Every finding on record at Woodside Manor Nursing Home Inc

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/25/2025 to 08/29/2025, for one (1) of one (1) main kitchen, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, raw shell eggs and raw chicken were not stored in a sanitary manner to prevent cross contamination, temperature controlled for safety (potentially hazardous) foods were not hot-held for service at 140 degrees Fahrenheit ( ) or above, thermometers were not stored in a sanitary solution, there was a severely dented can of food, condensation was dripping onto a food container from a hole in a reach-in cooler, and food items were undated and unlabeled. The findings are:Record review of the facility policy titled food storage, dated January 2008, revealed the policy included the following:All food products must be stored, labeled, and dated appropriately by the department procedure to prevent spoilage and possibility of food borne illnesses.Items will be placed in the refrigerator and freezer in a manner to prevent cross contamination.Raw meat will be stored separately in pans, if necessary, on the bottom shelves of the refrigerator or freezer.Eggs will be stored separately on the bottom shelf of the refrigerator. The facility policy Food Temperatures, last revised September 2023, included the following:The facility will ensure that all food is cooked and maintained at proper temperatures.Foods should be stored at the appropriate temperature to maintain safety. Hot foods: hold at 135 Fahrenheit or higher.The facility policy Thermometers, revised May 2020, included the following:Thermometers should be sanitarily stored within the kitchen department when not in use. Observations and an interview during the initial tour of the main kitchen on 08/25/2025 from 8:55 AM to 9:40 AM included the following:There was an approximately 1/2-inch hole in the interior ceiling of the four-door Traulsen reach-in cooler with condensate liquid dripping down and pooling on the lid of a container of tomato soup.There was a stainless-steel pan of what appeared to be approximately 24 cooked shell eggs and a stainless-steel pan of cut cubes that appeared to be cantaloupe that were unlabeled and undated in the 4-door Traulsen reach-in cooler. During an interview at that time, the cook stated the eggs and cantaloupe were prepared the previous afternoon.There was a tray holding five (5) crates of raw shell eggs with five (5) 32-ounce containers of pasteurized liquid eggs stored together and immediately adjacent to each other on the same tray. This was located in the four-door Traulsen reach-in cooler.There was a stainless-steel pan of raw chicken breasts stored directly above a box of raw single sliced bacon in the four-door Traulsen reach-in cooler.There was a 6-pound and 10-ounce can of fruit cocktail in the dry storage room that was severely dented at the end seams on the top and bottom.During observations and an interview on 08/25/2025 at 12:05 PM, there were several cheeseburger patties being held for lunch service in an open-holed pan on the steam table in the main kitchen. When checked by the surveyor using a digital thermapen (a high-performance, instant-read digital thermometer), the temperatures of the cheeseburger patties ranged from 123 Fahrenheit to 133 Fahrenheit. During an interview at this time, the cook stated the burgers had been cooked to about 180 Fahrenheit in the oven and were placed on the steam table a few minutes ago. The cook then placed the burgers back into the oven for reheating.During observations and interviews on 08/25/2025 at 12:08 PM, the cook provided the surveyors with the kitchen food service thermometers. There were four (4) bimetallic dial type and one digital probe thermometers in a plastic cup filled with a partially clear liquid with visible debris. During an interview at that time, the cook stated the thermometers were stored in clean water and was not sure when the last time it was changed. During an interview at that time, the Food Service Director stated they should be using a sanitizer solution to store the thermometers. 10 NYCRR: 415.14(h), 10 NYCRR: Subpart 14-1, 14-1.30, 14-1.31(c), 14-1.43(c,e), 14-1.95, 14-1.110(b), 14-1.112

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/25/2025 to 08/29/2025, for one (1) (Resident #48) of one (1) resident reviewed, the facility did not ensure the interdisciplinary team determined the Resident's right to self-administer medications was clinically appropriate. Specifically, Resident #48 was observed to have a bottle of antifungal powder at their bedside and the Resident stated they had been self-administering the medication. There were no medical orders in place for the powder, for the resident to self-administer or to keep medications at the bedside, and no comprehensive care plan was in place to address the self-administration of medications. This is evidenced by:Resident #48 had diagnoses including diabetes, chronic obstructive pulmonary disease (a disorder that restricts air flow in the lungs), and heart failure. The Minimum Data Set (a resident assessment tool), dated 08/27/2025, documented the resident was cognitively intact. During an observation and interview on 08/27/2025 at 9:17 AM, a bottle of miconazole nitrate 2% powder was at Resident #48's bedside. During an interview at that time, Resident #48 stated they had brought the medication with them when they were admitted to the facility, and the staff had been applying the powder underneath their breasts and within the skin folds of their groin.Review of Resident #48's Order Summary Report (medical orders), current as of 08/29/2025, included an order for miconazole nitrate topical cream 2%: apply to rash to right abdominal fold topically twice daily for 14 days. The orders did not include miconazole nitrate 2% powder, to self-administer medications, or for medications to be kept at the bedside. Review of the Comprehensive Care Plan, dated 08/21/2025, did not include measurable goals and/or interventions addressing Resident #48's ability to safely self-administer medications or store medications at the bedside. During an observation and interview on 08/28/2025 at 10:42 AM, the bottle of miconazole nitrate 2% powder remained at Resident #48's bedside. During an interview at that time, Resident #48 stated the powder was prescribed to them by a dermatologist and they had used the powder for a couple of years. During an interview on 08/28/2025 at 10:58 AM, Licensed Practical Nurse #3 stated Resident #48 did not have an order for miconazole nitrate 2% powder and the powder is considered a medication. They stated the resident should have had an order for the powder, been assessed for safety, and care-planned for the self-administration of medications.During an interview on 08/28/2025 at 11:04 AM, Nurse Practitioner #1 stated miconazole nitrate 2% powder is considered a medication and they did not know Resident #48 had been using the powder. During an interview on 08/28/2025 at 2:53 PM, the Director of Nursing, stated they were not aware Resident #48 had medications at the bedside. They stated for a resident to self-administer medications, they would have to ensure the resident was cognitively intact, could demonstrate safe self-administration of medications, the interdisciplinary team would discuss and approve the plan, provider orders for self-administration and having medications kept at their bedside would need to be in place, and the Resident's care plan would be updated to reflect this. The Director of Nursing stated Resident #48 had managed their medications independently prior to admission to the facility and was safe to self-administer medications. 10 NYCRR 415.3(f)(1)(vi)

Based on observation, interviews, and record review conducted during a Recertification Survey from 08/25/2025 to 08/29/2025, for two (2) (Residents #25 and #30) of two (2) residents reviewed, the facility did not ensure the residents' right to privacy and the confidentiality of their personal and medical records was maintained. Specifically, a computer stationed in a hallway by a resident's room was observed open, exposing Resident #25's personal and medical information, and there were no staff members present to secure the information for nine (9) minutes and a computer was observed open, exposing Resident #30's personal information and medication administration record and there were no staff members present to secure the information for several minutes. The findings are:The facility Workstation Security Policy, dated September 2013, included a laptop computer qualified as a workstation, and all staff should lock their computer when left unattended for any period of time. 1. Resident #25 had diagnoses including chronic pain, chronic kidney disease, and macular degeneration (a progressive eye condition). The Minimum Data Set (a resident assessment tool), dated 08/13/2025, documented the resident had moderately impaired cognition.During an observation and interview on 08/25/2025 at 9:25 AM, a computer was stationed on a medication cart in the hallway facing outward near a resident's room. The computer screen was open, exposing Resident #25's picture, name, date of birth , room number, and acetaminophen medication order. At 9:34 AM, Licensed Practical Nurse #1 returned to medication cart A and stated they should have closed the computer screen when they left the medication cart. 2. Resident #30 had diagnoses including Parkinson's Disease (nerve cell damage in the brain that affects movement), diabetes, and major depressive disorder. The Minimum Data Set, dated [DATE], documented the resident was cognitively intact.During an observation and interviews on 08/26/2025 at 8:16 AM with Licensed Practical Nurse #3 and the Administrator, Licensed Practical Nurse #3's medication cart was in the hallway, unlocked, and the computer screen was open with Resident #30's personal information and medication administration record exposed. During an interview at that time, the Administrator stated they should lock the medication cart and close the computer screen because they should not be open. The Administrator secured the medication cart and computer screen at that time. Licensed Practical Nurse #3 exited Resident #30's room, across the hall from the medication cart and stated they were in the resident's room administering a medication and had not been away from the cart for a long period of time.During an interview on 08/27/2025 at 9:39 AM, the Director of Nursing stated resident personal information should not be visible when the nurse is away from the medication cart. They would expect the nurse to close or minimize the computer screen when walking away.10 NYCRR 415.3(e)(1)

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/25/2025 to 08/29/2025, for one (1) (Residents #12) of one (1) resident reviewed, the facility did not ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, for multiple days, Resident #12 was observed with dark brown debris underneath their fingernails and was observed eating food with their hands. This is evidenced by the following:The facility policy Care of Finger and Toenails, dated October 2023, documented in part the purpose of this procedure is to clean the nail bed, keep nails trimmed, and prevent infections. Nail care is to be completed/offered on shower days and as needed. Nail care includes cleaning and regular trimming. Length of nails/trimming is based on resident preference. Resident #12 had diagnoses that included vascular dementia, anxiety, and depression. The Minimum Data Set (a resident assessment tool), dated 07/16/2025, documented the resident had severe cognitive impairment and required assistance with personal hygiene.Review of the current Comprehensive Care Plan, last revised 05/02/2025, and Kardex (care plan used by certified nursing assistants to direct resident care), current as of 08/29/2025, revealed Resident #12 required staff assistance with grooming and the resident could be combative with nail trimming. Interventions included the staff redirecting the resident by calling it a ''spa day, informing the resident their family had paid for a special nail day, and staff were encouraged to leave the resident in a position of safety and reattempt when they appeared calm. Review of current Order Summary Report (medical orders), dated 02/18/2025, revealed Resident #12 had a finger foods diet.During an observation on 08/27/2025 at 9:56 AM, Resident #12 was seated at the nurse's station and their fingernails on both hands were long with dark brown debris underneath multiple nails. The resident's nail polish was chipped or missing on most fingers and two fingers on their left hand had jagged nails. During an observation on 08/27/2025 at 3:05 PM, Resident #12 was seated at the nurse's station eating a slice of cake with their bare hands and continued to have dark brown debris underneath multiple fingernails.During an interview on 08/27/2025 at 3:12 PM, Certified Nurse Assistant #3 stated they used hand sanitizer to cleanse residents hands and Resident #12 required cueing with hand hygiene because they liked to eat with their hands. Certified Nurse Assistant #3 stated they did not clean Resident #12's hands that day and did not know if anyone else had prior to giving the resident a slice of cake. Certified Nurse Assistant #3 stated the resident should receive nail care on Tuesdays, it was apparent they had not received nail care, and staff would usually ensure nails and hands were clean before serving food and snacks. Certified Nurse Assistant #3 stated the resident had never refused care without eventually complying, especially when their family visited. During an observation on 08/28/2025 at 10:53 AM, Resident #12's fingernails on both hands had dark brown debris underneath and the thumb nail on their left hand had sharp edges. During an interview on 08/28/2025 at 11:07 AM, Licensed Practical Nurse #3 stated they had not received reports of Resident #12 refusing nail care. They stated the certified nursing assistants were usually able to provide nail care to the resident, but if they were to report a refusal, the nurse was expected to document the incident and reapproach the resident. During an interview on 08/28/2025 at 2:45 PM, the Director of Nursing stated Resident #12 had a history of digging in their brief and they suspected the dark brown debris underneath their fingernails was feces. The Director of Nursing stated they would expect staff to perform hand care before meals, as needed, and as tolerated. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/25/2025 to 08/29/2025, for one (1) (Resident #4) of one (1) resident reviewed, the facility did not ensure a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. Specifically, a nurse was observed performing wound care to Resident #4's right heel pressure ulcer, did not follow the medical orders in place for the wound treatment, and did not change gloves or perform hand hygiene in between removing the old dressing and applying the new dressing. This is evidenced by: Review of the facility Wound Care Policy and Procedure, last updated June 2022, included the person performing wound care should remove soiled gloves after removing an old dressing and put on a new pair of gloves before applying a new dressing according to the physician order. Resident #4 had diagnoses that included dementia, dysphagia (impaired ability to swallow), a pressure ulcer on the sacral (tailbone) region, and a pressure ulcer on the heel. The Minimum Data Set (a resident assessment tool), dated 07/30/2025, documented the resident had severe cognitive impairment, was at risk of developing pressure ulcers, had unhealed pressure ulcers, and received pressure ulcer care.Review of the Order Summary Report (medical orders) included an order, dated 08/19/2025, to cleanse the right heel pressure ulcer with wound cleanser, pat dry with gauze, apply a layer of medi-honey (a medical-grade honey product used to promote wound healing), and cover with a 3-inch by 3-inch adhesive foam dressing every day shift.Review of the current comprehensive care plan, dated 08/05/2025, revealed Resident #4 had impaired skin integrity as evidenced by the presence of pressure ulcers. Interventions included, but were not limited to, provide treatment as ordered by the medical provider. During an observation on 08/27/2025 at 10:29 AM, Licensed Practical Nurse #3 performed a dressing change to Resident #4's right heel pressure ulcer. Licensed Practical Nurse #3 removed the old dressing from the wound, cleansed the wound, and applied a new dressing without changing their gloves or performing hand hygiene in between. Additionally, Licensed Practical Nurse #3 did not apply the prescribed medi-honey to the wound area. During an interview on 08/27/2025 at 11:51 AM, Licensed Practical Nurse #3 stated the process for Resident #4's wound care was to remove the old dressing, cleanse with wound cleanser spray, doff (remove) soiled gloves, don (put on) clean gloves, then cover the area with a new dressing. They stated they did not know the Resident's wound care order had changed to include the application of medi-honey and should have checked the medical orders prior to performing the dressing change.During an interview on 08/28/2025 at 2:26 PM, the Infection Preventionist stated a nurse should check the medical orders prior to performing a dressing change in case the order has been modified. They stated when a soiled dressing is removed during wound care, the nurse should remove their gloves, perform hand hygiene, and don new gloves before applying a new dressing. During an interview on 08/28/2025 at 3:00 PM, the Director of Nursing stated they would expect nursing staff to follow wound care instructions per the medical order, check the order prior to performing wound care, and notify the medical team if the order could not be followed as written. They expected the nursing staff to follow the appropriate technique and change their gloves between removing an old dressing and applying a clean dressing.10 NYCRR 415.12(c)(1)

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/25/2025 to 08/29/2025, for two (2) (Hallway A Medication Cart and Hallway B Medication Cart) of two (2) medication carts and one (1) of one (1) Medication Storage Room, the facility did not ensure all drugs and biologicals were stored in locked compartments in accordance with State and Federal laws and did not ensure an account of all controlled drugs was maintained. Specifically, medication carts were left unlocked and unattended on multiple occasions, medications stored on top of a medication cart were left unattended, and a narcotic log was missing several nurse signatures to verify the accuracy of the narcotic count at shift change. The findings are:Review of the facility Medication Storage Policy and Procedure, last revised May 2023, included all medications will be stored within a locked medication room, cart, boxes, or refrigerators, and the handoff/sign off of keys will be conducted between each shift. Review of the facility policy Medication Administration, last revised 01/16/2022, included the medication cart is to be locked at all times when the nurse is not working at it, never leave the medication cart open and unattended, do not leave any medications on top of the cart when unattended, and medications should not be left bedside unless stated so in a physician's order.During an observation on 08/25/2025 at 9:27 AM, the Hallway B Medication Cart was unlocked, unattended, and there were medications sitting on top of the cart including one (1) unidentified blister pack (packaging for medications) of pills, one (1) bottle of latanoprost (eye drops), one (1) bottle of dorzolamide (eye drops), one (1) bottle of Rhopressa (eye drops), and one (1) bottle of nitroglycerin (heart medication). At 9:34 AM, Licensed Practical Nurse #1 returned to the cart. During an immediate interview, Licensed Practical Nurse #1 stated medications should not be left on top of the medication cart and the cart should be locked when unattended.During an observation and interview on 08/25/2025 at 12:55 PM, the August 2025 Narcotic Record Sign-in Sheet was reviewed and for 8 of 164 opportunities, there were missing signatures on various shifts and no documented evidence the narcotic count was verified by two (2) nurses. During an interview at that time, Licensed Practical Nurse #1 stated two (2) nurses should complete the narcotic count and sign the Narcotic Record with each shift change. They stated the narcotic logbooks should be checked and maintained by a nurse manager to ensure the narcotic count is verified every shift. During an observation and interview on 08/28/2025 at 8:16 AM, the Hallway A Medication Cart was unlocked, unattended, and there was an open, half-full bottle of Tylenol 500 milligrams tablets and a tube of muscle rub topical cream sitting on top of the cart. Licensed Practical Nurse #3 exited a resident's room and during an interview at that time, stated the bottle of Tylenol was left open because they had just administered it to a resident, and they had not left the medication cart unattended for long. During a continuous observation on 08/28/2025 from 11:07 AM to 11:43 AM, the Hallway A Medication Cart was unlocked and unattended. Licensed Practical Nurse #3 returned to the cart at 11:43 AM. During an immediate interview, Licensed Practical Nurse #3 stated they were moving too fast and forgot to lock their medication cart. During an interview on 08/28/2025 at 3:53 PM, the Director of Nursing stated that at no time should medications be left unattended on top of the medication cart and the cart should always be secured. During a follow-up interview at 4:21 PM, the Director of Nursing stated nurses are expected to verify the narcotic count by signing the Narcotic Record Sign-in Sheet at each shift change. 10 NYCRR 415.18(a), (e)(1-4)

Based on observations, interviews, and record review conducted during a Recertification Survey from 08/25/2025 to 08/29/2025, for one (1) (Resident #4) of two (2) residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, a nurse was observed removing an old dressing from a wound and applied a clean dressing without changing gloves. Additionally, staff was observed handling soiled and potentially contaminated laundry wearing gloves and no gown to protect clean laundry from potential contamination and themselves from potential exposure. The findings are:The facility Wound Care Policy and Procedure, dated June 2022, included wounds should be treated and cared for in a manner which prevents infection, gloves should be removed and hand hygiene performed after removing an old dressing, and new gloves should be applied before applying a new dressing. The State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, revised 04/28/2025, documented gloves should be changed and hand hygiene performed before moving from a contaminated body-site to a clean body-site during resident care. Resident #4 had diagnoses including a stage two (2) pressure ulcer of the left heel, a stage four (4) pressure ulcer of the sacral region, and diabetes. The Minimum Data Set (a resident assessment tool), dated 07/30/2025, documented the resident had severely impaired cognition, one (1) or more unhealed pressure ulcers, and received pressure ulcer care.Review of Resident #4's Comprehensive Care Plan, dated 06/24/2025, revealed the resident had impaired skin integrity related to a stage two (2) pressure ulcer on their right heel and a chronic stage four (4) ulcer on their coccyx (tailbone region). Interventions included, but were not limited to, staff were to perform skin rounds and provide treatment to the area as ordered by the medical provider. During an observation on 08/27/2025 at 10:29 AM, Licensed Practical Nurse #3 removed the soiled dressing from Resident #4's right heel pressure ulcer, cleansed the wound bed, and applied a clean dressing without changing gloves or performing hand hygiene in between. During an interview on 08/27/2025 at 11:51 AM, Licensed Practical Nurse #3 stated they should have removed the soiled dressing, cleansed the wound, then changed their gloves before applying a new dressing to the wound. During an interview on 08/28/2025 at 2:28 PM, the Infection Preventionist stated the nurse should have removed their gloves and performed hand hygiene in between handling the soiled and clean dressings.The facility Infection Control Policy and Procedure, dated November 2024, included staff handling linen should follow Standard Precautions (basic infection control guidelines which include wearing a gown and gloves to prevent the spread of infection whenever there is a possible exposure).The State Operations Manual Appendix PP-Guidance to Surveyors for Long Term Care Facilities, revised 04/28/2025, documented facility staff should handle all used laundry as potentially contaminated and use standard precautions and appropriate Personal Protective Equipment (items worn to prevent the spread of infection including gown, gloves, and masks). During an interview on 08/27/2025 at 8:53 AM, Laundry Staff #1 stated they only wore gloves to handle soiled linens and resident's personal clothing. The stated they wore gowns and gloves if residents were on isolation precautions (infection control practices used alongside standard precautions). During an observation on 08/28/2025 at 8:49 AM, Laundry Staff #1 was handling visibly soiled bed pads, towels, and hospital gowns which had a strong odor of urine and feces. Laundry Staff #1 was only wearing gloves while handling the soiled items.During an interview on 08/28/2025 at 10:34 AM, the Infection Preventionist stated housekeeping and laundry staff should wear gloves and a gown when handling soiled laundry. During an interview on 08/28/2025 at 11:52 AM, the Administrator stated staff should be wearing gloves and a gown when handling soiled laundry. 10 NYCRR 415.19 (a)-(c)

Based on observation, interview, and record review conducted during a Recertification Survey completed on 7/13/22, the facility did not ensure that for two (Resident #7 and Resident # 10) of two residents reviewed, each resident had the right to receive visitors of their choosing at the time of their choosing and in a manner that does not impose on other residents. Specifically, the facility had posted visiting hours, limited the number of visitors per resident, and required advanced scheduling of visitors. This is evidenced by the following: The Center for Medicare and Medicaid Services issued QSO-20-39 NH, revised on 3/10/22, documented facilities must allow indoor visitation at all times and for all residents as permitted under the regulations. While previously acceptable during the Public Health Emergency, facilities can no longer limit the frequency and length of visits for residents, the number of visitors, or require advance scheduling of visits. Additionally, the document included that facilities may ask about a visitors' vaccination status, however, visitors are not required to be tested or vaccinated as a condition of visitation. The facility Visitation Policy, last revised 1/7/22, documented that visitation hours were from 10 a.m. to 6 p.m. Monday through Friday, and 10 a.m. to 4 p.m. on Saturday and Sunday. Special accommodations, such as visiting outside of visitation hours, or compassionate care visits, could be made with the Administrator. In order to ensure proper social distancing and infection control guidelines, residents will be allowed two visitors at a time in resident rooms, and four visitors at a time in common areas. Visitation area visits can be restricted to designated areas only as determined by Administration and the New York State Department of Health. During an observation on 7/7/22 at approximately 8:15 a.m., a sign was located on the right-hand side of the second set of doors leading into the main entrance of the facility. The sign was visible from the first set of doors and included in large font [NAME] Manor is open for Visitation! Visitation Hours are Monday through Friday 10:00 a.m., to 6:00 p.m., Saturday and Sunday 10:00 a.m. to 4:00 p.m. When interviewed on 7/7/22 at 8:52 a.m., the Front Desk Receptionist (FDR) stated that visitation was from 10 a.m. to 6 p.m. Monday through Friday and 10 a.m. to 4 p.m. on weekends. At 12:07 p.m., the FDR stated that upon entrance to the facility visitors are screened and tested for COVID-19 and then must wait 15 minutes for the results. The FDR stated that if the resident is assigned to a private room, they can have a visit in their room and if the resident resides in a shared room the resident is brought to the lobby for the visit in order to allow for social distancing. 1.During an interview on 7/7/22 at 8:57 a.m., Resident #7 (identified by the medical record as cognitively intact) stated that their family had to call ahead of time before they visit. Resident #7 stated that the week before they had a family member die and their family was coming to tell them in person, but they forgot to call ahead and were required to do a window visit instead of coming into the facility. The resident stated that they did not know what the visiting hours were because they changed all the time and that there were multiple restrictions. 2.During an interview on 7/8/22 at 11:57 a.m., the family members of Resident #10 stated that they had to make an appointment to visit and that they have asked staff when they were going to do away with all the rules. They said that about a month ago they were visiting and had to go outside for the visit because they had more than two visitors. When interviewed on 7/12/22 at 8:04 a.m., the Director of Nursing (DON) stated that if a resident is in a private room, visitation can take place in the room with up to two visitors. The DON stated if a resident is in a semiprivate room, one of the residents can have a visit in their room if social distancing can be maintained. The DON stated that if visitors call in the morning requesting to schedule a visit, 99.9% of the time they can visit that day. The DON stated that schedules for visitation are arranged but if someone wants to visit outside of those times, they can be accommodated by alerting the DON as to what time the visitors are coming and how many because there cannot be too many people in a semiprivate room. When interviewed on 7/13/22 at 9:06 a.m., the Director of Social Work (DSW) stated visits do not need to be scheduled, but the visiting hours are Monday through Friday 10 a.m. to 6 p.m. and Saturday and Sunday 10 a.m. to 5 p.m. unless the resident is on compassionate care, palliative care, or hospice. The DSW stated that visiting hours help control the number of people in the building for infection control purposes and allow for COVID-19 testing. When interviewed on 7/13/22 at 9:18 a.m., the Administrator stated that visitation was open with visitation hours from 10 a.m. to 6 p.m. Monday through Friday and 10:00 a.m. to 4 p.m. on the weekends. Families were asked to call ahead for visitation to come outside the visitation hours as a heads up but it was okay if they did not. The Administrator stated that they wanted to make sure there were enough staff available for COVID-19 testing. The Administrator stated that room visits were limited to two people per resident room and four people per common area for infection control purposes. The Administrator stated that they had let family members know verbally and had sent out a mailing indicating that they can come after visitation hours. The Administrator stated that a copy of the updated policy was also sent to family members and/or resident's Health Care Proxy. The Administrator stated that they had notified staff via email that visitation was open. 10 NYCRR 415.3(c)(2)(iv)

Based on observations, interviews, and record reviews conducted during the Recertification Survey completed on 7/13/22, it was determined that for one (Resident #32) of five residents reviewed, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition. Specifically, Resident #32 did not receive the assistance with eating per their Comprehensive Care Plan (CCP). This is evidenced by the following: Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 6/15/22, documented that the resident had severely impaired cognition and required supervision and one-person physical assist for eating. The current CCP and the Certified Nursing Assistant (CNA) Kardex (drives daily care) for eating revealed Resident #32 required assistance with feeding, and staff were to alternate liquids and solids, cut up food into bite size pieces, and assist with finger foods. Additionally, the CCP documented that the resident was at a nutritional/dehydration risk, had significant weight loss, and was at risk for additional weight loss related to dementia with a decline in self-feeding, language barrier, missing teeth, and dysphagia (difficulty swallowing) with food holding requiring an altered consistency and adult failure to thrive. During an observation of the lunch meal on 7/8/22 from 12:23 p.m. through 1:15 p.m., Resident #32 was seated in a wheelchair at a dining room table drinking a 4-ounce (oz.) cup of strawberry shake. Resident #32's meal tray also included a bowl of three bean salad, tuna salad on a croissant, and a slice of apple pie. Resident #32's meal ticket included two 4 oz. cups of orange BOOST (liquid supplement) which was not included on the tray, finger foods and soft ground consistency. Resident #32 finished the strawberry shake and then continued to attempt to drink from the empty cup. At approximately 12:30 p.m., a staff person removed the empty cup from Resident #32's hand but did not offer any additional food or drink. At 12:52 p.m., another staff member started to sit down next to Resident #32 but was called away prior to offering the resident any food or drink. Resident #32 sat at the table without eating or drinking anything until 12:59 p.m., when CNA #1 sat down and fed the resident several bites of food without offering any liquids. At 1:17 p.m., CNA #2 stated that the kitchen staff usually put the BOOST supplements on resident meal trays but if not, then staff should ask the kitchen staff or nurses to get it. CNA#2 then retrieved two 4 oz. cups of orange BOOST for Resident #32 who immediately began drinking independently. During an observation on 7/11/22 at 9:26 a.m., Resident #32's untouched breakfast tray was on top of a meal cart with two 4 oz. cups of orange BOOST, a white thickened drink, dry cereal, and a breakfast sandwich. At 9:31 a.m., RN #1 delivered the tray to Resident #32 overbed table (resident was sitting up in bed) and left without offering the resident any food. Resident #32 was not eating or drinking. At 9:40 a.m., RN #1 returned to the resident's room and gave Resident #32 a half of the breakfast sandwich. During an observation of the lunch meal on 7/11/22 at 1:14 p.m., the Director of Nursing (DON) was seated next to Resident #32 assisting and encouraging them for a short period and then left the resident with a 4 oz. glass of orange BOOST in their hand. Resident #32 was tipping the glass and not drinking it. No other staff were observed assisting the resident until the DON returned at 1:26 p.m. When interviewed on 7/13/22 at 9:41 a.m., the Senior CNA stated that they often care for Resident #32 and that the resident required assistance throughout the meal including encouragement, cues, and at times needed to be fed the entire meal. The Senior CNA stated Resident #32 goes to the dining room for meals due to the need for assistance, eats mostly handheld foods, should be offered one item at a time, and should switch between solids and liquids. When interviewed on 7/13/22 at 10:23 a.m., the DON stated that Resident #32 needed to eat their meals in the dining room (vs in their room) with staff sitting next to them or checking on them frequently. When surveyor observations of meal times were discussed, the DON stated that Resident #32 should have received more frequent assist. [NYCRR 415.12 (a)(3)]

Based on observations, interviews and record review conducted during the Recertification Survey completed on 7/13/22, it was determined that for one (Residents #7) of 37 residents reviewed for food allergies and one (Resident #15) of one resident reviewed for preferences, the facility did not ensure that food was provided that accommodated resident allergies, intolerances, and preferences. Specifically, Resident #7's lunch tray that was ready to be served prior to Surveyor intervention, contained seafood that Resident #7 had a noted allergy to, and Resident #15 was not care planned for or offered a diet specified by their religious preference. The findings are: 1.Resident #7 had diagnoses including [CONDITION(S)], muscle weakness, and Type 2 diabetes. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #7 was cognitively intact and required supervision and set-up help for eating. The Comprehensive Care Plan (CCP) last reviewed 7/7/22, documented that Resident #7 was at risk for allergic reaction presenting with swelling related to allergies to blueberries, strawberries, seafood, and shellfish. An interdisciplinary progress note dated 4/17/21 and signed by the Registered Dietician (RD) documented that Resident #7 was at risk for allergic reaction presenting with swelling related to allergies to blueberries, strawberries, seafood and shellfish and that meal tickets alert staff to these allergies and offers a safe substitution when these items are on the menu. An interdisciplinary progress note dated 6/9/21 and signed by the RD documented that dietary continued to avoid strawberries, blueberries, seafood, and shellfish on Resident #7's tray. During an observation on 7/8/22 at 12:19 p.m. during lunch service preparation Resident #7's tray ticket documented an allergy to blueberries, strawberries, seafood, shellfish, and diet condiments all highlighted in red, and instructions to staff to read ticket thoroughly to ensure tray is allergen free. The tray ticket further included that the resident was to receive tuna salad on a croissant for their meal. A tuna salad on a croissant was plated by the cook for Resident #7's room tray and given to a dietary aide who placed it onto the tray carrier. After surveyor intervention, the tray was removed from the carrier and the tray ticket given to the cook for review. In an interview at the time, the cook stated that Resident #7's tray ticket included a fish allergy and that allergies are noted in red on the ticket. Further observation in the kitchen included a sign above tray line that read Be sure to check tray tickets for red or yellow precautions or allergies. In an interview on 7/8/22 at 12:22 p.m. the Food Service Director (FSD) stated that the kitchen's ticket programming system should have been programmed to not have tuna salad show up to serve Resident #7 if there was a seafood allergy noted. The FSD stated that the Dietician should audit the meal tickets. In an interview on 7/8/22 at 12:41 p.m. and again at 3:37 p.m., Resident #7 stated that if they eat tuna fish their face swells up requiring a trip to the Doctor. Resident #7 stated that they have had strawberries and blueberries served to them several times since they have been at the facility which they are also allergic to. In a telephone interview on 7/8/22 at 2:23 p.m. the RD stated that residents with food allergies should have an order and an individualized meal ticket. If a resident is allergic to seafood, the allergy would be indicated at the top of the ticket and if an entrée was being served that included something the resident was allergic to, the 'Meal Tracker' (food service electronic system) should have been programmed to indicate to serve the resident something different. The RD stated that Resident #7's tray ticket should not have printed out tuna salad to serve. The RD said the previous Food Service Director was recently let go with one reason being an issue with programming errors in the 'Meal Tracker' system. 2.Resident #15 had diagnoses including adult failure to thrive, depression, and anxiety disorder. The MDS assessment dated [DATE], documented that Resident #15 had moderately impaired cognitive skills. The current CCP, under nutritional status approaches, included that Resident #15 was noted to have changing food and religious preferences. There was no documentation to address Resident #15's religious preference of maintaining a kosher diet or that Resident #15 preferred to keep meat separated from diary. During a meal observation on 7/7/22 at 12:53 p.m., Resident #15 expressed concerns to the Director of Nursing (DON) regarding their meal. Resident #15 stated they were unable to eat their ice cream because they were unsure if it was kosher. The resident stated they wanted to give their ice cream to their tablemate and the DON replied that other residents had their own ice cream and to just leave it. Resident #15 was observed to eat their turkey and tomato sandwich but not did consume the ice cream. At no time was Resident #15 offered a substitute or an offer to check the ice cream to see if it was kosher. Review of Resident #15's meal ticket at this time included no pork, no cheese with meat and small servings. The meal ticket did not identify the resident's religious preferences. During an interview 7/7/22 at 1:25 p.m., Resident #15 stated they did not consume their ice cream because they cannot mix meat with diary. Resident #15 stated they have been served meat with dairy in the past and that they had notified the charge nurse about this. During an interview on 7/8/22 at 9:40 a.m., the Line Cook stated that dietary preferences were communicated to the dietician and then the dietician notifies the kitchen about preferences and dietary needs which are placed on the meal tickets. The Line Cook stated that they were unaware of any residents within the facility that maintain a kosher diet. During an interview on 7/8/22 at 2:15 p.m., the Registered Dietician (RD) stated that food preferences are completed upon admission and menus should be based on preferences. The RD stated that Resident #15 was sometimes kosher but sometimes not. The RD stated that Resident #15 had not been consistently kosher by mixing meat with dairy at times if the resident saw another resident having meat with dairy. The RD stated that they have offered Resident #15 matzo ball soup which was accepted. The RD said that they had not informed the kitchen that Resident #15 was kosher or put it on their care plan. During an interview on 7/11/22 at 9:39 a.m., the Certified Nursing Assistant (CNA) stated that Resident #15 does not eat pork because they are Jewish. The CNA stated that once in a while non-kosher items will come on Resident #15's meal tray but to their knowledge Resident #15 has never tried to not eat kosher. The CNA stated that Resident #15's faith to maintaining a kosher diet has been consistent and important to them. 10NYCRR 415.14(d)(4)

Based on observations, interviews, and record reviews conducted during a Recertification Survey and complaint investigation (#NY 014), completed on 7/13/22, it was determined that the facility did not establish and consistently maintain an infection control program designed to prevent the development and transmission of disease and infection. Specifically, for one (Resident #19) of two residents reviewed for wound care the facility staff did not complete appropriate hand hygiene and glove changes to maintain a clean environment, for one (Resident #27) of two residents reviewed for urinary catheters (catheter inserted directly into the bladder to drain urine into a drainage bag) staff did not ensure the catheter tubing and drainage bag did not touch the ground or was positioned properly to avoid infections, and for one of one glucose monitoring observations staff did not disinfect a glucometer (machine used for testing blood glucose) after use and prior to storing with clean supplies. This is evidenced by the following: 1. Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 6/24/22, documented that Resident #19 had moderately impaired cognition and was at high risk for pressure ulcers but had no current skin issues. The facility policy, Infection Control/Prevention Program, dated April 2021, documented that hand hygiene would be performed before and after moving from contaminated body sites to clean body sites. Physician orders, dated 7/5/22, included orders to the left wrist skin tear which were to apply antibiotic ointment, cover with a [MEDICATION(S)] (non-adhering pad) and kling (gauze wrap). Orders for the right lower extremity (right leg) skin tear included a xeroform (petroleum based fine mesh gauze used to treat wounds), cover with a [MEDICATION(S)] pad and wrap with kling. Physician orders also included to apply a [MEDICATION(S)] to the left knee daily for pain. During an observation of wound care on 7/8/22 at 10:05 a.m., Licensed Practical Nurse (LPN) #1 applied gloves, removed the soiled wound dressing (gauze and three steri strips) from the left wrist, and without changing gloves, cleansed the wound with wound cleanser from a spray bottle and gauze, applied antibiotic ointment with a cotton swab, then covered the wound with gauze and tape. LPN#1 then removed their soiled gloves and without performing hand hygiene applied a clean pair of gloves. LPN #1 removed the soiled dressing from the right lower leg skin tear, picked up the same bottle of wound cleanser and sprayed the wound to cleanse, applied a xeroform gauze, covered the wound with a [MEDICATION(S)] pad, gauze and tape. Without changing their gloves or perform hand hygiene, LPN #1 applied a [MEDICATION(S)] to Resident #19's left knee. LPN #1 then removed their gloves and performed hand hygiene. During an interview on 7/8/22 at 10:30 a.m., LPN #1 did not provide an answer when asked if gloves should be changed when going from soiled dressings to clean or different areas of the body or touching the wound cleanser bottle. LPN #1 stated that the wound cleanser was used for other residents. During an interview on 7/11/22 at 10:22 a.m., the Director of Nursing (DON) stated that the nurse should have changed gloves after removing the wound dressings, before cleaning and applying a new dressing, and again before treating a different wound. During an interview on 7/11/22 at 1:28 p.m., the LPN/Educator stated that nurses are expected to change gloves when moving from a dirty (soiled) dressing to clean (new) dressing. 2. Resident #27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 6/13/22, documented that the resident had moderately impaired cognition and required an indwelling urinary catheter. Review of the facility policy Catheter Care, Urinary Procedure, dated March 2019, revealed that 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 (causing an infection). In addition, the policy documented that the catheter tubing and drainage bag were to be kept off the floor. Current physician orders included indwelling urinary catheter care per facility policy/protocol. During an observation on 7/8/22 at 9:15 a.m., Resident #27 was seated in a wheelchair in the hallway with the urinary catheter collection bag positioned touching the floor (including the drainage port). The catheter tubing was dragging on the floor. During an observation on 7/8/22 at 11:57 a.m., Resident #27 was seated in a wheelchair in the hallway with the urinary catheter collection bag hanging from underneath the wheelchair seat without a cover and the drainage port was again touching the floor. During an observation 7/11/22 at 3:09 p.m., Resident #27 was seated in a recliner in their room. The urinary catheter collection bag was hanging from the resident's bedside table, well above the level of the resident's bladder. During an interview on 7/11/22 at 3:35 p.m., Registered Nurse (RN) #1 stated that urinary catheters should drain to gravity, and the collection bags should be below the level of the bladder, but not touching the floor. During an interview on 7/12/22 at 8:54 a.m., Certified Nurse Aide (CNA) #1 stated that the urinary catheter collection bag should hang from the level of the bed and the collection bags should never touch the ground. During an interview on 7/12/22 at 10:00 a.m., the LPN/Educator stated that staff are educated to position the urinary catheter collection bag below the level of the bladder and to place covers on it, so it is not touching the ground. The LPN/Educator also stated that if the urinary catheter collection bag is above the level of the resident's bladder it could pose a risk for infection. 3. During an observation of medication administration pass on 7/8/22 at 12:38 p.m., RN#1 performed a blood glucose point of care test on Resident #9 using a glucometer. After the testing was completed, RN#1 brought the glucometer machine out of the resident's room and placed it in a bin with clean supplies without cleaning it. When interviewed at this time, RN#1 stated they clean the glucometer with bleach wipes before each use. RN#1 stated that she did not clean the glucometer after use and that the clean items in the bin would need to be disposed of. During an interview on 7/11/22 at 10:12 a.m., the DON stated that the expectation is to wipe the glucometer machine with bleach wipes after each use. Review of the facility policy Checking BGs and disinfecting glucometers, last revised December 2019, revealed that blood glucose meters must be cleaned and disinfected after every use using a bleach wipe following product label instructions to disinfect the meter. 10 NYCRR 415.19(b)(4)

Based on observations and interviews conducted during a Recertification Survey completed on 7/13/22, it was determined that for one (first floor) of one resident use floors and one of one kitchen, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. Specifically, an exhaust ventilation system was not working, ceiling tiles were damaged, a baseboard heater was dented, urine odors were consistently present in a shared bathroom, the interior of multiple hot liquid mugs were heavily stained, and a kitchen light fixture was lacking a cover. The findings are: 1. Observations on 7/7/22 from 9:37 a.m. to 12:37 p.m. included: a) One-half of a ceiling tile in the shared bathroom between rooms 21 and 22 was broken off. b) The baseboard heater located by the entrance door to room 22 was damaged with a large dent. c) There was an approximately one-inch hole in a ceiling tile in the housekeeping closet located across from room 21. d) There was a strong smell of urine in the shared bathroom between rooms 27 and 28. This same observation was made again on 7/8/22 at 10:58 a.m. and on 7/11/22 at 9:16 a.m. During an interview on 7/7/22 at 11:09 a.m., Resident #27 stated that when the bathroom door is open there is a smell, and they do not like where their bed is located because of the smell. 2. Observations in the presence of the Operations Supervisor on 7/8/22 from 10:31 a.m. to 10:58 a.m., revealed that the mechanical exhaust ventilation was not drawing air through the ventilation ducts in the following locations: shower suite near the nurse's station, the shared bathroom between rooms 27 and 28, and in the janitor's closet next to the employee breakroom. When the surveyor placed a sheet of paper against the exhaust grates, there was no evidence that air was being pulled from the spaces. In an interview at that time, the Operations Supervisor stated the shared bathroom between rooms 27 and 28 smelled like urine and they did not know why the ventilation is not working in the above-mentioned locations. 3. Observations on 7/8/22 from 11:45 a.m. to 12:30 p.m. in the main kitchen included: a) The inside surfaces of several dark red Turnberry by Dinex mugs (located on 3 trays on a rolling cart) were heavily stained with a brown residue. b) A two-bulb fluorescent ceiling light fixture lacked a cover and was located between the tray line and the two-bay sink. 10NYCRR: 415.29, 415.29(h)(1,2), 415.29(j)(1). 713-1.9(d), 415.14(h), 14-1.88(c), 14-1.91(a)

Based on interviews and record reviews conducted during the Recertification Survey completed on 7/13/22, it was determined that for two (Resident #20 and Resident #3) of two residents reviewed, the facility did not ensure a written notification, which specifies the duration of the bed-hold policy, was provided to the resident and/or the resident representative at the time of transfer to the hospital. This is evidenced by the following: The undated facility 'Short-Term Admission Agreement' form documented that the resident had the right to be fully informed, verbally and in writing, at the time of admission and again at the time of transfer from the facility for any reason, of the facility's bed hold/bed reservation policy. 1. Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) Assessment, dated 5/12/22, documented that Resident #20 was cognitively intact. Review of the Notice of Transfer/Discharge Letters, dated 5/26/22 and 5/31/22, revealed that Resident #20 was transferred to the hospital. There was no information documented in either letter or in the medical record that the resident and/or family was notified in writing of the bed hold policy. A discharge MDS Assessment, dated 5/31/22, documented that Resident #20 had been discharged with a return to the facility anticipated. 2. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS Assessment, dated 6/29/22, documented that Resident #3 was cognitively intact. Review of a nurse practitioner progress note, dated 6/10/22, revealed that Resident #3 was being transferred to the hospital for [CONDITION(S)] (serious infection of the blood stream). Review of the Notice of Transfer/Discharge Letters, dated 6/10/22, revealed that Resident #3 was transferred to the hospital. There was no information documented in the letter or in the medical record that the resident and/or family was notified in writing of the bed hold policy. During an interview on 7/12/22 at 10:39 a.m., the Administrator stated that the Bed Hold Notice policy is included in the Admission Packet, which is provided to residents/resident representatives on admission to the facility. The Administrator said that upon transfer, the Bed Hold Notice policy is reviewed with the resident/resident representative and they are asked if they want a copy mailed to them. The Administrator explained that completion of the 'Notice of Transfer/Discharge Letter' should cover both the Transfer Notice and the Bed Hold Notice policies and should be discussed with the resident/resident representative. During an interview on 7/13/22 at 9:06 a.m., the Director of Social Worker stated the bed hold policy is provided upon admission and that families are notified via telephone that their bed may not be held each time they are sent to the hospital. [10 NYCRR 415.3(h)(3)(i)(a)]

Based on observations, interviews, and record review conducted during a Recertification Survey, completed on 7/13/22, it was determined that the facility did not ensure that the daily posting of licensed and unlicensed nursing staff directly responsible for resident care was up to date and accurately reflected the required data at the beginning of each shift. Specifically, the facility staffing sheets were not updated daily and/or reflected changes in the schedule. This was evidenced by the following: Observation on 7/7/22 at 10:03 a.m., revealed that the posted nursing staffing sheet was dated 6/30/22. Observation on 7/12/22 at 11:08 a.m., revealed that the posted nursing staffing sheet was dated 7/11/22. A review of the facility's Daily Staffing Sheets (contained names and hours of nursing staff working each shift, including shifts 'open' or not yet filled yet) provided by the facility, dated 6/2/22 to 7/11/22, and the posted nursing staffing sheets did not match and did not include the changes in the actual schedule on multiple days. During an interview on 7/12/22 at 11:12 a.m., the Receptionist stated it is their responsibility to fill out and post the staffing sheets every morning. The Receptionist stated that the staffing sheets are supposed to include the number of nursing staff in the building, the shifts, hours, and the resident census. If there were changes, the sheets needed to be updated the same day. The Receptionist stated that the posted staffing sheet for 7/11/22 did not match the actual staffing for Certified Nursing Assistants and that the 7/12/22 sheet had not yet been posted as they had been busy. During an interview on 7/12/22 at 11:20 a.m., the Administrator stated the staffing sheets were to be posted daily and updated to reflect actual number of nursing staff working in the building. The Administrator confirmed that no changes were made to the staffing sheets from 6/2/22 to 7/11/22 to reflect call-ins or other staffing changes made during that period. 10 NYCRR 415.13

Based on observation, record review and interviews conducted during a Focused Infection Control Survey completed on 4/1/22, it was determined that the facility did not implement policies and procedures to ensure that all staff were completely vaccinated for COVID-19 and did not include a process for ensuring the implementation of additional precautions, intended to mitigate the transmission, and spread of COVID-19. Specifically, it was determined that less than 100% of the facility staff were completely vaccinated. The facility had three staff working directly with residents, two who were not vaccinated and did not have any exemption and one who had an invalid medical exemption. Additionally, the facility did not have a contingency plan for unvaccinated staff without valid exemptions. The facility policy, Employee COVID-19 Vaccination and Exemption of Vaccination Policy, dated March 2022, included it is the policy of this facility that employees, contract staff, volunteers and any individuals providing care, treatment or other on-site services will be vaccinated against COVID- 19 or will have an approved exemption. The facility policy did not include a contingency plan that addressed actions and consequences the facility would take for staff who indicated they would not get vaccinated and did not have a valid exemption. A review of the COVID-19 Staff Vaccination Status for Providers provided by the facility, revealed the facility employs 70 staff, 57 documented as completely vaccinated, two partially vaccinated (one vaccine), two pending medical exemptions (both direct care workers), six with granted exemptions and three staff with temporary delays. This resulted in a 94.2% staff vaccination rate. Review of the medical exemption documentation for CNA #1, dated 1/28/22 and signed by a physician, did not include which of the authorized COVID-19 vaccines were contraindicated or a recognized health condition that would exempt CNA#1 from receiving any of the COVID-19 vaccines. The statement included that CNA#1 preferred to opt out of the vaccine due to concerns of possible adverse side effects. The current staffing schedule for 4/1/22, included Licensed Practical Nurse (LPN)#1 was working the unit on the evening shift and who was listed as pending a medical exemption. In an observation on 4/1/22 at 8:35 a.m., all staff were observed wearing full Personal Protective Equipment (PPE) on resident care units. When interviewed on 4/1/22 at 12:38 p.m., the Administrator stated that the Medical Director had reviewed medical exemption documentation for staff and that they were not aware that the exemption for CNA#1 was not valid. The Administrator stated that the two pending medical exemptions (LPN #1 and an activity aide) were pending as the staff were attempting to get them, but they were not aware if they had seen their medical providers as of this day. The Administrator stated that all staff who remained unvaccinated for COVID-19 without a valid medical exemption had to be vaccinated or would be furloughed by 3/31/22 but that all furloughs were put on hold due to the current COVID-19 outbreak in the facility. The Administrator stated that there were 21 residents (current facility census of 33) and 13 staff who tested positive for COVID-19 since 3/27/22. 10 NYCRR 415.19(a) (1-3)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for five (Residents # 9, #14, #22, #23, and #35) of five residents reviewed for unnecessary medications, the facility did not have a consistent process in place to ensure that pharmacy recommendations were reviewed timely and acted upon by the medical provider. This is evidenced by the following: The facility policy, Pharmacy Services, dated (MONTH) (YEAR), revealed that the pharmacist will report any irregularities to the attending physician, the facility's Medical Director, and the Director of Nursing, and these reports must be acted upon. Any irregularities noted must be documented on a separate written report that is sent to the attending physician, the facility's Medical Director, and the Director of Nursing and lists at a minimum the resident's name, irregularity and relevant drugs. The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what if any action has been taken to address it. If there is no change, the physician should document the rationale in the resident's medical record. There was no pharmacy recommendation found in Residents # 9, #14, #22, #23, and #35's medical records. Upon request, the facility contacted the pharmacist and provided a copy of her e-mail. Review of an e-mail from the pharmacist, dated 10/30/19 at 1:58 p.m., revealed that the dates identify when recommendations were made for each of the listed residents: a. Resident #35 on 10/30/18, 11/16/18, 3/26/19 and 10/18/19. b. Resident #23 on 2/22/19, 5/17/19, 7/22/19, and 8/15/19. c. Resident #9 11/16/18, 3/26/19, 5/17/19, 6/19/19, 7/22/19, 8/15/19, and 9/19/19. d. Resident #14 on 4/19/19, 5/17/19, 7/22/19 and 10/18/19. e. Resident #22 on 2/22/19 and 8/15/19. The pharmacist provided a copy of a Consultant Pharmacists Medication Regime Review Report for recommendations created between 9/1/18 and 10/30/19 that included the resident's name and recommendation but did not include the date the recommendation was made or the physician response. Interviews conducted on 10/30/19 included the following: a. At 11:55 a.m., the Unit Secretary stated the Nurse Manager (NM) gives the pharmacy recommendations (Pharmacists Medication Regime Reviews) to the Nurse Practitioner (NP). She said that after the NP signs the form, she files it in the resident's medical record. The Unit Secretary then reviewed Resident# 23's medical record and stated there were no pharmacy recommendation forms in the chart. b. At 1:34 p.m., the Director of Nursing said that monthly the pharmacist e-mails the Medication Regime Reviews and then sends that information to the Registered Nurse Manager. She stated she could only provide e-mails for the recommendations made for (MONTH) 2019. c. At 2:11 p.m., the Consultant Pharmacist stated when she completes the monthly Medication Regime Reviews for each resident, she then generates a report and any recommendations would be e-mailed to the Director of Nursing, the Administrator, and the Medical Director. When interviewed on 10/31/19 at 10:00 a.m., the Administrator stated the facility was unable to provide documentation of the monthly reported drug irregularities or the physician's response for Residents # 9, #14, #22, #23, and #35. (10 NYCRR 415.18(c)(2))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one resident groups, the facility did not ensure that concerns and recommendations of the resident group relating to care and life in the facility were acted upon promptly. Specifically, voiced concerns in Resident Council Meetings regarding food snacks, ambulation of residents, dining room seating, and rough towels were not resolved. This is evidenced by the following: Review of the (MONTH) 23, 2019 Resident Council Minutes revealed the following: a. Residents complained that their seating was frequently changed in the dining room and they were not told why. The Social Worker (SW), who was present at the meeting, told the Resident Council it was done to improve the efficiency for residents and staff. The residents stated they understood but asked that they be told beforehand and requested that residents that can have conversations with one another be seated together. The documentation for the follow-up of the 7/23/19 Resident Council Meeting revealed that the Director of Dietary will notify residents one day before changes in the dining room seating occurs by announcing it in the dining room. b. Residents would like nursing staff to walk with them when they are not on therapy services. Residents feel as though they improve with therapy and then lose it all when therapy ends. They would like to know more about the walking schedule that therapy and nursing were working on. The documentation for the follow-up of the 7/23/19 Resident Council Meeting revealed that if a resident was interested in walking, then the resident should talk to nursing and the Certified Nursing Assistant (CNA). The nursing staff would be willing to walk residents with therapy approval. Therapy was also willing to give residents independent exercises to do on their own if they were interested. c. The residents have expressed that the towels feel like sandpaper, and a request to use fabric softener was made. Residents would like an afternoon snack. The Administrator discussed the idea of an afternoon snack cart that goes around to able residents. Residents were accepting and excited about that idea. The documentation for the follow-up of the 7/23/19 Resident Council Meeting revealed that fabric softener was being used on all towels. The idea of a snack cart in the afternoon will be brought up when a new Recreation Director was hired. Review of the (MONTH) 22, 2019 Resident Council Minutes revealed that a resident expressed the desire to walk and asked for an update on the walking schedule. The SW explained that nursing and therapy were working on the logistics and she would notify residents when there was a plan. The SW also explained that the Director of Recreation position was still open. A Resident Council Meeting was held on 10/28/19 at 2:07 p.m., and the residents stated that issues and concerns that were voiced in (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019 have not been resolved. The residents said the dining room seating continues to change and they are not told why. The residents said they keep asking for nursing to walk them, but it is not happening. The residents said that the towels are like steel wool and the snack cart never happened. When interviewed on 10/30/19 at 1:59 p.m., the SW said she was the grievance officer. She said that she did not treat the issues brought up in Resident Council Meetings as complaints or grievances because she addresses their issues at the next meeting. The SW said that the snack cart was not done because they did not have a new Director of Recreation. She said that if a resident wants snacks at bedtime, they can ask for them. She said the ambulation was being worked out with Physical Therapy and nursing. She said they created a list and nursing started to walk residents. She said she spoke to the laundry staff and they use fabric softener. During an interview on 10/31/19 at 10:00 a.m., the Administrator said she has only been at the facility for two weeks, but her expectation would be that any issue or concern brought up at the Resident Council Meeting be investigated like any other grievance. She said the issue or concern should be investigated and the resolution should be reported to the residents at the next meeting. Interviews conducted on 11/1/19 included the following: a. At 11:20 a.m., the laundry staff said they use dryer sheets in the dryer. b. At 2:00 p.m., the Assistant Director of Nursing said they are working on an ambulation list. (10 NYCRR 415.5(c)(6))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #16) of two residents reviewed for Activities of Daily Living (ADLs), the facility did not ensure that each resident's care plan was revised to reflect the resident's current condition. Specifically, the resident's care plan was not revised to include resident-specific interventions for refusals of care and getting out of bed. This is evidenced by the following: Resident #16 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/5/19, included that the resident had severely impaired cognition, was totally dependent on staff for transfers, and rejected care on one to three days over the seven-day look back period. The current Comprehensive Care Plan and the Certified Nursing Assistant (CNA) Resident Profile included under ADLs that the resident transferred with two assist and a mechanical lift, was independent with wheelchair mobility approximately 75 percent of the time. The care plans included that there was no behavior plan, and neither care plan included any instructions related to refusals of care or refusals to get out of bed. During multiple observations on the day shift between 10/29/19 and 11/1/19, the resident was in bed, wearing a hospital gown and eating breakfast and lunch on all occasions. Additionally, neither the television or the radio were on. On multiple occasions the resident was heard singing to herself, pleasantly confused talking non-sensically to herself, and was waving staff and visitors into her room when passing by in the hall. Review of the interdisciplinary progress notes and the CNA ADL computer documentation, from 10/1/19 through 10/31/19, revealed that the resident was transferred out of bed on six occasions for the month. On 10/5/19, the nursing progress note included that the resident was wheeling herself around the facility and eating lunch in the dining room. There was no documentation of refusals to get out of bed. In an interview on 10/30/19 at 2:30 p.m. and again on 10/31/19 at 3:30 p.m., the CNA stated the resident often refuses care but not so much with her and was usually very good when she cares for her. When asked why she never got out of bed that week, the CNA said that the resident said no when asked. When interviewed on 11/1/19 at 10:35 a.m., the Registered Nurse Manager stated that the Licensed Practical Nurse asks the resident daily if she wants to get out of bed. She said staff should re-approach the resident or let her know of refusals. She said that the resident's behaviors and interventions should be in the care plan. (10 NYCRR 415.11(c)(2)(iii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of five residents reviewed for unnecessary medications, and one of three residents reviewed for non-pressure related skin conditions, the facility did not provide services consistent with professional standards of quality. Specifically, the electronic medical record had documentation of Resident #35 having no bowel movements for several shifts and the facility had not assessed the resident's condition or initiated the bowel protocol. For Resident #12 staff did not identify or report bruising. This is evidenced by the following: 1. Resident #35 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/10/19, revealed that the resident had severely impaired cognition, was incontinent of bladder and bowel, and required extensive to total assist of staff for toileting and personal hygiene. The facility policy, dated as last reviewed 1/22/14, included that night staff are to check the bowel movement book for any resident who had not had a bowel movement by the morning of day three and inform the day shift who are to initiate the bowel protocol starting with prune juice and continuing with physician orders. During an observation of toileting on 10/30/19 at 1:45 p.m., the resident was attempting to get out of her reclined geriatric chair stating over and over that she had to go to the bathroom. The resident was toileted by two staff and incontinent of a small amount of urine and extremely agitated during the whole procedure requiring a third staff member to help transfer her. Review of the current Comprehensive Care Plan and Certified Nursing Assistant (CNA) Resident Profile revealed that the resident was incontinent, to toilet per request, and to check and change the resident. The current physician orders [REDACTED]. Neither medication was signed off as given from 10/1/19 through 10/30/19. The MARs did include that the resident had a large liquid stool on 10/27/19 (day shift). Review of the point of care 'vitals' report (electronic medical record form used by CNAs to document bowel movements every shift) revealed that none was documented for bowel movements for all shifts from 10/8/19 through 10/21/19 and from 10/27/19 (evening shift) through 10/31/19 (day shift- total of 12 shifts). In an interview on 10/31/19 at 1:30 p.m., the Licensed Practical Nurse (LPN) stated that the resident was not on any bowel alert list at that time and she was not aware that the resident had gone 12 shifts recently with no recorded bowel movements. When pointed out (by surveyor) where on the electronic medical record the bowel alerts were located, the LPN stated that she did not realize where to look as it was a new computer system but that yes, the resident was on the bowel alert list. The LPN stated that the resident had been very agitated lately and it could be that she needs some Milk of Magnesia. In an interview on 10/31/19 at 1:55 p.m. and again on 11/1/19 at 10:35 a.m., the Registered Nurse (RN) Manager stated that the nurses are to monitor the computer every shift for alerts, start the bowel protocol, and call the provider. She said that the LPN was looking in the wrong place for the alerts. The RN Manager said that it could just be a lack of documentation, but she would want to be notified in order to assess the resident and she was not. 2. Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/16/19, revealed the resident was cognitively intact, required the extensive assistance of two staff members for bed mobility, transfers and toileting and one staff member for hygiene. The Comprehensive Care Plan, dated 2/19/19, directed to observe the resident's skin and report any changes. Review of the nursing progress notes, dated 10/16/19 and 10/31/19, revealed that the resident had no skin issues. During an observation on 10/29/19 at 10:16 a.m., the resident was sitting in bed and had two reddish purple colored areas on the base of the right thumb. The resident stated that the bruises were from the bedrail. During a joint observation with the surveyor and RN Manager on 10/31/19 at 11:08 a.m., the resident was observed with a purple colored area that was approximately 1 centimeter in diameter at the base of the right thumb and two purple colored bruises were on the resident's mid right forearm underneath two identification bracelets. The resident stated the bruises on his forearm were from the overbed table. During an interview on 10/30/19 at 1:24 p.m., the CNA stated she provided personal care to the resident and she did not see any bruises. Interviews conducted on 10/31/19 included the following: a. At 10:52 a.m., the LPN said that the resident did not have any bruises. b. At 11:08 a.m., the RN Manager stated the resident did not have any bruising, and no one reported any bruising to her for the resident. She stated the CNAs observe the residents' skin daily with cares and would bring any skin issues to the nurse's attention who would in turn report them to me. She said that an incident report and investigation would need to be completed. (10 NYCRR 415.12)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for vision and hearing, the facility did not ensure each resident received timely treatment and/or assistive devices to maintain hearing. Specifically, Resident #29 did not have an audiology appointment scheduled for 14 months, and the audiologist recommended amplification devices which were not attempted despite the facility having them on-site. This is evidenced by the following: Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/20/19, revealed the resident had severely impaired cognition, was sometimes understood, sometimes understands, had moderate difficulty with hearing, and did not have hearing aids. The nursing Admission Assessment, dated 7/16/18, included to speak loudly to the resident, as hearing was highly impaired. An admission Hearing Aid Assessment, dated 7/16/18, included that (per hospital nurse) hearing aids were lost prior to hospitalization . The Comprehensive Care Plan for impaired communication related to hearing impairment was initiated on 9/17/18 and last revised on 10/11/19. Approaches include to use communication devices as needed when communicating. The Certified Nursing Assistant (CNA) Care Card, dated 2/19/19, revealed that the resident was very hard of hearing and did not have hearing aids. A Nurse Practitioner (NP) order, dated 9/20/19, requested an audiology referral. The audiology consult note, dated 10/21/19, revealed that the resident had severe to profound hearing loss in both ears. Recommendations included amplification device, to consider a pocket talker which can be purchased online or at an electronic store and uses standard head phones instead of aids. Hearing aids can be purchased but family would have to be present for testing. Observations on 10/30/19 included the following: a. At 11:41 a.m., the resident was in activities, in a circle of residents who were drinking water and talking. Resident #29 did not speak to anyone and did not have any head phones or amplifier present. b. At 11:56 a.m., the resident was seated at the dining room table. Her eyes were closed, and she did not respond when spoken to loudly. The tablemate said, She cannot hear you. c. At 2:07 p.m., the resident was in the hallway and appeared to be sleeping. She did not respond when spoken to. During an interview on 10/30/19 at 1:22 p.m., the CNA said the resident loves to eat and loves activities but does not usually participate as she is very hard of hearing. She said she uses hand gestures and a loud voice. She said it is better if you look straight at the resident to speak, and that she does read lips sometimes. She said the resident does not have hearing aids. Interviews conducted on 10/31/19 included the following: a. At 9:18 a.m., the unit clerk said the resident went for a hearing appointment because someone was interviewing her and having difficulty and thought she was very hard of hearing. She said audiology was ordered and an appointment was made but it took several months before she went. b. At 1:44 p.m., the Social Worker said she spoke with the resident's family and told them to call the audiology office to review the recommendations. She said she told the family the facility had a head phone amplifier. She said she did not make a suggestion to try the facility one first. She said she told the family they could buy one on their own, and the family member said they would discuss it with other family members. Interviews conducted on 11/1/19 included the following: a. At 10:11 a.m., the NP said she made the audiology referral because the resident told her she was having difficulty hearing. She said she had not seen the audiology consult but that an amplifier would be great for the resident. She said she did not know the facility had one, but it should be attempted. b. At 11:14 a.m., the Registered Nurse Manager said the audiology referral was given to the NP. She said no one provided any follow through and that they should have. (10 NYCRR 415.12(3)(b))