICATION NAME] and [MEDICATION NAME] (blood thinning medications) for the [MEDICAL CONDITION] of the left lower extremity. The Nurses' Notes documented that the resident's appetite was poor; the resident was refusing medications; labs (laboratory studies) were being monitored; and vital signs were monitored periodically. Review of a Nurse's Note, written by a night shift licensed practical nurse (LPN #1), dated [DATE] at 4:00 AM revealed the resident's temperature was 96.4 degrees (normal 98.6), heart rate was 68 (average 80) , and respirations were 18 (normal 12 to 20) . An additional Nurse's Note, written by LPN #1 at 7:00 AM, revealed the resident had an episode of emesis (vomit), described as "clear/ brownish tinged." The LPN documented that there were no signs of pain or gastrointestinal (GI) upset and the resident's vital signs (temperature, blood pressure, pulse, respiratory rate) were stable. The LPN documented that the physician was notified and the resident "was placed on report". Review of an untitled document, identified as the physician's answering service message ticket system (by the Director of Nursing (DON)) revealed that on [DATE] at 7:00 AM, the night shift LPN (#1) notified the service that the resident had a change in condition. "Message: Small amount of clear emesis". Review of a Nurse's Note, written by the Registered Nurse (RN) Supervisor, dated [DATE] at 8:30 AM revealed the resident had a change in condition. The RN Supervisor documented that the resident was cold, had a blood sugar of 486 (normal 60 to 120) and was verbally unresponsive. The RN Supervisor documented that a blood pressure could not be obtained, respirations were shallow at 30, and an apical pulse (heart rate assessed by listening to the heart beat with a stethoscope) was 58 and irregular. The resident responded to sternal rub ((the application of painful stimulus by vigorously rubbing the sternum with the knuckles of a closed fist to assess consciousness) and opened her left eye. The resident's oxygen saturation (SPO2 - amount of oxygen in the blood)) was 78 percent (%) (normal ,[DATE]%) and the resident was placed on oxygen at 4 liters. The resident's abdomen was distended and with a firm mass noted in the right lower quadrant. The RN Supervisor documented that she was "unable to distinguish" the resident's last bowel movement and "no bowel sounds were present". Further review of the Nurse's Note, revealed that the RN Supervisor placed a call to the resident's Health Care Agent and "discussed current change in condition, DNR status, and no artificial nutrition or hydration. Per Health Care Agent, plan of care collaboration with nursing to keep resident at facility/ comfortable as possible." The RN Supervisor also documented that a call was made to the physician's answering service at "8:50 AM" to report the resident's change in condition and plan of care and "Nursing staff to monitor, awaiting call back". Review of the physician's answering service message tickets revealed the day shift LPN Supervisor contacted the Physician [DATE] at 8:25 AM. "Message: Change in Condition". Review of a Physician's Telephone Order, signed by the LPN Supervisor, dated [DATE] at 8:47 AM revealed an order was obtained to send the resident to the hospital via ambulance for treatment and evaluation. Review of Nurse's Notes, written by the RN Supervisor dated [DATE] at 9:30 AM revealed the day shift LPN Supervisor spoke with the Physician and the Physician ordered to send the resident to the hospital due to emesis, no bowel sounds; and a right lower quadrant mass. At 9:40 AM, the RN Supervisor called the resident's Health Care Agent back and updated her on the physician's orders [REDACTED]. The RN Supervisor documented that the Health Care Agent agent agreed and was on the way to the facility. At 10:45 AM, the RN Supervisor documented that the Health Care Agent arrived at the facility at 9:45 AM and was notified that an ambulance was called. At 10:50 AM, the RN Supervisor documented that the ambulance arrived at the facility and upon entering the resident's room, the resident was "noted with no breathing". The RN Supervisor documented that the resident was absent of vital signs at 10:50 AM and the Physician's answering service was called to update the Physician regarding the resident's death. Further review of the physician's answering service message tickets revealed the following: -A call was placed to the Physician on [DATE] at 9:47 AM by the RN Supervisor. "Message: Sending her to hospital, Wants to speak with you". - At 11:01 AM, a call was placed by the RN Supervisor. "Message: passed away 10:50 AM." During an interview on [DATE] at 12:51 PM, the day shift LPN Supervisor stated that there were two supervisors working during the day shift on [DATE], "one RN and one LPN (myself)". The LPN Supervisor stated that he was aware that the resident had emesis just before 7:00 AM, and that the physician was called and orders were "to monitor". During the interview, the LPN Supervisor stated that he was called to the Dining Room around 8:00 AM (breakfast time), by the LPN Medication Nurse (LPN #2) who was monitoring the dining room. LPN #2 reported that Resident #36 "did not look right and she was dusky". The LPN supervisor stated that Resident #36 was alert, verbal, and "looking at us". The LPN Supervisor stated that the LPN Medication Nurse could not get a blood pressure, the resident's heart rate was in the mid 50's, and the PO2 was in the 70's. The LPN Supervisor stated "We got the resident in bed and placed her on oxygen" and the RN Supervisor joined them in the resident's room to do her assessment. The LPN Supervisor went on to say that he called the physician "sometime about 8:30 AM" and the physician called back about 10 or 15 minutes later. The LPN Supervisor said he reported the resident's current condition; the resident's vital signs; and that the resident had no palpable blood pressure (obtaining a blood pressure by feeling the pulsation of blood over an artery). The LPN Supervisor stated that the physician gave the order to send the resident to the hospital. The LPN Supervisor said that the resident was a DNR but had no limitations of care in place. The LPN Supervisor added after he received the order to send the resident out to the hospital, there was a page for a supervisor to go assist on another floor. The LPN Supervisor stated that he ran down to Resident #36's room and told the RN Supervisor that the physician gave the order to send the resident to the hospital. The LPN Supervisor stated he then went to handle the other situation and he did not document in the medical record (other than the order) because the RN Supervisor took over. The LPN Supervisor also stated that "in an emergency situation, we call the MD, he gives us the orders - to send or not and then we contact the family if there are no limitations in place". During an interview on [DATE] at 2:58 PM in the presence of the Administrator, the Director of Nursing (DON) stated that the expectation in an emergency situation is that the physician is called. The DON stated "If no limitations of care are in place, the ambulance would be called immediately and then the call to the family". During a telephone interview on [DATE] at approximately 10:20 AM, the Communications Supervisor for the ambulance service stated that "they received the call at 10:27 AM on [DATE] to dispatch an ambulance and the ambulance arrived onsite at 10:38 AM." During a telephone interview on [DATE] at approximately 10:30 AM, the RN Supervisor stated that she "was told by the LPN Supervisor of the physician's orders [REDACTED]." The RN Supervisor stated "she was trying to advocate for the HCP (agent) and the resident". The RN Supervisor said "she felt the resident was actively dying, based on her assessment" and that she was "not sure of what the facility policy is on when there is an acute change in a resident's condition." During an interview on [DATE] at approximately 7:37 AM, LPN #2 stated that when she completed the resident's fingerstick (pricking the finger to obtain a sample of blood to test blood sugar) just before breakfast; she recalled that the resident was pale, but alert and responsive. During an interview on [DATE] at 8:35 AM, the Assistant Director of Nursing (ADON) stated that when a resident is a DNR "it does not mean not to treat." The ADON stated the expectation is that the physician should be called and the physician will give orders to send (to the hospital) or not. During an interview on [DATE] at 9:25 AM, the Physician stated that the information he received from the LPN Supervisor on [DATE] was more than sufficient evidence that the resident needed to be sent to the hospital. The Physician stated that his expectation is that in an acute situation or when there is a significant decline in a resident's condition, the resident should be sent out to the hospital immediately, particularly if there were no Advanced Directives in place to keep the resident at the facility. The Physician stated "the reason we would send a resident out to the hospital is that we cannot handle the situation at the facility and with the hope to preserve life." The Physician stated the resident should have been transferred to the hospital about 20 minutes after he gave the transfer order. During an interview on [DATE] at 10:45 AM, the Social Worker (SW) stated he never had a meeting or a discussion with staff members, the resident or the Health Care Agent that there was a change in the residents condition that warranted the need to have a meeting to further re-evaluate or discuss limitations of care for the resident. The SW stated that the resident had a DNR and a HCP. The SW stated that he had no documentation that the HCP was activated. During an interview on [DATE] at 11:18 AM, the NP stated the "bottom line is that the MD gave an order to send the resident to the hospital and the order should have been followed." Review of a facility policy and procedure entitled "Change in Resident's Condition or Status" dated [DATE] revealed the resident's responsible party will be notified of a change in condition except in medical emergencies and notifications will be made as soon as possible. In summary, Resident #36 experienced a significant change in condition on [DATE] at approximately 8:00 AM. The Physician ordered that the resident be sent to the hospital at 8:47 AM; the ambulance was called at 10:27 AM and the resident expired when the ambulance arrived in the resident's room at 10:50 AM. There was an approximate one and one half hour delay sending the resident to the hospital. 415.12