Ideal Senior Living Center

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of five (5) residents(Resident #36) reviewed. Specifically, Resident #36 had dysphagia (difficulty swallowing) and was not supervised during meals as ordered.Findings include: The facility policy Daily Routine, Care of Resident, revised 11/2024, documented meals would be served to each resident. Verbal, physical encouragement, and/or assistance was given as needed per resident preference and plan of care.
Resident #36 had diagnoses including dysphagia. The 12/16/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required set up assistance for eating and did not have a swallowing disorder.
The 06/08/2022 physician order documented a regular diet; supervision with meals; cut meat into small pieces, encourage small bites, slow rate, and alteration of solids/liquids.
The 06/08/2022 Comprehensive Care Plan documented a potential for alteration in nutrition and respiratory status due to impaired ability to swallow related to oral pharyngeal dysphagia. Interventions included encourage small bites, slow rate, and alteration of solids/liquids; regular textures; cut meat into small bites/pieces; thin liquids; and upright position as tolerated. The care plan did not include supervision at meals.
The undated care instructions documented the resident required setup or clean-up assistance at meals and did not include the need for supervision.
The 08/06/2025 Speech Language Pathologist #1 evaluation and plan of care documented a recommendation for supervision with meals; meat cut into small pieces; and encouragement of small bites, a slow rate, and alternation of solids/liquids.
The 02/17/2026 lunch meal tickets documented supervision with meals.
During an observation on 02/17/2026 at 12:19 PM, Resident #36 was eating their lunch alone in their room. At 12:23 PM, Certified Nurse Aide #3 entered the room to ask the resident if they needed anything, then exited the room.
The 02/19/2026 lunch meal ticket documented supervision with meals.
During an observation on 02/19/2026, Certified Nurse Aide #3 delivered Resident #36's lunch tray at 12:42 PM and exited the room, leaving the resident alone to eat. At 12:50 PM, the resident consumed most of their meal. The tray was removed from the room at 1:09 PM. No staff were observed entering the resident's room between 12:42 PM and 01:09 PM.
During an interview on 02/20/2026 at 01:31 PM, Certified Nurse Aide #3 stated the level of assistance a resident needed was on their care plan; it was their responsibility to make sure items on the tray matched the meal ticket; and if the ticket documented supervision with meals, then someone had to keep an eye on the resident while they ate. They stated they passed Resident #36's lunch trays on 02/17/2026 and 02/19/2026 and did not stay in the room while the resident ate and they should have. The resident preferred to eat lunch in their room and had been doing so for a while, so they thought the lack of supervision was an oversight.
During an interview on 02/20/2026 at 12:31 PM, Speech Language Pathologist #1 stated they recommended Resident #36 be supervised during meals on 08/06/2025. They were not aware the resident ate lunch alone in their room. Staff should provide supervision in the resident's room. They expected their recommendations to be followed.
During an interview on 02/20/2026 at 1:22 PM, Licensed Practical Nurse #2 stated the level of assistance needed with eating was in the resident's care plan. It was the responsibility of the person passing the meal tray to check the meal ticket to ensure all instructions, including supervision, were followed. Supervision meant the resident should be watched during their entire meal. On the days Resident #36 ate in their room, staff should stay with them.
During an interview on 02/23/2026 at 9:48 AM, Registered Nurse Unit Manager #4 stated anyone who passed a meal tray was responsible for looking at the meal ticket and if it said supervision with meals, then supervision should be provided. If a resident preferred to eat in their room, then someone should be assigned to stay in their room with them while they ate. They were not aware Resident #36 ate alone in their room last week. If they knew they would have followed up to make sure someone was present with the resident when they ate in their room. If there was an order for supervision, then someone should supervise the resident to keep them safe.
10 New York Codes, Rules and Regulations 415.12 (h)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of two (2) residents (Resident #9) reviewed. Specifically, Resident #9 had significant weight loss and did not have nutritional assessments reflecting current nutritional needs and interventions to prevent further weight loss; and the medical provider did not address the resident's weight loss.Findings include:The facility policy Weight and Reweight, revised 05/2025, documented monthly weights would be obtained on all residents unless an order indicated otherwise and a reweight would be obtained if a resident weight changed five pounds or more from last recorded weight. Weight changes of five pounds or more after the reweight would be reported to the charge nurse, dietitian, and provider. The facility procedure for estimating energy needs, revised 11/29/2017, documented energy needs would be estimated using Mifflin-St Jeor for all residents. Per the Academy of Nutrition and Dietetics Nutrition Care Manual for Adults, the Mifflin-St Jeor Equation is a formula used to estimate Basal Metabolic Rate (BMR), which was the number of calories the body needed at rest to maintain vital functions such as breathing and circulation. The Mifflin-St. Jeor Equations was used to estimate resting energy expenditure only. Adjustments to activity would be needed. Physical activity should be carefully considered when estimating total energy expenditure. Activity energy included activities of daily living, fidgeting, and maintaining posture. Injury factors would be assessed in addition to activity factor if indicated. The facility procedure for estimating protein needs, revised 11/29/2017, documented protein needs would be estimated at 15 to 16% for mild to moderate stress, 17 to 18% for surgical wounds and Stage 1 or 2 pressure ulcers, and 19 to 20% for stage 3 or 4 pressure ulcers and deep tissue injuries. The procedure did not designate what to calculate the percentage from, or what to do with the percentage calculated.Resident #9 had diagnoses including hip fracture, leg fracture and dementia with mood disturbance. The 11/29/2025 significant change Minimum Data Set (assessment tool) documented the resident had severe cognitive impairment, weighed 138 pounds, and had no weight changes. Resident #9's weight record documented on 07/30/2025 the resident weighed 155.8 pounds.The 08/01/2025 Registered Dietitian #6 nutrition progress note documented the resident had poor intake and their family member agreed to trial Ensure Plus (nutritional supplement).The 08/04/2025 Registered Dietitian #6 nutritional assessment documented Resident #9 was admitted for surgical repair of right hip fracture, weighed 155.6 pounds, had poor intake below 50%, and had an order for Ensure Plus three times a day, which was poorly accepted. Kilocalories were estimated as 1541 daily (Resting Metabolic Rate (1142) multiplied by a stress factor of 1.35) and protein needs were 66 grams (under one gram per kilogram body weight. No activity factor was included in calorie estimation). They documented calorie needs were increased, and protein needs were increased to 17% of calorie needs, and yogurt and pudding were added between meals.Resident #9's weight record documented on 08/13/2025, the resident weighed 145.3 pounds without a documented reweigh (6.7% severe weight loss in two weeks).The 08/14/2025 Registered Dietitian #6 progress note documented Resident #9 weighed 145.3 pounds (66 kilograms) and had a 6.6% weight loss in one month with meal intakes of 64%. They recommended decreasing the Ensure Plus supplement from three times a day to two times a day. They requested a reweight for a 4.7 pound weight loss in one week and there was no need to re-estimate needs because intake was good. They would follow up if new interventions were needed.The 09/22/2025 Registered Dietitian #10 nutrition progress note documented meal intake had declined to 42% and their weight was 145.7 pounds on 09/17/2025. They decreased the Ensure Plus from three times daily to twice a day because of stable weights.The Comprehensive Care Plan, revised 10/23/2025, documented the resident had behavioral issues with agitation and yelling out, fair intake of 58%, was overweight, was meeting needs, and had supplements in place. The resident received Ensure Plus (nutritional supplement) 237 milliliters once daily as of 09/22/2025. There was no documented evidence the care plan included severe weight lossResident #9's weight record documented on 08/13/2025 the resident's weight was 145.3 pounds (6.8% loss in one month).There was no documented evidence of follow-through on the reweight, estimated nutritional need changes or nutritional interventions to prevent further weight loss following the confirmation of weight loss on 08/20/2025 with a reweight of 145.1 pounds. The 08/29/2025 Nurse Practitioner #9 routine visit note documented nutrition notes had been reviewed, the resident weighed 143.8 pounds, and weights were overall stable.The 11/02/2025 Registered Dietitian #10 quarterly nutrition note documented meal intake was 51-75% daily, Ensure Plus was provided twice a day, weight was 145 pounds (66 kilograms), and the resident had a 6.9% weight loss in three months, which was a notable issue. Kilocalories were estimated as 1200 daily (Resting Metabolic Rate 994 multiplied by a stress factor of 1.2) and protein needs were 46 grams (under 0.7 grams per kilogram body weight). No activity factor was included in calorie estimation. They documented excess energy intake related to exceeding estimated needs.The 11/27/2025 documented weight was 138 pounds (4.9% loss in one month, 11.3% loss in four months).The 12/03/2025 documented weight was 135 pounds (4.2% loss in one month, 7.3% loss in three months, 13.4% loss in five months).The 12/03/2025 Registered Dietitian #6 nutritional assessment documented Resident #9 was readmitted from the hospital following surgical repair of a tibia fracture, had a deep tissue injury to the right hip, weighed 138 pounds (63 kilograms), was eating 51-75%, and had no weight changes in one, three, or six months. They received Ensure Plus once a day. Kilocalories were estimated as 1310 (Resting Metabolic Rate 971 multiplied by a stress factor of 1.35) and protein needs were 56 grams (under one gram per kilogram body weight). No activity factor was included in calorie estimation. They documented calorie needs were increased, and protein needs were increased to 17% of calorie needs because of the deep tissue injury.The 12/09/2025 Registered Dietitian #6 nutritional progress note documented the resident weighed 135 pounds, received Ensure Plus once a day, ate 86% of their meals, and exceeded their needs. There was no documented evidence of assessment of weight status or estimated needs.The 12/18/2025 Registered Dietitian #11 nutritional progress note documented the resident had significant weight loss over three months, consumed 89% of meals, received Ensure Plus twice a day, and weight gain would be beneficial. There was no documented evidence of estimated nutritional need changes or nutritional interventions to prevent further weight loss. The resident received Ensure plus once a day.The 12/23/2025 Nurse Practitioner #9 routine visit note documented nutrition notes had been reviewed, the resident weighed 136.6 pounds, and weights were slowly improving.The 12/24/2025 documented weight was 132.2 pounds (4.2% loss in one month, 9.3% loss in three months). There was no documented evidence of estimated nutritional need changes or new nutritional interventions to prevent further weight loss.The 01/07/2026 documented weight was 133.2 pounds (8.2% loss in three months, 14.4% loss in six months).The 1/20/2026 Physician #12 progress note documented the resident weighed 133 pounds and weights were stable.The 01/21/2026 Registered Dietitian #11 nutritional progress note documented the resident had significant weight loss over three months, was eating 86% of meals, and no changes were needed to the plan because weight was stabilizing. There was no documented evidence of estimated nutritional need changes or new nutritional interventions to prevent further weight loss.The 02/10/2026 documented weight was 132.6 pounds (11.6% loss in six months).The 02/13/2026 Nurse Practitioner #9 routine visit documented the dietitian noted some weight loss and added supplements and snacks. There was no documented evidence of the addition of any new nutritional supplements or snacks.During an interview on 02/20/2026 at 9:44 AM, Certified Nurse Aide #13 stated they obtained re-weights when the nurse told them to. If a resident refused a meal or snack, they would encourage, reapproach, and offer other items. If they had concerns about weight loss or poor intake they told their charge nurse. Resident #9 ate in the dining room, and they would encourage and coax them to eat. They did not see dietitians out in the dining rooms during meals.During an interview on 02/20/2026 at 9:53 AM, Licensed Practical Nurse #14 stated they compared the weights when they entered them into the electronic medical record, and requested a reweight on those with four-pound fluctuations. Resident #9 usually fed themself and ate well but needed encouragement at times. They recorded solids, fluids, and supplements on a form at the nursing desk daily and the certified nurse aide entered the data into the electronic medical record. If they refused to eat something, staff encouraged and offered something else. The dietitians were not usually around for meals, but they let them know if they had any concerns. During an interview on 02/20/2026 at 10:00 AM, Registered Nurse Unit Manager #15 stated the certified nurse aides obtained weights, and the charge nurse entered them into the electronic medical record. If the weight difference was five pounds or more a re-weight was obtained that day. Resident #9 usually ate the meal themself but needed to be watched for encouragement. When the resident first came to the floor in August of 2025, they were very agitated, anxious, and could not sit still. They tried Seroquel (antipsychotic medication) but that did not help the agitation, so it was tapered off and they started Rexulti (antipsychotic) with favorable results. When the resident refused to eat, the nurses offered them strawberry ice cream and other items. They lost weight recently, after their injury and prior to starting Rexulti. Nutrition staff tried Ensure but the resident's fluid intake was not the best. They usually notified nutrition, family, and medical of any nutritional concerns. Dietitians occasionally rounded at meals, but nursing usually told them about any changes. Dietitians usually attended the interdisciplinary care plan meetings, but not always. They did not attend the significant change care plan meeting in November of 2025.During an interview on 02/20/2026 at 11:16 AM, Registered Dietitian #6 they printed a weight report every morning and looked for five-pound discrepancies. They made a re-weight list through electronic mail or the electronic medical record for nursing. They brought up any weight concerns in the daily morning meeting. The charge nurse or nurse manager entered them into the electronic medical record. If a resident had significant weight loss they were changed to weekly weights and discussed at the monthly weight management meeting. If it was new weight loss, they sent an electronic mail to the interdisciplinary team and provider, assessed why the weight loss happened, talked with resident and family, and implemented what they were willing to eat. They documented monthly on residents with significant weight loss, including diet, intake, supplements, skin, bowels, labs, and any goals. Nutritional needs were estimated on any complete nutrition assessments, weight changes, new skin issues, or referrals. Energy needs were calculated using Mifflin-St Jeor and protein needs were estimated with a percentage of calorie needs. Resident #9 needed supervision with touch assistance with meals. The resident lost weight and had poor intake on admission. They had no recent weight loss, but they had lost weight back in November of 2025 when they had a fracture and went to the hospital. They could not recall if they notified anyone of the weight loss. During the significant weight loss in August of 2025, they asked for a reweight and the resident was provided Ensure Plus, yogurt, and pudding. No additional changes were made since the weight loss in August of 2025. They did not see the resident at meals and was not taught to do meal rounds. They followed resident meal intakes and any issues through nursing and nursing documentation, and reviewed meal documentation when assessments were due. The resident's weights had stabilized recently, however when weight loss continued, they thought they were responsible for notifying the provider. Nutritional intervention changes were communicated to the interdisciplinary team through electronic mail, care plan meetings, and the morning meeting. They attended the care plan meetings on the rehabilitation floor, and another dietitian attended Resident #9's care plan meetings when they were available. Protein needs were assessed based on a percentage of calorie needs per the facility policy, which they had not seen before in practice, including their internship. Energy needs were estimated using Mifflin-St Jeor and multiplying an injury factor as needed. They did not use an activity factor because their policy did not include one. If calorie needs were underestimated, protein needs would be underestimated. If a resident's weight status was not addressed or assessed, they could continue to lose weight. Registered Dietitian #6 stated on 08/04/2025, an injury factor was used to calculate energy needs for the surgical wound. Protein needs were estimated at 17% of energy needs. On 8/14/2025, a re-weight was requested due to significant weight loss, but they did not follow up on the re-weight, assess the weight status or add an intervention other than decreasing the Ensure Plus from three times a day to twice a day. On 11/02/2025, the previous dietitian helped complete the assessment from a remote location using what was in the electronic medical record. On 12/3/2025, an injury factor was used to calculate energy needs for the surgical wound and deep tissue injury. Protein needs were estimated at 17% of energy needs. No new interventions were implemented except Ensure Plus was decreased to once a day. On 12/09/2025, when the new weight of 135 pounds (4.2% loss in one month, 7.3% loss in three months, 13.4% loss in five months) was obtained, they talked about it in the weight management meeting that month, and the resident was getting Ensure Plus daily. No changes were made, and nutritional needs were not addressed. During an interview on 02/20/2026 at 12:17 PM, Physician #12 stated they were made aware of significant weight changes through dietitian updates. Once notified they reviewed the resident to see if any medical interventions were indicated. Weights were monitored because they correlated with clinical functioning and overall wellbeing. Physician #12 did not acknowledge being notified of the resident's weight loss in August 2025, December 2025, or January 2026. They stated there were monthly weight meetings and they were open to constructive feedback regarding why the information was not reflected in the electronic medical record. 10 New York Codes, Rules and Regulations 415.12 (i)

Based on observation, interview and record review during the recertification survey conducted 4/1/2024-4/5/2024, the facility did not ensure staff were educated on the policy and procedure regarding the use and storage of foods brought to residents from outside the facility to ensure safe and sanitary storage, handling, and consumption for 3 of 3 resident units (Units 1, 2, and 3). Specifically, staff were not aware of the policy and procedure to properly reheat, and measure temperatures of resident food brought in from outside the facility. Refer to F 561 Self Determination.
Finding include:
The facility policy Use and Storage of Food Brought to Residents from the Outside dated 1/2021, documented training would be provided by dining services on safe food handling practices and the policy regarding food brought to residents from the outside. If prepared food must be reheated before service, it may be reheated in the microwave oven available on the resident unit. Nursing should ensure that foods are reheated to 165 degrees Fahrenheit for at least 15 seconds before being served to the resident. These foods may not be brought into, or reheated in, the dining services department (main kitchen).
The facility policy Food Brought into Patients from the Outside dated 1/2022, documented if food prepared outside of the food and nutrition services department was allowed, nursing must verify that the patient was prescribed a regular diet. Nursing should document in the patient's chart the food items that were brought to the patient. If prepared food must be reheated before service, it may be reheated in the microwave oven available on the resident unit. Nursing should ensure that foods are reheated to 165 degrees Fahrenheit for at least 15 seconds before being served to the resident. These foods may not be brought into, or reheated in, the dining services department.
During an interview on 4/1/2024 at 10:57 AM Resident #87 stated while living on the 1st floor they were allowed to have a Sunday treat which consisted of a bagel with melted cheese. The resident's friend brought in the cheese, and the bagel came from the facility kitchen. The cheese was melted on the bagel in the facility's microwave. When the resident relocated to the 3rd floor, they were told staff could not microwave food received from outside sources. They stated they were upset because they could no longer have the bagel and melted cheese, they had become accustomed to having every Sunday.
The following observations were made on 4/3/2024 between 2:25 PM and 2:45 PM:
- the 3rd floor Daffodil Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom.
- the 3rd floor Tulip Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom.
- the 2nd floor [NAME] Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom.
- the 2nd floor Lily Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the resident dining room.
- the 1st floor [NAME] Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom.
- the1st floor [NAME] Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom.
During an interview on 4/1/2024 at 11:15 AM, registered nurse #2 stated that staff do not heat up residents' food for them and there was no microwave that could be used. Residents could have cold foods held in the dining room refrigerator or they would have to eat the food cold as staff could not heat up the foods brought from outside. Staff were not trained on how to reheat food or what temperatures should be reheated to.
During an interview on 4/1/24 at 2:21 PM, the Food Service Director stated residents could not reheat food brought into them and were not allowed to use microwaves. They were unaware of any nursing staff that had been trained on how to reheat food or what temperature to reheat food. Food service staff could not do anything with foods brought in from the outside.
During an interview on 4/3/24 at 2:25 PM, licensed practical nurse #24 stated there was only a microwave for staff in the staff breakroom and it was not for resident use. They were unsure why there was a policy and thermometer at the microwave as they were not able to heat up residents' food on the units. They had not been trained on proper reheating temperatures or procedures. Nursing staff would not check thermometers for proper accuracy or calibration. They were also unsure if the thermometers were sanitized or how to do so.
During an interview on 4/3/24 at 2:35 PM, licensed practical nurse #23 stated they were not formally trained on how to reheat residents' food brought in from the outside. Depending on the type of food and container, staff could try to reheat food for residents. They believed food service staff would calibrate thermometers if needed. The only microwave on the unit was in the staff breakroom. Lily court was the only unit that had a microwave in the dining room area.
During an interview on 4/3/24 at 2:39 PM, licensed practical nurse #22 stated food from the outside was often cold food and would not need to be reheated. There were guidelines on the unit but there was no official training. Sani cloth wipes could be used to wipe down thermometer probes between uses.
During an interview on 4/3/24 at 2:45 PM, licensed practical nurse #21 stated staff should not use microwaves to reheat food for residents. There should be a microwave for staff use and one for residents to use, but they were not sure where a microwave was for resident use. They were not sure why there was a policy or thermometer in the staff breakroom as they do not use them.
During an interview on 4/3/24 at 2:51 PM, the Administrator stated only Lily court had a microwave available to use in the dining room for reheating residents' food. There were policies on the units, but they were not sure if staff were trained on the policy and procedure. The facility tried to only take food that would not require reheating. They stated there should be one policy and procedure. Staff should not know what to do with food brought in from the outside.
10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews during the recertification survey conducted [DATE]- [DATE], the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding advance directives to the staff responsible for the resident's care for 1 of 24 residents (Resident #87) reviewed. Specifically, Resident #87 updated their Medical Orders for Life Sustaining Treatment (MOLST) during a hospitalization to reflect a change from wanting cardiopulmonary resuscitation (CPR) to do-not-resuscitate (DNR) code status. When the resident was readmitted to the facility their medical record and code status indicators were not revised to reflect the resident's advance directive wishes and the facility continued with cardiopulmonary resuscitation orders.Findings included:The facility policy, Advance Directives reviewed [DATE], documented all properly executed advance directives are honored including do-not-resuscitate orders, living wills, health care proxies, and electronic Medical Orders for Life-Sustaining Treatment. The Admissions department, social worker, Nurse Manager, and physician are all responsible to assess advance directives and electronic medical orders for life sustaining treatment to assure that the advance directives have been expressed in a clear and convincing manner.The facility policy, Cardiopulmonary Resuscitation: Skilled Nursing Home revised [DATE], documented all residents who have a valid do-not-resuscitate order will have a purple dot placed on their name band and in the electronic medical record program. Any changes to a resident's cardiopulmonary resuscitation or do not resuscitate status will be communicated to staff immediately upon the change. When a resident changed status from cardiopulmonary resuscitation or do not resuscitate the staff were to update the medical record and print/apply a new name band. Resident #87 was readmitted to the facility with diagnoses including syncope (loss of consciousness) and collapse, chronic kidney disease, and hypothyroidism (underactive thyroid). The [DATE] Minimum Data Set documented the resident had intact cognition and participated in the assessment and goal setting. Resident #87's comprehensive care plan effective [DATE] documented the resident had advance directives of cardiopulmonary resuscitation per their wishes and an electronic Medical Orders for Life Sustaining Treatment.Resident #87's Medical Orders for Life Sustaining Treatment in effect prior to their hospitalization on [DATE], was signed by the resident on [DATE] and documented attempt cardiopulmonary resuscitation when they had no pulse and/or was not breathing. A hospital discharge summary documented the resident was hospitalized [DATE]-[DATE] for syncope after blacking out during a shower at the nursing facility. The resident's code status at discharge was do not resuscitate/do not intubate (placement of a breathing tube). The electronic Medical Orders for Life Sustaining Treatment electronically signed by the resident on [DATE] at 6:16 PM and by the hospital physician on [DATE] at 8:59 PM documented the resident's wishes included do not attempt resuscitation (allow natural death). The section for review and renewal of the medical orders for life sustaining treatment included a review by the hospital physician on [DATE] at 8:59 PM and documented the previous form was voided and a new form was completed. The resident's medical record face sheet with a last admission date of [DATE] at 1:30 PM, documented the resident had advance directives of full cardiopulmonary resuscitation (CPR), refer to the electronic Medical Orders for Life Sustaining treatment. The [DATE] at 11:08 AM medical readmission order by nurse practitioner #20 documented advance directives, full cardiopulmonary resuscitation. Refer to electronic Medical Orders for Life Sustaining Treatment. The electronic Medical Orders for Life Sustaining Treatment section for review and renewal was signed on [DATE] at 8:25 PM by facility physician #6 and documented the outcome of the review was no change.The resident's comprehensive care plan revised on [DATE] by social worker #9 documented the resident had advance directives of cardiopulmonary resuscitation per their wishes and an electronic Medical Orders for Life Sustaining Treatment. There was a cardiopulmonary resuscitation order in place. During observations on [DATE] at 3:17 PM and [DATE] at 9:54 AM, Resident #87's identification bracelet on their right wrist did not have a purple dot to indicate do-not-resuscitate.The electronic medical record documented the code status indicator for Resident #87 as full cardiopulmonary resuscitation and the resident had an electronic medical order for life sustaining treatment. During an interview on [DATE] at 12:06 PM, Resident #87 stated they had signed a do-not-resuscitate order and that was what they wished to remain. During observations on [DATE] at 4:08 PM and [DATE] at 9:55 AM, there was a list of residents with their code status posted in the Tulip Court (third floor) open breakroom. The list documented Resident #87 was a full code, meaning the resident wished to receive cardiopulmonary resuscitation. During an interview on [DATE] at 2:50 PM, licensed practical nurse #1 stated they would check resident's chart for their code status. A resident would have a purple dot next to their name in the chart if they had a do-not-resuscitate order. The resident's medical orders also indicated their code status. The licensed practical nurse stated they would also check the resident's identification bracelet as they would have a purple dot on the bracelet if they had a do-not-resuscitate order.During an interview on [DATE] at 4:08 PM, Registered Nurse Unit Manager #2 stated they posted a listing of what residents were to receive cardiopulmonary resuscitation and what residents had do-not-resuscitate orders, so staff had a visual of what the code status was for the residents on the unit. The listing was updated weekly and as needed if a code status changed. They stated in the event of an emergency, the nursing staff would respond to the resident and check the resident's identification bracelet. If the resident had a purple dot on their identification bracelet it meant they had a do-not-resuscitate order.During an interview on [DATE] at 10:06 AM, certified nurse aide #10 stated they would look in the electronic medical record and on a resident's identification bracelet for code status. The purple dot on the resident's identification bracelet meant the resident was a full code (cardiopulmonary resuscitation). During an interview on [DATE] at 10:10 AM, certified nurse aide #7 stated they would look at a resident's identification bracelet for their code status. If there was a purple dot, the resident was a full code (cardiopulmonary resuscitation). During an interview on [DATE] 10:16 AM, certified nurse aide #11 stated they would look at the resident's identification bracelet for code status. If the resident had a green or red dot that meant they were a full code. During an interview on [DATE] at 10:16 AM, certified nurse aide #8 stated they would look at a resident's wrist band for code status. A purple dot meant the resident wanted cardiopulmonary resuscitation. During an interview on [DATE] at 10:19 AM, licensed practical nurse #15 stated if a resident was found unresponsive, they would check the resident's identification band for a purple dot as that meant the resident was a do-not-resuscitate. They would also look in the resident's orders in the electronic medical record. They would not check the resident's electronic Medical Order for Life Sustaining Treatment as they did not have access to the system where it was located. Their access expired. During an interview on [DATE] at 10:23 AM, certified nurse aide #12 stated they would look at the resident's identification bracelet for code status. A blue dot meant the resident was a full code. If there was no dot, the resident had a do-not-resuscitate order. During an interview on [DATE] at 10:26 AM, physician #6 stated when a resident was admitted to the facility, part of the initial discussion was about what their current advance directives were and if the resident wanted to keep their current advance directives or make changes. If the resident wanted their advance directives changed, the social worker completed a new electronic Medical Orders for Life Sustaining Treatment form, and the physician would sign off once completed. For a readmission, the nurse that took report reviewed the electronic Medical Orders for Life Sustaining Treatment at the time of admission and the social worker reviewed the resident's advance directives with the resident within 24 hours of admission. The advance directives were not always reviewed by the physician immediately upon readmission. Physician #6 stated they expected staff to check the patient lists on the unit or the resident's identification bracelet for their code status. A resident's identification band was marked if the resident had a do-not-resuscitate order. It was important that the electronic Medical Orders for Life Sustaining Treatment matched the physician order in the computer, so the wrong directive was not provided during an emergency. At 11:42 AM, Physician #6 stated if cardiopulmonary resuscitation was provided against the resident's wishes, it could prolong life when the resident did not want it prolonged. It also had the potential to cause suffering as ribs could be broken during cardiopulmonary resuscitation and possibly lead to hospitalization and intubation. If a resident was not provided cardiopulmonary resuscitation when they requested, the person could pass away. During an interview on [DATE] 10:42 AM, Director of Nursing stated the nursing staff checked the resident's identification bracelet to determine code status; a purple dot meant the resident was do-not-resuscitate and no dot meant cardiopulmonary resuscitation. The code status was also listed in the resident's orders. When a resident was admitted or readmitted , the admitting nurse received a nurse-to-nurse report in addition to the hospital records. The admitting nurse entered the advanced directive orders. The unit secretary doubled checked the resident's identification band against the advance directive order in the resident's record for accuracy before it was applied to the resident. The electronic medical order for life sustaining treatment was mostly used when the resident needed to be transferred to the hospital, not for day-to-day or emergency use. The written order and the electronic medical order for life sustaining treatment should match. If a resident who wished to be do-not-resuscitate was resuscitated, they could be injured in the process, and it would be against their wishes. If a resident wanted to be resuscitated and was not, they would die. During an interview on [DATE] at 11:26 AM, Administrator #3 stated when a resident was admitted , they received hospital notes with advance directives and the admission nurse would verify the code status with the electronic Medical Order for Life Sustaining Treatment. The verification would be done by the physician. The unit secretary printed an identification band with the resident's code status. The Administrator was not sure if the dot on the identification band meant cardiopulmonary resuscitation or do-not-resuscitate. They were unaware of how the resident's chart or electronic Medical Order for Life Sustaining Treatment was updated if a resident's wishes changed. At 12:05 PM, Administrator #3 stated they expected the admitting nurse to confirm the paperwork from the hospital matched the facility's regarding advance directives and they should enter the order accurately in accordance with the electronic Medical Orders for Life Sustaining Treatment. During an interview on [DATE] at 12:53 PM, Licensed Practical Nurse Unit Coordinator #14 stated they were responsible for admissions, readmissions, and discharges. Advance directives were a part of admission and readmission. Advance directive orders were entered and were received by the nurse-to-nurse report and through the paperwork provided by the hospital. The social worker also confirmed advance directives. After the advance directive order was entered by nursing, the social worker verified it with the electronic Medical Orders for Life Sustaining Treatment, if the resident had one. Staff would check the resident's orders for code status. They stated they did not check Resident #87's electronic Medical Order for Life Sustaining Treatment when the resident was readmitted . During an interview on [DATE] at 1:44 PM, social worker #9 stated they discussed a resident's advance directives with the resident and/or the resident's family within 24 hours of admission. They checked the paperwork that came from the hospital and the electronic Medical Orders for Life Sustaining Treatment. A resident's advance directives were always reviewed either by nursing or by social work. They did not always document the advance directive was reviewed on readmissions. Both social work and nursing were responsible for a resident's advance directive plan of care and to make sure the facility records were updated if a resident came back from the hospital with a change in their electronic Medical Order for Life Sustaining Treatment. It was important the electronic Medical Orders for Life Sustaining Treatment and the physician's order in the resident's medical record matched so a mistake was not made if the resident had an emergency. 10NYCRR 400.21(c)

Based on observation, interview, and record review during the recertification survey conducted 4/1/2024-4/5/2024, the facility did not ensure residents were provided special eating equipment when consuming meals and snacks for 1 of 1 resident (Resident #57) reviewed. Specifically, Resident #57 was not provided with a two handled cup with a spout lid at meals as ordered.
Findings include:
The facility policy Assistive Eating Devices revised 1/2024 documented assistive eating devices were available to any resident for whom the equipment would be beneficial in assisting the resident's ability to self-feed. Nursing was responsible for ensuring that each individual received the assistive devices ordered for each meal.
Resident #57 was admitted to the facility with diagnoses including transient ischemic attack (stroke), Alzheimer's disease, and dysphagia (difficulty swallowing). The 2/5/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required substantial assistance with eating, and required a mechanically altered diet.
The comprehensive care plan initiated 3/2/2022 documented a focus of activities of daily living with compromised self-sufficiency. Interventions effective 1/1/2024 included set-up and clean up assistance for feeding and a 2 handled cup.
The comprehensive care plan initiated 7/10/2023 documented the resident had dysphagia (impaired swallowing). Interventions included alternate liquids and solids, and small bites/swallows. An intervention effective 9/18/2023 documented nectar thick liquids via a sippy cup with a spout.
A 1/12/2024 speech language pathologist #18 evaluation documented the resident had mild to moderate oral/pharyngeal dysphagia. Recommendations included nectar thick liquids with a sippy cup with spout.
A 1/12/2024 physician order documented nectar thick liquid with a sippy cup with a spout.
A 4/1/24 occupational therapist #16 evaluation documented the resident was referred by nursing for improvements in feeding skills. Staff reported the resident was able to feed themself after set-up. The resident was seen during mealtime and was appropriately managing a 2 handled cup for drinks and regular silverware for food. The resident declined offers for assistance. The resident's care plan and certified nurse aide care card updated to reflect improvement. No skilled occupational therapy was warranted at that time.
The 4/3/2024 occupational therapist #16 discharge summary documented the resident was able to feed themselves after set-up and required a two handled cup for drinks.
The care instructions dated 4/1/2024 documented the resident received a pureed no added salt diet, nectar thick liquids, a 2 handled sip cup with a spout. Upright position during meals and 30-45 minutes after.
During an observation on 4/1/2024 at 12:36 PM Resident #57's meal ticket documented adaptive equipment of a two handled cup with a sippy lid.
During the following observations the resident was not provided with a two handled cup with a sippy lid for beverages:
- on 4/1/2024 at 12:37 PM drinking cocoa.
- on 4/2/2024 at 8:41 AM drinking milk and orange juice.
- on 4/2/2024 at 12:22 PM drinking hot cocoa.
- on 4/2/2024 at 12:27 PM licensed practical nurse #13 gave the resident a protein shake in a carton with a straw.
- on 4/3/2024 at 8:40 AM drinking juice and a protein shake with a straw in the carton.
- on 4/3/2024 at 10:54 AM drinking cocoa.
- on 4/3/2024 at 12:37 PM drinking a protein shake with a straw from a carton.
- on 4/5/2024 at 8:39 AM drinking a protein shake in a carton and juice from a cup with a straw.
During an interview on 4/5/2024 at 8:45 AM, certified nursing aide # 8 stated the meal ticket indicated if adaptive equipment was needed, and staff checked for the presence of adaptive items if they were included on the meal ticket. If the resident was supposed to have adaptive equipment and did not, it could negatively impact them if they spilled the cup and got burned or they could choke.
During an interview on 4/5/2024 at 9:04 AM, occupational therapist #16 stated it was not appropriate to give resident #57 a protein shake in a container or any cup with a straw and they should only have a two handled mug with a spout lid for beverages. It was important for this resident to have a two handled mug with a spout lid as it allowed them the highest level of independence with meals.
During an interview on 4/5/2024, licensed practical nurse # 17 stated their role at mealtimes was to make sure residents did not choke. They stated if a resident required adaptive equipment for meals, it would be on their meal ticket. If the meal ticket documented a double handled cup with a spout, they should have received it. If the cups were not supplied, they should call the kitchen for a replacement. They stated it was important for a resident to have the adaptive equipment ordered because of choking risk.
During an interview on 4/5/2024 at 11:24 AM, speech and language pathologist # 18 stated they evaluated the resident for a decline. They attempted to have the resident drink with a straw and the resident was not able to do so. They determined the two handled cup with a spout was the most appropriate device for the resident. They expected the resident to have the two handled cup with a spout for all liquids. They did not think a straw in the protein shake container was appropriate because the resident was not able to use it when previously evaluated. It was important for a resident to have the proper adaptive equipment for meals to prevent aspiration (food or liquid entering the lungs).
During an interview on 4/5/2024 at 11:37 AM, registered nurse Unit Manager #2 stated when a resident required adaptive equipment for meals it was listed on their meal ticket and in the care plan. If the equipment was not delivered, staff should call the kitchen for the equipment. They stated a straw in a protein shake container or a regular cup with a flat lid and straw were not appropriate for Resident #57. No substitutions could be made to a resident's adaptive equipment before being evaluated by occupational therapy, physical therapy, or a speech and language pathologist. They stated Resident #57 required the adaptive equipment for safety reasons because they did not previously have the strength to suck from a straw.
10NYCRR 415.14(g)

Based on observation, record review, and interviews during the recertification survey conducted 4/1/2024 - 4/5/2024, the facility did not ensure residents had the right to make choices about aspects of their life in the facility that were significant to 1 of 1 resident (Resident #87) reviewed. Specifically, Resident #87 was not allowed to have cheese (brought in from the outside) melted on a bagel in the facility's microwave oven when they were relocated to different unit in the facility.
Findings Include:
The facility policy Use and Storage of Food Brought to Residents from the Outside dated 1/2021, documented training would be provided by dining services on safe food handling practice and on the policy regarding food brought to residents from the outside. If prepared food must be reheated before service, it may be reheated in the microwave oven available on the resident unit. Nursing should ensure that foods were reheated to 165 degrees Fahrenheit for at least 15 seconds before being served to the resident. These foods may not be brought into, or reheated in, the dining services department.
The facility policy Food Brought into Patients from the Outside dated 1/2022, documented if food prepared outside of the food and nutrition services department was allowed, nursing must verify that the patient has been prescribed a regular diet and nursing should document in the patient's chart the food items that were brought to the patient. If prepared food must be reheated before service, it may be reheated in the microwave oven available on the resident unit. Nursing should ensure that foods are reheated to 165 degrees Fahrenheit for at least 15 seconds before being served to the resident. These foods may not be brought into, or reheated in, the dining services department.
Resident #87 was admitted to the facility with diagnoses including hypertension and renal (kidney) disease. The 1/21/2024 Minimum Data Set documented the resident was cognitively intact and required set up assistance with eating.
The comprehensive care plan initiated 12/20/2022 documented a focus of nutritional status with interventions including identify food preferences and cater to food preferences.
The comprehensive care plan initiated 6/9/2023 documented a focus of resident preferences. Preferences would be individualized to promote autonomy, quality of life, and physical and emotional well-being. Interventions did not include the resident's preference for a bagel with melted cheese,
During an interview on 4/1/2024 at 10:57 AM Resident #87 stated while living on the first floor they were allowed to have a Sunday treat which consisted of a bagel with melted cheese. The resident's friend brought in the cheese, and the bagel came from the facility kitchen. The cheese was melted on the bagel in the facility's microwave. When the resident relocated to the third floor, they were told staff could not microwave food received from outside sources. They stated they were upset because they could no longer have the bagel and melted cheese, they had become accustomed to having every Sunday.
During an interview on 4/1/2024 at 11:15 AM registered nurse #2 stated that staff did not heat up residents' food for them and there was no microwave that could be used. Residents could have cold foods held in the dining room refrigerator, but they would have to eat the food cold as staff could not heat up the foods brought from outside. They stated they were not trained on how to reheat food or what temperatures food should be reheated to.
During an interview on 4/1/2024 at 2:21 PM, the Food Service Director stated residents could not reheat food brought into them and were not allowed to use microwaves. They were unaware of nursing staff that had been trained on how to reheat food or what temperature to reheat food to. Food service staff could not do anything with foods brought in from outside the facility.
During an interview on 4/3/2024 at 2:25 PM, licensed practical nurse #24 stated there was only a microwave in the staff breakroom and was not for resident use. They were unsure why there was a policy and thermometer near the microwave as they were not able to heat up residents' food on the units. They had not been trained on proper reheating temperatures or procedures.
During an interview on 4/3/2024 at 2:35 PM, licensed practical nurse #23 stated they were not formally trained on how to reheat residents' food brought from the outside. Depending on the type of food and the container, staff could try to reheat food for residents. The only microwave on the 3rd floor unit was in the staff breakroom. The 1st floor was the only unit that had a microwave in the dining room area.
During an interview on 4/3/24 at 2:39 PM, licensed practical nurse #22 stated food from the outside was often cold food and would not have needed to be reheated. There were guidelines on the unit for reheating food but there was no official training.
During an interview on 4/3/24 at 2:45 PM, licensed practical nurse #21 stated staff could not use microwaves to reheat food for residents. They were not sure why there was a policy or thermometer in the staff breakroom as they do not use the microwave for residents.
During an interview on 4/03/24 at 2:51 PM, the Administrator stated only the 1st floor had a microwave available to use in the dining room for residents' food to be reheated. They were not aware there were multiple policies for foods brought in from the outside which could be confusing for staff on reheating food. There were policies on the units for reheating food, but they were not sure if staff were trained.
10 NYCRR 415.5(b)(3)

Based on observation, record review and interview during the recertification survey conducted 2/1/22-2/4/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain personal grooming for 1 of 5 residents (Resident #34) reviewed. Specifically, Resident #34 was not provided with facial hair grooming per their preference.
Findings include:
The facility policy ADL Assistance revised 2/4/10, documents necessary care and services are provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, subject to the residents right of self-determination. Based on the Comprehensive Care Plan, the facility will ensure that: a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene.
Resident #34 had diagnoses including pneumonia, chronic obstructive pulmonary disease (COPD), and syncope. The 1/21/22 Minimum Data Set (MDS) assessment documented the resident was had moderate cognitive impairment and required extensive assistance of two persons with activities of daily living (ADLs) including personal hygiene and dressing.
The comprehensive care plan (CCP) effective 11/1/21 documented the resident had compromised self-sufficiency in ADLs. Interventions included encourage the resident to actively participate in ADLs and provide extensive assistance with upper body dressing and hygiene.
The 11/1/21 care instructions documented the resident required extensive assistance of one person with personal hygiene.
The certified nurse aide (CNA) ADL documentation record documented the resident was provided extensive assistance with personal hygiene on 2/1/22, 2/2/22 and 2/3/22 on the day and evening shifts.
The following observations of Resident #34 were made:
- on 2/1/22 at 11:13 AM, the resident had facial hair on their chin, approximately 1 inch in length. The resident stated they did not like the hair on their chin, but they were unable to remove it themself.
- on 2/2/22 at 10:49 AM and 1:06 PM; on 2/3/22 at 9:38 AM; and on 2/4/22 at 9:17 AM the resident was in their room, sitting in a recliner chair and had long facial hair on their chin.
When interviewed on 2/4/22 at 9:20 AM, CNA #7 stated personal hygiene included toileting, bathing, providing peri care, applying lotion, brushing hair and shaving. The CNA stated they did not ask the Resident #34 if they wanted their chin shaved and did not shave the resident's chin. The CNA stated they should have asked the resident if they wanted to be shaved because the resident had pain in their hands and was unable to shave themself.
When interviewed on 2/4/22 at 9:28 AM, licensed practical nurse (LPN) #8 stated personal hygiene included showers, bed baths, denture cleaning, oral hygiene, hair care, ensuring proper footwear, shaving and nail care. The LPN stated a CNA should ask the resident if they wanted to be shaved and shave them if they did. Shaving should be included as part of personal hygiene and should be performed daily if requested by the resident.
10NYCCR 415.12(a)(3)

Based on observation and interview during the recertification survey conducted 2/1/22-2/4/22, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 3 residents (Residents #19, 25 and 91) reviewed. Specifically, Residents #19, 25 and 91 had unclean room floors and Resident #19 had a torn/stained floor mattress.
Findings include:
The facility policy Damp Mopping Hard Floor Surfaces with the Microfiber Mop dated 10/1/18 documents to begin damp mopping the floor by placing microfiber mop on floor and pushing forward along all corners and edges of the floor. This serves to push dirt out of the corners and edges of the room and prevents build-up. As floor is damp mopped, move any furniture or items on floor, sweep floor, and then return items and furniture to proper place. Be sure to mop under and behind the bed and furniture which cannot be moved, push tool and dirt to doorway.
The facility policy Environmental Services Equipment dated 10/1/18 documents the care and upkeep of all equipment by the Environmental Services Department is the responsibility of all members of the Department and must be carried out on daily basis.
The following observations were made on 2/1/22:
- at 12:08 PM, Resident #25 was sitting in bed in their room, the floor was unclean with visible smears and spots.
- at 4:40 PM, Resident #19 was lying in bed, with a mattress beside the bed on the floor. The mattress was torn, spotted, and stained with white blotches.
On 2/2/22 at 2:00 PM, an anonymous resident stated during the resident council meeting, that resident rooms and bathrooms had not been cleaned consistently. The resident stated their room had not been cleaned in the last 3-4 days.
The following observations were made on 2/3/22:
- at 12:26 PM, Resident #19 was lying in bed with a mattress on the floor beside their bed. The floor mattress had a large tear, approximately 6-8 inches across, and had spots of white liquid on it.
- at 12:29 PM, Resident#25 was in their room. The floor was spotted and smeared and had dirty footprints.
The following observations were made on 2/4/22:
- at 12:49 PM, Resident #91 was observed in their room. The shelving had dust and debris underneath. There was dust buildup in the corners of the floor. The resident stated they were allergic to dust.
- at 9:43 AM, the rooms of Residents #19 and 25 had dirty floors with smears and debris.
When interviewed on 2/4/22 at 9:43 AM, housekeeper #1 stated they went to the unit every day to clean, and the resident rooms were wiped down. The housekeeper stated cleaning included wiping down the furniture, cleaning the bathrooms, emptying the garbage, and mopping the floors. The housekeeper stated that the floor solution did not leave floors smeared or streaked and the floors should look clean and not have streaks after they had been washed.
During an interview on 2/4/22 at 10:08 AM, the Director of Environmental Services stated that nurses requested the floor mats from environmental services. The floor mats should be in good condition without tears or stains. The condition of the mattress in room Resident #19's room was unacceptable and should have been covered or discarded.
During an interview on 2/4/22 at 12:49 PM, Resident #91 stated that the housekeeper came in and barely cleaned anything. The resident stated they did not see the housekeeper dust or wipe any items off and was not mopping the floor daily.
10NYCRR 415.5(h)(2)