Valley Health Services Inc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview during the recertification survey, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, for one (1) of one (1) resident (Resident #144) reviewed. Specifically, Resident #144 did not have their tap bell (manual device used to request assistance) in reach when out of their room as planned. Findings include:The undated facility policy Fall Prevention, documented when a resident was identified at risk for falls a plan of care would be implemented. All residents would have a fall risk assessment upon admission, quarterly, annually, and as needed. Once identified as a risk for falls the Nursing Care Coordinator and the interdisciplinary team would establish a comprehensive plan of care, addressing the individual needs of each resident.Resident #144 had diagnoses including dementia with behavioral disturbances, fractures of the arm and thigh bone. The 12/05/2025 Minimum Data Set documented the resident had severely impaired cognition, had periods of inattention and disorganized thinking, had no behaviors, used a wheelchair, was dependent or required moderate assistance for all activities of daily living, had a fall with major injury and used a bed and chair alarm.The 12/05/2025 Incident Report documented on 12/05/2025 the resident was found on the floor in the hallway next to their wheelchair. The resident sustained a fracture to their left humerus (arm), left patella (knee), and left great toe. A new order was obtained for a chair alarm when out of bed and the resident would be evaluated for further interventions upon the resident's return to the facility.The 12/05/2025 physician order documented to have a tap bell in the resident's reach when they were not in their room every shift for safety.The 01/08/2024, Comprehensive Care Plan, revised 12/05/2025, documented the resident was at moderate risk for falls related to deconditioning, gait, balance, recent fall at home, and a fall out of the wheelchair on 12/05/2025. Interventions included to have a tap bell in reach when they were not in their room.The following observations were made of Resident #144:-on 01/05/2026 at 11:33 AM in the hallway in their wheelchair sleeping with their hands across their lap. There was no tap bell on the overbed table next to them.-on 01/06/2026 at 1:09 PM in their wheelchair in the hallway across from the nurses' station with no tap bell within reach.-on 01/07/2026 at 9:39 AM sitting in hallway in their wheelchair across from the nurses' desk eating breakfast with no tap bell on the overbed table.-on 01/08/2026 at 4:42 PM sitting in their wheelchair down the hallway from the nurses' station between rooms [ROOM NUMBERS] with no tap bell within reach. During an interview on 01/09/2026 at 10:25 AM Licensed Practical Nurse #42 stated fall interventions were on the care plan. Resident #144 was supposed to have a tap bell when they were out of bed to use if they needed something. They stated they were not aware the resident was missing their tap bell, but other staff sometimes brought the resident back to the hallway and did not put the tap bell out.During an interview on 10/09/2025 at 10:32 AM, Licensed Practical Nurse #24 stated fall interventions were on the care plan. Resident #144 was supposed to have their tap bell within reach when out of bed even if they did not use it.During an interview on 01/09/2026 at 10:59 AM, Nursing Care Coordinator #31 stated they oversaw all the care plans on the unit. They expected if a resident had a fall intervention on the care plan, it should be in place. Resident #144 should have a tap bell when they were not in their room so if they were in the hallway, they should have a tap bell. The resident had a fall with broken bones on 12/05/2025 and was to have a tap bell in case they needed attention.During an interview on 01/09/2026 at 12:18 PM, the Director of Nursing stated Resident #144 fell in December 2025 and had several fractures. The intervention for a tap bell to be within reach when not in their room was added to the resident's fall care plan so the resident had something when they were in the hallway. The resident was in the hallway frequently and staff was not always around. They did not know if the resident was fully capable of using it, but it would be there if they needed it. The resident should always have the tap bell when in the hallway outside their room.10NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the recertification survey, the facility failed to provide ongoing programs to support each resident in their choice of activities, for one (1) of one (1) Resident (Resident #70) reviewed. Specifically, Resident #70 did not have a person-centered care plan that reflected their interests and preferences and was not offered meaningful activities that met their interests and preferences.Findings include:The facility policy Activities Program, last reviewed 8/2025, documented the Activities Program was a structured plan of social, recreational, cultural, spiritual and therapeutic events designed to enhance quality of life. Activities were to include cognitive stimulation, physical activity, creative expressions, spiritual practices, and social interaction. Activities would be adapted to meet the needs of residents with cognitive or physical impairments. Activities staff were to be trained and receive ongoing education in resident's rights, person-centered programming, and dementia-specific approaches. Residents were to be evaluated on admission and at least quarterly by the Activities staff to develop and maintain a person-centered care plan. Participation and resident responses to activities were documented in the medical record by Activities staff.Resident #70 had diagnoses including Parkinson's disease (progressive neurological disorder), severe dementia, and aphagia (inability or refusal to swallow). The 12/24/2025 Minimum Data Set (assessment tool) documented the resident had severely impaired cognition, was dependent for all activities of daily living, and activity preferences included listening to music.The 1/6/2026 Comprehensive Care Plan documented the resident was alert and disorientated, eye movement was sometimes used for responses, however, the resident frequently chose to keep their eyes closed. The resident was dependent on staff for activities and awareness and attended programs with assistance from staff as a passive participant. Interventions included encourage ongoing family involvement, invite the resident's family to attend special events and activities as able, invite the resident to scheduled activities, provide an activities calendar and update with changes, thank the resident for attendance at activities functions, assist with activities of daily living as required during an activity, and escort to activity functions. When the resident was unable to participate in organized activities, offer social and sensory stimulation. The resident enjoyed hand massages, being read to, and listening to the radio.The 9/25/2025, Resident Ability and Preference Form documented the resident liked to be read, go outside when they could, listen to music, and have their window drapes open. The resident liked Country Western music, being read to with no type of book identified, and sunlight on their face. The resident was non-verbal, and the plan was to continue with one-to-one visits including hand massages and reading.The resident's activity participations documented:- on 09/01/2025 Activities Aide #15 sat with them with while they had their hair cut.- on 09/27/2025 was visited and seemed to respond to Activities Aide #15's voice.- on 10/19/2025 Activities Aide #15 stopped to check in on the resident and play music. The resident reacted to their voice.- on 10/26/2025 Activities Aide #16 talked to the resident about the weather and provided a gentle hand massage- on 12/20/2025 the resident appeared asleep, and Activities Aide #15 played music from the phone.The following observations of Resident #70 were made:- on 01/05/2026 at 12:23 PM sitting up in bed with the radio on a hip-hop/pop music station.- on 01/06/2026 at 10:13 AM sitting in their wheelchair near the nursing station with five other residents, staring at the ceiling. The television was off and there was no radio on in the area.- on 01/07/2026 at 10:00 AM sitting up in bed staring at the ceiling with the room lights off. Neither the television nor the radio was on. At 11:03 AM, in bed with their eyes closed. Neither the television nor the radio was on. At 12:23 PM, in bed, eyes closed, and the room lights off. Neither the television nor the radio was on. At 3:43 PM in bed with their head tilted towards the wall with eyes open. The room lights were off and neither the television nor the radio was on.During an interview on 01/09/2026 at 10:37 AM Certified Nurse Aide #12 stated Resident #70 was gotten up by the overnight shift and then usually laid down after lunch. When the resident was up, they usually sat in front of the television in the common area. When the resident was in their room, the radio was put on. They were unsure what kind of music the resident liked, and the radio was primarily tuned to today's hits and occasionally country music. The resident could not talk but they could hear and should not sit in a quiet room all day.During an interview on 01/09/2026 at 10:43 AM, Licensed Practical Nurse #14 stated Resident #70 always had their eyes closed and there was not much the resident could physically do but they enjoyed music. The radio in the resident's room should be on a music station with the genre of music they enjoyed. The resident enjoyed classic rock music per their family. The resident also enjoyed when activities staff came and did massages.During an interview on 01/09/2026 at 10:49 AM, Nursing Care Coordinator #7 stated the resident should have a television or radio on in their room if they were in there for an extended period. The resident's preference in music should be played and it should be on their care plan. The radio stations were limited in the building, even in the dining room only one radio station would come in. They stated some residents had compact disks to play their favorite music type.During an interview on 01/09/2026 at 11:48 AM, the Director of Activities stated there was an initial activities assessment done when the resident was admitted , and preferences were updated once a year on a form kept in a binder in the activities office. The care plan was updated to reflect likes and dislikes based on the form. Families were also interviewed to get input for residents who could not communicate their preferences. For those residents they tried to play music in their rooms or have them attend live entertainment. All participation or refusal in activities was recorded in a note in the resident's electronic medical record. The activities staff were encouraged to check in with residents monthly or twice a month, it depended on what the resident wanted from activities and what their care plan included. Resident #70 was non-verbal, and their family did not come very often. The resident mostly communicated through eye movement. They were unsure how often Resident #70 was seen by activities staff, but it should be more than once a month. Resident #70's care plan should reflect what kind of music they liked to listen to. 10NYCRR 415.5(f)(1)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one (1) of one (1) resident (Resident #115) reviewed. Specifically, Resident #115 was not re-evaluated by therapy for positioning in their Broda chair (a specialty positioning wheelchair) and staff used a wedge pillow in the chair which did not maintain proper body alignment. Findings include:The facility policy Adaptive Positioning Equipment, dated 7/10/2025, documented residents requiring wheelchairs, positioning chairs, splints, and other adaptive equipment will be assessed by rehabilitation staff, and issued adaptive equipment as needed. If concerns arise after admission regarding the resident's positioning needs, the Nursing Care Coordinator was responsible for documenting the concern/need and sending occupational therapy or physical therapy rehabilitation request for wheelchair, splints, and positioning devices. The resident would be assessed for needs by the appropriate discipline. Resident #115 had diagnoses including contractures (restricted joint mobility) of left and right lower legs. The 10/22/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, did not use a wheelchair, was dependent for most activities of daily living, had functional limitation in range of motion in both legs, and did not receive physical and occupational therapy. The 08/06/2025 Comprehensive Care Plan documented the resident had an alteration in musculoskeletal status related to contractures of the bilateral extremities. Interventions included anticipate needs, give analgesic (pain) medications as ordered by the physician, and monitor for fatigue and falls. The care plan did not document the use of a wedge pillow for positioning. The 11/03/2025 at 10:11 AM, Nursing Care Coordinator #7 progress note documented the resident had a witnessed fall, slid out of their chair towards the left side and landed on their left side (shoulder and head) when they hit the floor. Emergency medical assistance was called to assist with transfer from the floor to stretcher and transport to the hospital. The 11/07/2025 Hospital Discharge Summary documented the resident was admitted for observation after a ground level fall with head trauma. The plan was to return to long term care facility. The 11/08/2025 physician order documented occupational therapy evaluation for range of motion/muscle strength and positioning bed/chair. The 11/10/2025 Physician #8 readmission progress note documented the resident was seen for readmission after a ground level fall with a head strike on 11/03/2025. The resident had mobility impairment related to bilateral knee contractures. The resident was seated in a recliner chair with arms flexed, knees flexed, was unable to straighten, and did not raise arms at shoulder level. The 11/08/2025 through 11/15/2025 Occupational Therapists #10 and #11 progress notes documented continued occupational services were initiated to increase safety awareness and facilitate independence with activities of daily living to enhance the resident's quality of life. The plan was to trial an abductor/contracture cushion while in bed and in positioning chair to maintain proper position. Staff and the resident were educated on use of the knee contracture cushion. The 01/09/2026 care instructions documented the resident should have an abductor/contracture cushion placed between their knees, two rolls behind the back of the knees used in bed and in the positioning chair (Broda chair). There was no documentation that included the use of a wedge pillow or how to ensure the resident was properly positioned in their Broda chair. Resident #115 was observed in their Broda chair: -On 01/06/2026 at 9:20 AM, reclined, leaning to the right. Staff raised the chair to sitting position.-On 01/07/2026 at 10:20 AM, leaning far to the right, moaning, and not able to sit up straight; at 12:15 PM, in the dining room, reclined and leaned to the right while asleep; and at 1:00 PM, sitting near the 2 East nursing station, leaning to the right side.- On 01/08/2026 at 11:35 AM, sitting near the 2 East nursing station leaning forward and to the right side. At 11:48 AM, Certified Nurse Aide #8 repositioned the resident by centering them in the chair. During an observation and interview on 1/08/2026 at 1:06 PM, Certified Nurse Aide #13 stated the resident leaned a lot in their chair because their legs hurt with the contractures. The resident was able to move themselves, but staff also helped to reposition them. During an interview on 01/09/2026 at 9:35 AM, Certified Nurse Aide #8 stated the resident required one person to reposition and provide care. The resident was able to move their arms but not their legs. The resident required repositioning frequently as they held the side of the chair and pulled themselves down. They used a wedge pillow to help prop the resident on the side of the chair to prevent them from pulling themselves down. They stated without the wedge pillow the resident leaned into the crack of the chair and could fall out of the chair. They were not sure who initiated the blue wedge pillow. During an interview on 01/09/2024 at 10:16 AM, Licensed Practical Nurse #14 stated the resident had a wedge pillow that was supposed to be on their right side. The resident was hard to keep in a good position. They had a pillow under their legs that was from therapy, and they thought the wedge pillow on the right was from therapy to keep the resident from leaning to the right. The pillows needed to be adjusted often. The wedge was important to have in place because it kept the resident from falling out of the chair. The resident went to the hospital a month ago for a fall out of their chair. They thought physical therapy assessed the resident when they returned and added the blue wedge pillow. Physical therapy would not reevaluate the resident unless the nursing staff requested an evaluation. During an interview on 01/09/2026 at 11:13 AM, Occupational Therapist #11 stated the resident used a Broda chair and had an abductor pillow. The resident was given the abductor contracture pillow in November 2025. The resident required repositioning throughout the day. They had done frequent education with staff. The abductor pillow was for the knees which helped with the upper body positioning and would center the resident. If the resident side sat, staff should re-center the resident. They were not aware of the blue wedge pillow, and it was not issued by therapy. Nursing should reach out to therapy to work on positioning for the resident. If nursing noticed position issues, they should request a therapy evaluation. During an interview on 01/09/2026 at 11:54 AM, Nursing Care Coordinator #7 stated the resident was assessed when they were readmitted from the hospital in November 2025. They added the abductor wedges between the knees at that time. They should have issued a positioning chair, but they issued the Broda chair. The resident required repositioning by staff and liked to be reclined. If nursing staff noticed impaired positioning, they should reposition the resident. They were not sure where the blue wedge pillow came from. They had not sent a therapy referral, and the handwritten referral would need to be completed for a repositioning evaluation and should be given directly to the Director of Therapy. 10 NYCCR 415.11(c)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents who required nephrostomy tubes (a tube that drains urine from the kidney through an opening in the skin) received services consistent with professional standards of practice for one (1) of one (1) resident (Resident #161) reviewed. Specifically, Resident #161 had a nephrostomy tube and the physician orders did not include specific instructions to document the description of the output, when to change the drainage bag, to monitor for tube patency or blockage, and to monitor for signs and symptoms of infection; the care plan did not include care instructions or indicate what to monitor for and report; and staff were unsure if licensed practical nurses or certified nurse aides were responsible the drainage bag was emptied, measured, and documented. The drainage was not consistently measured and documented as ordered. Additionally, medical was not notified when there was no output. Findings include:There was no documented evidence of a facility policy addressing nephrostomy tube care.Resident #161 had diagnoses including nephrostomy placement, urinary tract infection, and sepsis (system wide infection). The 12/11/2025 Minimum Data Set (a health status assessment tool) documented the resident had moderate cognitive impairment, had an indwelling catheter (including nephrostomy tube), and did not reject care. The 12/05/2025 at 2:40 PM, Registered Nurse #31 Nursing admission Assessment documented the resident had a drain to their left back with bloody drainage. The urinary assessment was left blank and not completed.The 12/05/2025 Registered Nurse #31 progress note documented the resident had an incision with a drain noted to the left flank.There was no documented evidence Registered Nurse #31 requested clarification of the drain or notified the provider of the bloody drainage. The 12/08/2025 Physician #8 admission progress note documented the resident recently had a nephrostomy tube placed at the hospital on [DATE] for left staghorn calculus (a large kidney stone that fills the renal pelvis). The nephrostomy tube to the left back was draining bloody discharge and needed follow up. Physician orders documented:- From 12/06/2025-01/06/2025 apply gauze to left flank around drain and cover with a dry dressing once a day.- On 12/08/2025 empty nephrostomy output and measure every shift. - On 01/06/2025 apply gauze to left flank around drain and cover with a dry dressing once daily on Mondays.There was no documented evidence of an order to empty and measure nephrostomy output from admission on [DATE] until 12/08/2025. There was no documented evidence of physician orders to monitor or record the description of the nephrostomy tube output, an order to change the bag, an order to monitor the tube for patency or blockage, or to monitor/ report any signs or symptoms of infection.The Comprehensive Care Plan initiated 12/18/2025 documented the resident had renal insufficiency related to left staghorn calculus status post left nephrostomy tube placement. Interventions included monitor labs and signs and symptoms of acute renal failure, document, and report such as urine output less than 400 milliliters in 24 hours. There was no documentation related to care instructions or monitoring of the nephrostomy tube. The December 2025 resident care completed by the certified nurse aides documented the nephrostomy was emptied and output was recorded every shift. There was no documentation of output measurements. Documentation that the nephrostomy was emptied was missing on the following days/ shifts:-On 12/06/2025 on the night shift.-On 12/07/2025 on the evening and night shifts.-On 12/10/2025 on the evening and night shifts.-On 12/11/2025-12/18/2025 on the evening shifts.-On 12/20/2025 on the evening shift.-On 12/21/2025 on the evening and the night shifts.-On 12/22/2025-12/23/2025 on the evening shifts.-On 12/25/2025-12/26/2026 on the evening shifts.-On 12/28/2025 on the evening shift.-On 12/30/2025-12/31/2025 on the evening shifts. The December 2025 Medication Administration Record documented by licensed staff the nephrostomy tube was emptied, and output was measured on every shift. There was no documentation this was completed on the following days/ shifts:-On 12/09/2025 on the day shift.-On 12/13/2025 on the night shift.-On 12/14/2025 on the day shift.-On 12/15/2025 on the evening shift.-On 12/20/2025 on the evening shift.-On 12/24/2025 on the day shift.-On 12/26/2025 on the day shift.-On 12/28/2025 on the night shift.-On 12/30/2025 on the day shift. The 12/30/2025 outpatient Urology after visit summary documented the appointment was a new patient visit for left nephrostomy tube. There were no instructions regarding the tube. The check out note documented the resident needed a consult for percutaneous nephrolithotomy (a minimally invasive surgery to remove large or complex kidney stones).The 12/30/2025 Nursing Care Coordinator #32 progress note documented the resident returned from their urology appointment and needed a percutaneous nephrolithotomy consult. They would call the office for an appointment tomorrow (12/31/2025).The January 2026 resident care completed by the certified nurse aides documented the nephrostomy was emptied and output was recorded every shift. There was no documentation of output measurements. Documentation that the nephrostomy was emptied was missing on the following days/ shifts:-On 01/01/2026 on the evening and night shifts.-On 01/02/2026-01/03/2025 on the evening shifts.-On 01/04/2026 on the evening and night shifts.-On 01/06/2025 on the evening shift.-On 01/07/2025 on the day and night shifts.-On 01/08/2025 on the evening shift.The January 2026 Medication Administration Record documented by licensed staff the nephrostomy tube was emptied, and output was measured on every shift. There was no documentation this was completed on 01/04/2026 on the night shift and on 01/05/2026 on the evening shift. On 01/07/2026 Licensed Practical Nurse #33 documented there was zero (0) milliliters of output on the evening shift, Licensed Practical Nurse #34 documented zero (0) milliliters of output on the night shift. There was no documented evidence the medical provider was made aware there was no output. During an observation and interview on 01/05/2026 at 11:07 AM, Resident #161 was lying in bed with clothes on. They stated if they did not complain, they did not get the care they were supposed to. They were at the facility because they had kidney problems and needed an operation to get rid of a kidney stone. They had a stone on each side and a tube in between. During an observation on 01/07/2026 at 10:39 AM, Physician Assistant #35 was in the resident's room asking them questions. They did not ask the resident about their nephrostomy tube or look at it.The 01/07/2026 Physician Assistant #35 progress note documented the resident was seen for a mandatory 30-day review. There was no documented assessment or plan of the nephrostomy tube. During a follow up observation and interview on 01/07/2026 at 10:48 AM, the resident was in their room seated in their wheelchair. They stated their drainage bag was emptied once a day in the morning and maybe before bed. They were not sure the last time it was emptied. The tubing was visualized on the left side of the body and contained tea colored drainage. They stated they had just gotten back from therapy. There was a bed sheet tied around their torso with a knot. They tried to show the surveyor the drainage bag, but it was wrapped up in the bed sheet and they were unable to get to it. They stated the sheet was to hold the tubing during therapy. The resident leaned forward in the wheelchair and lifted their shirt. A dry, intact, undated dressing was present on their left lower back with a drainage tube coming out of the center of the dressing.The 01/08/2026 resident care record documented Certified Nurse Aide #36 emptied and recorded the output of the nephrostomy tube at 9:57 AM.During an interview on 01/08/2026 at 10:27 AM, Certified Nurse Aide #36 stated Resident #161 had a tube to their back. They were not sure what it was, the nurse took care of it, they did not do anything with the drainage bag.During an interview on 01/08/2026 at 10:32 AM, Licensed Practical Nurse #37 stated nephrostomy tube care involved making sure it was clean, and the dressing was changed. The drainage bag was like a urinary catheter bag and was emptied once a shift by the certified nurse aides or the nurses. If the certified nurse aides emptied the bag, they told them the output so it could be documented in the Medication Administration Record. Resident #161 was currently at an appointment, so they had emptied their drainage bag this morning before they left. During an interview on 01/08/2026 at 10:36 AM, Nursing Care Coordinator #32 stated the licensed practical nurses were responsible for the dressing changes and documented the output every shift on the Medication Administration Record. The nurses could delegate to the certified nurse aides to drain and measure the output but the certified nurse aides did not document on that so they would have to relay that information to the nurse. If there was no documentation it meant it was not done. Output should be monitored to see the trending and monitor the color for urology follow up. Resident #161 had consistently less drainage. If the bag was not draining or being emptied there was risk for infection. There was no formal education on nephrostomy tubes but if the licensed practical nurses had questions or were not familiar with them, there was always a registered nurse on they could go to for questions. During a telephone interview on 01/08/2026 at 1:22 PM, Licensed Practical Nurse #34 stated there was no training or education on nephrostomy tubes. They changed Resident #161's dressing early this morning because they had an appointment. As a nurse they were responsible to empty the drainage bag and make sure it was intact. It was important the bag was emptied to make sure fluid was coming out of the affected area. They were not sure if there was a problem if there was no drainage or if the bag was not emptied.During an interview on 01/08/2026 at 1:45 PM, the Director of Infection Control and Staff Development stated there was no education for care of a nephrostomy tube. The rehabilitation unit had them frequently, so they were up with the practices. There was an order for care of the nephrostomy tube, and it was signed off on the Medication Administration Record or the Treatment Administration Record. The order should be followed and if it was not documented, it was not done. The drainage bag should be emptied otherwise the urine could backflow to the kidney and the resident could get an infection. They were not sure who was responsible the drainage bag was emptied. 10NYCRR 415.12(k)(3)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure that residents who required dialysis (used to filter waste products from the blood when the kidneys stop working properly) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #117) reviewed. Specifically, Resident #117 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site, and there was not consistent ongoing communication and collaboration between the facility and the dialysis center. Findings include:There was no documented evidence of a facility policy addressing dialysis.Resident #117 had diagnoses including end-stage kidney disease. The 10/19/2025 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact, did not reject care, and required hemodialysis treatments.The Comprehensive Care Plan initiated 01/07/2024 documented the resident needed hemodialysis related to kidney failure. Interventions included dialysis three times a week; and not to draw blood or take blood pressure in the arm with graft (dialysis access site). The care plan did not address the type or location of the dialysis access site, a plan for monitoring, or completion of pre and post dialysis assessments. The 05/28/2025 physician order documented the resident attended dialysis on Monday, Wednesday, and Friday at 5:30 AM. The order did not include pre or post dialysis assessments or access site monitoring. There was no documented evidence the dialysis site was monitored or that pre or post dialysis assessments were completed. The dialysis communication book (used for communication between facility and dialysis center) dated December 2025-January 2026 documented:-Outpatient dialysis daily treatment summaries were completed by the dialysis facility and included pre and post dialysis weights, blood pressures, any medications administered, or labs obtained for all dialysis days (12/01/2025, 12/03/2025, 12/05/2025, 12/08/2025, 12/10/2025, 12/12/2025, 12/15/2025, 12/17/2025, 12/19/2025, 12/21/2025, 12/23/2025, 12/25/2025, 12/28/2025, 12/30/2025, 01/02/2026, 01/05/2026, and 01/07/2026). There was no documented evidence the information was reviewed by the facility upon the resident's return from dialysis treatments. -The dialysis center registered dietitian Monthly Nutrition Reports dated 12/02/2025 and 01/07/2026 were completed by the dialysis center. There was no documented evidence the reports were reviewed by the facility. -There was no documented evidence of communication from the facility to the dialysis center.During an observation and interview on 01/05/2026 at 3:11 PM, Resident #117 was sitting in their wheelchair in their room. They stated they were on dialysis for the past eight years and went three times a week. They were picked up at 5:30 AM and returned between 11:00-11:30 AM. Before they left, the nurse just took their blood sugar. A dry, intact, white gauze dressing was observed just above their right antecubital (front of elbow). During a follow up observation and interview on 01/06/2026 at 1:07 PM, Resident #117 was sitting in their wheelchair in their room. There was no dressing to their right arm. They stated they took their own dressing off the day after dialysis as it had to be kept on for 12 hours. The facility staff never looked at their dialysis site. There was an arteriovenous fistula (a surgically created connection between an artery and a vein for dialysis access) on the right arm. The resident stated they recalled a time they had bleeding from their access site, and they had to go to the hospital, but they did not remember the details regarding how long ago. They stated they took a binder to dialysis, but did not know what the facility did with the binder after they got back.During an interview on 01/08/2026 at 11:01 AM, Certified Nurse Aide #6 stated they helped to get Resident #117 cleaned up and dressed before dialysis. There was a binder that went with them. When the resident returned to the facility, they helped them get settled back in and the binder was turned into the nurse's station.During an interview on 01/08/2026 at 12:25 PM, Licensed Practical Nurse #5 stated after Resident #117 returned from dialysis they looked over the information in the binder to make sure everything went ok, gave them their pills, checked their blood sugar, and then the resident went to lunch. If the binder had something noted, they let Nursing Care Coordinator #4 know. Otherwise, nothing special was done for dialysis residents. Resident #117 had something for dialysis to their right arm, but they were not sure what it was called. They came back with a dressing over it, but they were not sure who took the dressing off, but they were not responsible to do anything with it.During an interview on 01/08/2026 at 12:59 PM, Nursing Care Coordinator #4 stated there was a binder that went with Resident #117 to dialysis treatments. Dialysis filled out information in the binder and the nurse looked at it when they returned. The nurse would let them know if any changes were needed and they updated the orders. They believed the resident had an access site in their left arm but could not remember what it was called. The facility staff did not monitor the site, the dressing just stayed in place, and the facility did not do anything with it at all, just left it alone. Dialysis sites were monitored when they worked in the hospital but since they had worked at the facility, it was not something that was done. They thought without monitoring the site could move. There were no pre or post dialysis assessments. They stated they and the nurses had a general knowledge of dialysis, but everything related was handled by the dialysis center and not the facility. During an interview on 01/08/2026 at 1:45 PM, the Director of Infection Control and Staff Development stated they were not sure of the standards of practice for a dialysis resident. They were not sure if there was any documentation or if the site was monitored. Dialysis was not common in the facility. 10NYCRR 415.12(k)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure a residents who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for the resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (1) of one (1) resident (Resident #7) reviewed. Specifically, Resident #7 had a history of trauma with episodes of night terrors, and did not have a person centered care plan to address potential triggering events to avoid re-traumatization; and there was no social work follow up addressing the resident's night terrors.Findings include:The facility policy Trauma Informed Care, revised 05/23/2025, documented any care plan that referenced or discussed the resident's trauma must be clearly marked at the beginning of the care plan as confidential. All staff were to be trained on trauma informed care upon hire and annually. Training included defining and discussions of key terms such as event, experience, effect, realization, recognition, response, triggers, and care planning considerations. Social Services staff were to use an assessment tool for identifying residents that have experienced a traumatic event/post-traumatic stress disorder. A plan of care was to be developed to address the trauma with appropriate interventions to support the resident identified as having suffered a traumatic event/post-traumatic stress disorder. Triggers and events were identified and care planning initiated to limit traumatization.The facility policy Provision of Social Services, last reviewed 11/4/2009, documented the facility was to provide a Social Services Program to meet psychological needs of the individual resident. Services were provided based upon a comprehensive assessment which assured the resident the maximum attainable quality of life with their emotional and physical well-being, self-determination, self-respect, and dignity.Resident #7 had diagnoses including anxiety disorder, insomnia, and chronic obstructive pulmonary disease (lung disease). The 11/19/2025 Minimum Data Set (assessment tool) documented the resident was cognitively intact, had no behaviors, required supervision or moderate assistance with most activities of daily living, and was taking an antipsychotic (mood stabilizer) with an indication noted.The 5/2/2024 Comprehensive Care Plan documented the resident was on quetiapine (an antipsychotic) related to insomnia, could receive psychiatric consults as needed, and was stable. Interventions included to administer psychotropic medications as ordered, consult with the pharmacy and medical provider to consider dose reduction when clinically appropriate, discuss with the medical provider and the family regarding ongoing use of medication, review behaviors and interventions and alternate therapies attempted and their effectiveness, and to monitor and document any signs of adverse reactions of psychotropic medications.The 10/28/2024 physician order documented the resident was to receive quetiapine (an antipsychotic) 25 milligrams once daily for insomnia. The Comprehensive Care Plan initiated 7/15/2025 documented the resident had a trauma history from early adulthood as the resident served in a combat zone in the military. Interventions included to allow the resident time to answer questions and verbalize feelings, perceptions, and fears as needed and to consult with pastoral care, social services, psychiatric services, and others as needed. There was no documented evidence of factors that could trigger the trauma. The 07/17/2025 note by Social Worker #28 documented a trauma assessment was completed with the resident, their care plan was reviewed and updated.There was no documented evidence of a trauma assessment in the resident's medical record. The 12/04/2025 Pharmacist #38 miscellaneous note documented the resident's medication was reviewed by the interdisciplinary team. The use of the resident's quetiapine for sleep was discussed and the resident being adamant about its continued use. A gradual dose reduction trial was suggested to determine the lowest possible dose.The 12/09/2025 Nursing Care Coordinator #7 progress note documented the resident agreed with the gradual dose reduction trial of their quetiapine. The resident was to start a 12.5 milligram dose that evening. They would monitor for changes in behavior or sleep pattern.The 01/6/2025 Nurse Care Coordinator #7 progress note documented the resident had a complaint of not sleeping well due to night terrors since their quetiapine was decreased. The nurse practitioner was made aware, and the quetiapine was increased to 25 milligrams. The resident was updated.There was no documented assessment of the resident by social services or the provider following the statement of the resident having night terrors.During an interview on 01/09/2025 at 10:49 AM, Nursing Care Coordinator #7 stated they, social work, activities, and dietary were all responsible for care plans; it was an interdisciplinary care plan. Resident #7's expression of night terrors was new to them. They had done a gradual dose reduction of the resident's quetiapine the resident had agreed to trial. The resident came to them and informed them they were having night terrors at night since the reduction. Nursing Care Coordinator #7 stated they informed medical, and they increased the resident's quetiapine back to 25 milligrams. There were no other recommendations besides increasing the quetiapine back to its original dose. Social Services was made aware of the resident stating they were having night terrors, but they did not believe the resident was offered mental health services.During an interview on 01/09/2026 at 12:35 PM, the Director of Social Services stated if they were alerted to a resident having nightmares or night terrors through staff report or morning report, they would check in with the resident and see how things were going. They were informed of Resident #7 experiencing night terrors in morning report. When they first met the resident, the resident told them they experienced night terrors in the past. A history of night terrors should be care planned and the resident's care plan did not include night terrors but did indicate a trauma history from serving in a war zone. They had not followed up with the resident regarding their night terrors because the resident had not been feeling well, and they were waiting on influenza results. The Director of Social Services stated they received some trauma-informed training in orientation and following up on symptoms such as night terrors was a part of trauma-informed care. There should have a been a conversation with the resident regarding their night terrors and to see if there was anything in the environment that triggered the resident and could be addressed. 10 NYCCR 415.12(f)(1-2)

Based on observations, record review, and interviews during the recertification survey the facility failed to ensure a resident's ability to safely self-administer medications was clinically appropriate for two (2) of (2) residents (Residents #4 and #137) reviewed, and three anonymous residents present at the resident group meeting. Specifically, Residents #4 and #137 applied their own prescription creams without an order or assessment for their ability to do so; and three anonymous residents present at the resident group meeting stated they wanted to administer their own medications or creams and were told by facility staff they could not be assessed to do so.Findings include:The pharmacy policy Self-Administration of Medications, effective date 05/2018, documented to maintain a resident's high level of independence residents who desired to self-administer medications were permitted to do so if the facility's interdisciplinary team determined the practice was safe and there was a medical order to do so. If a resident desired to self-administer medications, an assessment was conducted by the interdisciplinary team including the resident's cognitive and physical ability to do so. If the resident was assessed to be able to safely administer medications, an additional assessment of bedside medication storage was conducted. If a resident did not want to self-administer medications, it would be noted in their chart.1) During a resident meeting on 01/05/2026 at 2:06 PM, one resident stated they asked to be assessed to self- administer their heart medication to be able to administer when needed. Two other residents stated they wanted to be able self-administer medications or creams.The 06/05/2025 Resident Council meeting minutes documented a resident voiced they wanted to be able to self-administer their medication and store it in their room. The response by the Administrator was medications had to be kept in the medication room. There was no documented additional follow up. 2) Resident #4 had diagnoses including a Stage 2 pressure ulcer (partial skin loss) of the right buttock. The 11/27/2025 Minimum Data Set documented the resident was cognitively intact, was independent or required supervision for activities of daily living and had two Stage 2 pressure ulcers and received wound care.The 10/10/2022 Comprehensive Care Plan, revised 11/25/2025, documented the resident had pressure ulcers or the potential for pressure ulcers related to immobility to the right medial buttock and a resolved right inner gluteal wound. Interventions included to administer treatments as ordered, assess, monitor, and record wound healing weekly and as needed, and educate the resident as to the cause of skin breakdown. There was no documented evidence the resident was care planned to self-administer wound care. The 10/28/2025 physician order documented apply Calmoseptine (an over-the-counter ointment with zinc and menthol that protects, soothes, and promotes healing for minor skin irritations) External Ointment 0.44-20.6% every shift for wound care.There was no documented physician's order to self-administer the wound cream.The 12/18/2025 Skin/Wound Assessment documented the resident had a Stage 2 wound that was improving with pink epithelial (skin) tissue present and beefy red granulation tissue (new healthy skin) measuring 0.3 centimeters in length and 0.3 centimeters in width. The skin surrounding the wound was red.The 3/15/2025 Assessment of Ability for Self-Administration of Medication documented the resident was not safe to self-administer their medications.During an interview on 01/05/2026 at 10:33 AM Resident #4 stated they did their wound care, and the nurses only checked it occasionally. They stated they cut a napkin into four pieces and put the medicine on the napkin pieces. They sat on the toilet to do their own wound care.During an observation and interview on 01/09/2026 at 9:25 AM, Resident #4 had a small pin hole on their right buttock with no redness, odor, or swelling. The resident explained they took care of the area twice a day with the menthol zinc cream. They stated the doctors told them it was not going to heal and to just continue to treat it. If there was drainage they took care of the wound three times a day. They did not want the nurse to bother with the wound every day so they asked if they could take care of it and the nurses let them. The nurses looked at the wound once a week but did not do any treatments for it unless they told the nurse there was bleeding. The resident did not want to show the wound care in progress but demonstrated the soft napkin they cut in half, took a fingertip amount of the menthol zinc ointment they kept in the room, put that on the napkin and applied it to the area while seated on the toilet seat. During an interview on 01/08/2026 at 1:13 PM, Licensed Practical Nurse #42 stated Resident #4 had a non-healing wound that was a hole but had skin surrounding it. The wound was not draining and did not have a dressing. The resident had Calmoseptine ointment applied. They stated the resident did all the washing of the area, but the nurses applied the ointment. They stated the resident was able to apply their own ointment.3) Resident #137 had diagnoses including venous insufficiency (poor circulation), lymphedema (chronic swelling), and high blood pressure. The 12/11/2025 Minimum Data Set documented the resident was cognitively intact and required moderate assistance or supervision for activities of daily living.The 05/11/2024 Comprehensive Care Plan, revised 05/28/2024, documented the resident had an activities of daily living self-care performance deficit related to impaired balance and limited mobility. Interventions included the resident required supervision for upper body dressing and moderate assistance for lower body dressing and to encourage the resident to discuss feelings about their self-care deficit.The 05/26/2025 physician order documented to apply Cerave itch relief cream 1% (pramoxine HCI) to arms, legs, and torso topically two times a day for eczema (skin condition), dry skin, and itching.The 06/12/2025 physician order documented apply Bengay Greaseless Cream (topical pain reliever) 10-15% (menthol-methyl salicylate) to the left side lower back topically three times a day for pain.The 07/22/2025 physician's order documented to apply Biofreeze Cool the Pain external gel 4% (topical pain reliever) to knees topically three times a day for arthritis in the knees.The 08/12/2025 physician's order documented to apply triamcinolone acetonide external cream 0.1% (a potent synthetic corticosteroid used to reduce inflammation, itching, redness, and swelling) to the arms and legs topically every 24 hours as needed for itchiness and rash.The 05/14/2024 Assessment of Ability for Self-Administration of Medication documented the resident was not able to self-administer medications.There was no updated assessment of the resident's ability to self-administer medications.During an interview on 01/05/2026 at 11:40 AM, Resident #137 stated they knew the Department of Health was in the building because a male staff member they did not know came in and took the prescription creams and Bengay they applied to themselves and put it in the nurses' cart. They stated their creams were never put in the cart. They stated they applied all their creams themselves except for the muscle rub; the nurses did that.During an interview on 01/09/2026 at 10:05 AM, Licensed Practical Nurse #24 stated Resident #137 had the Cerave in their rom at one point as the resident put that on themselves, but the other creams were kept in the medication cart. The resident could apply their own Cerave but not the muscle rub or Biofreeze. The resident expressed in the past wanting to apply their own creams. They stated they had not informed anyone the resident expressed wanting to apply their own creams. Residents had the right to apply their creams if they were able to do so and it should have been communicated to the care coordinator.During an interview on 01/09/2026 at 10:59 AM, Nursing Care Coordinator #31 stated the facility conducted self-administration assessments. The assessment was initiated if the resident's Brief Interview for Mental Status documented they were cognitively intact. If they were cognitively intact, they would likely be able to self-administer. It was mostly creams the residents wanted to apply. Nursing also had to make sure the resident could do the treatment appropriately, they could reach what they needed, and perform the task start to finish. They were unsure if there was a paper assessment, but they tried to do a note in the electronic medical record. They were also unsure if Resident #137 was assessed for the cream they wanted. They were unsure if Resident #4 was assessed for applying the wound cream. They knew the resident was cognitively intact. They were unsure if there was a list of residents who were able to self-administer their medications. If a resident wanted to self-administer their medications, it should be communicated to the Nursing Care Coordinator.During an interview on 01/09/2026 at 12:18 PM, the Director of Nursing stated they did not have many residents in the facility who could self-administer. There was an initial assessment and then an annual assessment. They just became aware the assessments were not being done annually. They stated they could not locate the facility's policy on self-administration so they pulled the pharmacy policies they had as the facility would follow that. They stated they knew there were residents doing creams in the facility they were not aware of. A resident who wanted to self-administer medications, should be assessed for self-administration even if there were concerns by the staff. The assessment would be documented in the electronic medical record.10NYCRR 415.3(e)(1)(vi)

Based on observations and interview during the recertification survey, the facility failed to post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for five (5) of five (5) days (01/05/2025-01/09/2025). Specifically, the current daily resident census, staffing hours, and nurse staffing schedules were located on the Unit 1 [NAME] nursing office door and window that was not easily accessible to all visitors or residents. Findings include: The facility policy Posting of Nurse Staffing Information, dated 01/16/2024 documented the facility complied with regulations including posting of nurse staffing information. The daily staffing information would be posted on the first floor next to the window of the nursing office at the beginning of each shift. Data would be legible and posted in a prominent place accessible to residents and visitors.During multiple observations from 01/05/2025-1/09/2025, there was a sign in the main lobby above the visitors' sign-in sheet about 5 feet from ground on a pillar documenting the staffing numbers and sheets were on the 1st floor nursing office. During multiple observations from 01/05/2025-01/09/2025, the daily nursing schedule, daily staffing numbers, and daily census was posted on the Unit 1 [NAME] nursing office door and window across from the Unit 1 [NAME] elevator. During an interview on 01/09/2026 at 12:53 PM, the Director of Nursing stated the staffing numbers was posted on the glass window of the nursing office on the first floor. There was no staffing sheet posted on the second floor at the facility's main entrance. The facility could provide transport to the posting if a resident wanted to see it and they could tell a visitor where it was located if they wanted to know. They stated the sign was not easily seen from wheelchair height. 10 NYCRR 415.13

Based on observations, record review, and interview during the recertification survey the facility failed to ensure that residents who displayed or were diagnosed with a mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem to attain the highest practicable mental and psychosocial well-being for one (1) of one (1) resident (Resident #136) reviewed. Specifically, Resident #136 exhibited symptoms of depression following their admission to the facility and need for long-term care and did not receive mental health counseling or routine psychiatric evaluations. Findings include: The facility policy Provision of Social Services, dated 11/24/2009, documented the facility would provide a social service program to meet the psychological needs of the individual resident. Services were provided based upon a comprehensive assessment, which assured the residents' maximum attainable quality of life (i.e., emotional and physical well-being, self-determination, self-respect, and dignity).Resident #136 had diagnoses including hemiplegia (one sided paralysis) and hemiparesis (one sided weakness) following a stroke. The 07/01/2025 admission Minimum Data Set (an assessment tool) documented the resident was admitted from a hospital; had moderate cognitive impairment; had no symptoms of feeling down, depressed, or hopeless; no behaviors; felt it was very important to do things with groups of people; required extensive assistance for most activities of daily living; was frequently incontinent of urine; and did receive antidepressant or antianxiety medications.The 06/26/2025 physician order documented Aricept 10 milligrams (a medication used to treat dementia), one tablet by mouth at bedtime for mood stabilizer. The Minimum Data Set did not include a diagnosis of dementia or Alzheimer's.The 7/03/2025 Comprehensive Care Plan documented:-the resident used psychotropic medications related to disease process, treatment with Aricept and psychiatry consult as needed. Interventions included consult with pharmacy, physician to consider dosage reduction when clinically appropriate at least quarterly; and educate the resident/family/care givers about risk, benefits and the side effects.-the resident had a mood problem related to disease process. The treatment included Aricept, psychology consult offered upon admission, however, resident declined; mood was stable at the time. Interventions included to assist the resident, family, care giver to identify strengths, positive coping skills and reinforce these; behavioral health consults as needed (psycho-geriatric team, psychiatrist etc.); and encourage the resident to talk and express their feelings.The 10/04/2025 at 9:45 PM, Licensed Practical Nurse #26's progress note documented the resident was very weepy and upset that morning. The resident made the comment I wish I was not here anymore. The resident seemed depressed. During the evening shift, the resident was very agitated, stating how they would call the police and have everyone fired. The resident said they just wanted to go to bed and refused their dinner and drank very little this shift.The 10/04/2025 at 9:50 PM, Director of Nursing's progress note documented they spoke with the resident regarding their previous comments about not wanting to be here anymore. The resident appeared sad and frustrated with their situation and denied a plan to harm themselves.The 10/05/2025 at 3:43 PM, Registered Nurse #29 progress note documented they were called to see Resident #136 because of their depressed mood. The resident stated they felt sad and ready to give up. The resident stated they had no plans of suicide or hurting themselves.The 10/07/2025 at 3:36 PM, Director of Social Worker progress note documented they attempted to visit with the resident to follow up on a change in mood and making passive suicidal statements regarding wishing to be dead. The resident was sleeping soundly at the time and unable to rouse. A mental health consult was submitted for follow up, and social services would follow up.The 10/08/2025 at 7:09 PM, Social Worker #28 progress note documented they attempted to see the resident for a mental health consult. The resident stated they needed to go to the hospital, as they were burning up all day. Nursing staff entered the room to change the resident's clothing. The resident was unwilling to engage in a mental health consult at that time. There was no documented evidence that a mental health consult was submitted.The 11/19/2025 Minimum Data Set documented the resident had moderate cognitive impairment, no documented symptoms of feeling down, depressed or hopeless; sometimes felt lonely or isolated; did not reject care; and required substantial/maximal assistance with toileting, and partial/moderate assistance for dressing and bathing.The 12/08/2025 Nurse Practitioner #27 90-day mandatory assessment documented the resident was discouraged about their recent stroke and not being able to live independently. They discussed the resident's current weepiness and frustration. The plan was to consider a low dose antidepressant, but they would wait for family input. The resident was weepy and teary during the assessment. The resident's problem list included stroke with left hemiparesis, dysphagia (difficulty swallowing), and dementia.There were no documented physician orders for psychiatry consults, or social service consults addressing the resident's psychological status. Nursing progress notes documented the following: -on 12/23/2025 at 1:27 PM by Licensed Practical Nurse #26 the resident refused to eat breakfast and lunch this shift. The resident was weepy and refusing to get out of bed for lunch. The resident became easily agitated when asked to get out of bed. -on 12/27/2025 at 10:40 PM by Registered Nurse #25 the resident was increasingly agitated and confused this shift. Registered Nurse #25 spoke to the resident's family who was concerned the resident may attempt to leave the building. A wander alert device was applied to the resident's wheelchair. The Resident was resistive to care and refused medications this shift. -on 12/31/2025 at 2:09 PM by Licensed Practical Nurse #22 the resident continued to refuse medications and had a poor appetite. The family was in to visit, and the resident refused to talk with the family member. The family requested a mental health evaluation.-on 01/02/2026 at 6:49 PM by Licensed Practical Nurse #24 the resident refused to eat breakfast or take medications. The resident refused to get out of bed for lunch and supper. The resident stated, I do not want to get out of bed. I do not want to eat; I want to die. The resident was agitated when approached by staff who assured the resident the nurses were there to help.-on 01/02/2026 at 7:50 PM by Licensed Practical Nurse #23 the resident refused their medications despite encouragement and reapproach, emotional support was provided.-on 01/03/2026 at 1:54 PM by Licensed Practical Nurse #22's progress note documented the resident refused out of bed for most of the shift. The resident got up for breakfast, and ate half their meal, and demanded to return to bed after their meal and refused lunch and medications. -on 01/05/2026 at 11:15 AM by Nursing Care Coordinator #7 the nurse practitioner was updated on the resident's behaviors. The resident noted to be weepy and anxious at times and refusing medication and meals. The nurse practitioner ordered to start mirtazapine (antidepressant/appetite stimulant) 7.5 milligram. The resident's family agreed. There was no documented evidence of physician orders for psychiatry consults, or social service consults. The 01/09/2026 at 11:04 AM, secure file transfer electronic email documented there were no psychiatry or psychology consults.Resident #136 was observed:-On 1/05/2026 at 11:37 AM in bed asleep with the room dark and the curtains pulled closed.-On 01/05/2026 at 1:05 PM in bed asleep. The resident did not attend the dining room to eat lunch and there was no meal tray in the room.-On 01/06/2026 at 12:51 PM in bed asleep, their room was dark, and their curtains were pulled closed.-On 01/07/2026 at 10:28 AM in bed asleep, the room was dark, and the blinds were pulled closed.-On 01/07/2026 at 12:13 PM in asleep in bed during lunch.-On 01/07/2026 at 12:43 PM in their room asleep. At 12:47 PM, a maintenance staff knocked on the door to enter and the resident did not wake up. At 12:58 PM, all the hallway lunch trays were passed, and the resident remained asleep in their room. -On 01/08/2026 at 11:03 AM in bed asleep with the curtains pulled closed.During a telephone interview on 01/5/2026 at 3:02 PM, Resident #136's family member/health care proxy stated the resident had dementia and recently started to be mean to staff and family. They stated the registered nurse notified them they were starting the resident on a new medication for depression.During an interview on 01/08/2026 at 11:31 AM, Resident Aide #21 stated Resident #136 seemed to be having a hard time adjusting to long term care. They were doing okay at first and now seemed very depressed. They stated the resident ate breakfast on 01/07/2026 but they would not eat lunch. They stated the resident would get really upset if they got to the dining room and other residents were already there and eating. They would refuse to eat and demand to go back to bed. The resident already mentioned they would not be eating lunch today.During an interview on 01/08/2026 at 1:11 PM, Certified Nurse Aide #20 stated the resident seemed more depressed and confused. The resident would usually go to breakfast if they were approached a certain way, but after breakfast, they wanted to go right back to bed. They were going to all the activities and then started to refuse all medication, meals and activities. The resident was on their own in the community and had a stroke and was just admitted to long term care. The resident was refusing all drinks and food and would get irritated with staff when they ask the resident to attend activities or meals. During an interview on 01/09/2026 at 11:37 AM, Nursing Care Coordinator #7 stated Resident #136 was admitted to the facility's rehabilitation unit after a stroke and in August 2025 they were transferred to long-term care. They stated the interventions in place to assist with the resident's mood was one to one visits, and family visits with the resident's niece. The resident was weepier lately and was started on mirtazapine because of decreased appetite. The resident ate breakfast and then would ask to lie down and would not get back up for the rest of the day. They thought the resident has only been this way for a week or two. The resident was having a hard time adjusting to the facility. The facility had a Licensed Mastered Social Worker that conducted mental health rounds. Resident #136 was not on the list to be seen during the recent mental health rounds. They stated it would be beneficial for the resident to be seen by mental health social work to give the team recommendation for the resident. During an interview on 01/09/2026 at 12:23 PM, the Director of Social Services stated on 01/05/2025 they put in a mental health consult for Resident #136. The request went directly to their consultant social worker who was a Licensed Masters Social Worker. They stated the resident had a little bit of increased confusion with mood change, refusing out of bed and refusing meals and medications. The consultant would do a one on one and would do an assessment of the resident and review their preexisting diagnoses and make suggestions for the physician to make medication changes. They stated the mood issues were recent. The resident became a long-term care resident in August 2025. When the resident was sleeping more and not coming out of their room for meals, staff should encourage the resident to come out for their meals and participate in activities During an additional interview on 01/09/2026 at 1:04 PM, the family member/health care proxy stated, they noticed more changes to the resident's behavior in the last month. The nurses were aware of this change in behavior, but it was worse. There were two nurses that really understood the resident but when those nurses were off, the resident would get very agitated. They had not been seen by psychiatry; it was winter, and the resident was depressed and had dementia. 10 NYCRR 415.12(f)(1)

Based on observations, record review, and interviews, the facility failed to ensure residents were free of any significant medication errors for one (1) of one (1) resident (Resident #5) reviewed. Specifically, Resident #5 was administered lispro insulin (a fast-acting insulin) that was opened and undated. Findings include:There was no documented evidence of a facility policy addressing insulin administration or storage. Manufacturer specifications for insulin lispro documented opened vials/ pens were discarded after 28 days.Resident #5 had diagnoses including diabetes. The 11/15/2025 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact and received hypoglycemic (lowers blood sugar) medications (including insulin). The 10/24/2025 physician order documented insulin lispro was administered before meals and at bedtime based on the following sliding scale (amount of insulin administered based on blood glucose levels):-if glucose level 0-150 milligrams/deciliter give 0 units-if glucose level 151-200 milligrams/deciliter give 2 units-if glucose level 201-250 milligrams/deciliter give 4 units-if glucose level 251-300 milligrams/ deciliter give 6 units-if glucose level 301-350 milligrams/ deciliter give 8 units-if glucose level 351-400 milligrams/ deciliter give 10 units The 01/07/2026 blood sugar summary documented the resident's blood sugar at 7:25 AM was 165 milligrams/deciliter and at 11:51 AM the blood sugar was 331 milligrams/deciliter. The January 2026 Medication Administration Record documented on 01/07/2026 at 7:30 AM Licensed Practical Nurse #5 administered 2 units of insulin lispro and at 11:30 AM they administered 8 units of insulin lispro. The following observations were made during medication administration on 01/07/2026 from 11:43 AM- 11:49 AM with Licensed Practical Nurse #5:-at 11:46 AM, Licensed Practical Nurse #5 obtained the resident's blood sugar with a result of 331 milligrams/deciliter. -at 11:48 AM, Licensed Practical Nurse #5 handed the insulin lispro pen to the surveyor to show the dial was set at 8 units. The surveyor did not observe an opened date on the pen and asked if the nurse could find an opened date. They stated the label with the opened date must have come off. -At 11:49 AM Licensed Practical Nurse #5 entered the resident's room with the insulin pen and an alcohol swab. They lifted the resident's shirt, rubbed their skin with the alcohol wipe, and injected the insulin into the resident's left lower abdomen.There was no documented evidence the administered insulin had an opened date and was used within the recommended time frame after opening. During an interview on 01/07/2025 at 11:50 AM, Licensed Practical Nurse #5 stated insulin was good for 28 or 30 days after opening. Whoever opened the insulin pen was responsible for labelling it with an opened date. They stated they used the same insulin pen for both insulin administrations at 11:49 AM and the breakfast dose. They did not check the date on the pen, and they should have. They just figured it was ok because it was in the resident's insulin pen bag. Without an opened date they did not know if the medication was expired. Residents should not receive expired medications because it could hurt them. They went through the cart all the time and the evening and night shifts did not label the pens when they opened them. They said they would discard the pen.During an interview on 01/07/2026 at 11:58 AM, Nursing Care Coordinator #4 stated opened dates were expected to be checked prior to insulin administration to ensure the insulin was not expired. Insulin did not last long after opening; they thought 30 days was all it was good for. If there was not a date, the nurse should discard the pen, get a new pen and label it with the date opened. Expired medications may not be effective. The night shift was responsible to go through the cart nightly and discard any expired medications. During an interview on 01/08/2026 at 1:45 PM, The Director of Infection Control and Staff Development stated there was no formal education on medication administration. It used to be part of orientation, but they had gotten away from it when COVID hit. They wanted to get back in the process. When administering insulin, the opened date should be checked prior to administration as it was part of the right medication in the five medication rights to ensure it was not expired. Licensed staff should have general knowledge from schooling. Insulin was a high risk/ significant medication. Residents should not receive expired insulin as it could be detrimental to their health, it might not even work, and residents should receive the most effective treatment for their diabetes. 10NYCRR 415.12(m)(2)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of communicable diseases and infections for two (2) of six (6) residents (Resident #5 and #137) reviewed, and for the facility legionella (a bacteria in water that can cause Legionnaire's disease) program. Specifically,-Resident #5 was on enhanced barrier precautions for a urinary catheter (drains urine from the bladder through a tube). Urinary catheter care was provided by Certified Nurse Aide #6 and precautions were not followed; Licensed Practical Nurse #5 did wear appropriate personal protective equipment when administering medications; and the resident's care plan did not include the use of enhanced barrier precautions.-Resident #137 was on contact precautions for conjunctivitis (pink eye). Precautions were not ordered until three days after symptoms appeared and medication treatment was ordered; their care plan was not updated to include the use of contact precautions; and Certified Nurse Aide #41, Licensed Practical Nurse #42, and Housekeeper #43 did not practice appropriate use of personal protective equipment when entering and exiting the resident's room.-the facility's legionella policy was not reviewed annually as required, facility water risk assessments were not completed annually as planned, water samples were not collected at the first draw as planned, and water samples tested were received outside the 48-hour hold window. The assessment forms and sampling results were not retained on site for a minimum of three years as required.Findings include:PRECAUTIONS The facility policy Infection Control, revised 11/2025, documented transmission-based precautions were used in accordance with the clinical presentation and were placed at the time the resident exhibited signs of a transmissible disease. There were four categories including contact, droplet, enhanced barrier, and airborne. Residents placed on precautions required an order, a progress note documented the type of precaution and reason, and a care plan was initiated. The appropriate sign was placed outside the resident's door when precautions were initiated. Signs designated the appropriate personal protective equipment to be worn, and the equipment was available outside the room. Bins for linen and garbage were placed inside the resident's room. Any equipment used and removed from the resident's room needed to be cleansed and disinfected between uses. Meal trays removed from resident rooms were placed in a plastic bag and placed on the dirty cart to return to the kitchen. This alerted kitchen staff to wear gloves when dealing with the dirty tray. Staff donned the appropriate personal protective equipment prior entering the room to perform cleaning duties. 1)Resident #137 had diagnoses including venous insufficiency and obesity. The 12/11/2025 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact and required supervision or partial to moderate assistance for most activities of daily living. Nursing progress notes documented:-On 01/02/2026 at 12:25 PM by Licensed Practical Nurse #42 the resident's left eye had increased drainage, redness, and puffiness. The resident complained of discomfort to the area. Nursing Care Coordinator #29 was made aware.-On 01/02/2026 at 9:33 PM by Registered Nurse #25 they went to see the resident who complained of redness and irritation to their left eye. Yellow drainage was noted, on call medical provider was made aware, and there was a new order for azithromycin (antibiotic) four times a day for five days. Physician orders documented:-On 01/02/2026 azithromycin ophthalmic solution one percent, one application to left eye, four times a day for conjunctivitis for five days. This order was discontinued at 9:41 PM.-On 01/03/2026 erythromycin ophthalmic (antibiotic for the eye) ointment five milligrams per gram. Instill one application in left eye four times a day for conjunctivitis for five days.-On 01/05/2026 (three days after the onset of symptoms) contact precautions for conjunctivitis to the left eye. Staff to wear gown and gloves for all interactions with the resident. There was documented evidence of a Comprehensive Care Plan the resident was on contact precautions. During an observation and interview on 01/06/2026 at 1:24 PM, Licensed Practical Nurse #42 walked in and out of Resident #137's room, removed the resident's lunch tray without wearing any personal protective equipment. Licensed Practical Nurse #42 placed the dirty tray on the tray cart. Licensed Practical Nurse #42 stated Resident #137 was on contact precautions for pink eye. They stated they picked up the roommate's lunch tray, they probably should have worn personal protective equipment, but they were in a hurry.During an observation and interview on 01/07/2026 at 12:17 PM, Certified Nurse Aide #41 entered the resident's room with a water pitcher they just filled. They did not perform hand hygiene prior to entering the room and did not wear any personal protective equipment. They stated they remembered the resident was on precautions when they dropped off their lunch tray, but they forgot when they brought their water pitcher back.During an observation and interview on 01/07/2026 at 2:13 PM, Housekeeper #43 was in the resident's room replacing the trash bag. They did not have a gown on. They used their gloved hands to take out the used trash bag and put a new trash bag in. They stated they did not do patient care and therefore they were not in contact with resident's fluids, so they did not need to wear personal protective equipment. They stated they wore a gown when they cleaned the room, but they were just grabbing the garbage, so they did not need to.During an interview on 01/09/2026 at 2:32 PM, the Director of Infection Control and Staff Development stated a resident with pink eye was on contact precautions and staff should wear gown and gloves in that room. If a resident was on contact precautions, any time the room was entered by any staff, a gown and gloves were required to be worn. This included picking up lunch trays, changing the trash, and returning a water pitcher. 2) Resident #5 had diagnoses including retention of urine. The 11/15/2025 Minimum Data Set assessment documented the resident was cognitively intact and had an indwelling catheter. The Comprehensive Care Plan initiated 07/30/2025 documented the resident had a chronic indwelling catheter due to urinary retention. Interventions included signs and symptoms of discomfort and infection were monitored for and documented. The care plan did not address enhanced barrier precautions. The 12/01/2025 physician order documented the resident was on enhanced barrier precautions; staff was to don a gown and gloves with all hands on care every shift for urinary catheter. The following observations were made:-On 01/05/2026 at 10:16 AM, Resident #5 was seated in their wheelchair in their room. There were two enhanced barrier precaution signs outside their door frame.-On 01/07/2026 at 11:43 AM Licensed Practical Nurse #5 was administering Resident #5's medications wearing only gloves and no gown.During an interview on 01/08/2026 at 11:06 AM, Certified Nurse Aide #6 stated Resident #5 had a urinary catheter. That morning, they provided care including cleaning the catheter insertion area, draining the bag, and changing the bag from the bed bag to the leg bag. They stated they only wore gloves to provide this care. The gowns were only used if a resident was coughing and not when providing catheter care. Enhanced Barrier Precautions used were to prevent droplets and contaminations. They stated the sign outside the room was new and they were reading it for the first time. They stated they should have worn a gown according to the sign and nobody told them that before. During an interview on 01/08/2026 at 12:27 PM, Licensed Practical Nurse #5 stated the certified nurse aides emptied the catheter bags and documented the output. They had to wear gloves to do this and if they were on precautions a gown was also worn. Enhanced Barrier Precautions meant there were extra precautions to make a sterile field to put equipment on if they had wounds or catheters. It was to keep residents from getting infections.During an interview on 01/08/2026 at 12:51 PM, Nursing Care Coordinator #4 stated for urinary catheter care, staff should wear gown, gloves, and masks because it was direct care. Residents with urinary catheters were on enhanced barrier precautions. Staff knew they needed to wear this personal protective equipment because of the sign outside the door. Enhanced barrier precautions prevented the spread of bacteria. During an interview on 01/08/2026 at 1:45 PM, the Director of Infection Control and Staff Development stated there was annual education on infection control and included enhanced barrier precautions. This education was also provided upon hire. They placed signs daily and staff were expected to follow the signage. LEGIONELLAThe facility policy Water Sampling and Management Plan, revised 10/31/2023, documented the Director of Environmental Services was responsible for environmental surveillance for Legionella through water sampling and conducting an annual environmental assessment of the water system in collaboration with the Administrator and the Director of Infection Control. Sampling was completed annually, and the plan was reviewed and revised annually in accordance with the findings from the environmental assessment. Water samples were first draw samples. The assessment forms, water sampling and management plan, and sampling results were retained onsite for a minimum of three years, in accordance with applicable rules and regulations. There was no documented evidence the policy was reviewed annually in 2024 or 2025 as required.The facility's water risk assessments and testing results since the last standard survey were requested on 01/05/2026. On 01/06/2026 the surveyor again requested the facility's water risk assessments and testing results, and the Director of Infection Control and Staff Development stated they were still working on gathering that information. The information requested was received on 01/07/2026.The Environmental Assessment of Water Systems in Healthcare Settings, Department of Health Form 5222 completed by the former Administrator documented there was one known case of Legionnaires' disease that was possibly or definitely facility acquired on 10/10/2023. The date of assessment was blank. There was no documented evidence a facility water risk assessment was completed annually in 2024 or 2025. The Legionella water testing results documented:-samples were collected on 05/29/2024 between 1:15 PM and 1:40 PM, received by the lab on 05/31/2024 at 11:45 AM, and processed on 05/31/2024 at 2:00 PM.-samples were collected on 08/28/2024 between 9:53 AM and10:33 AM, received by the lab on 08/30/2024 at 11:45 AM, and processed on 08/30/2024 at 1:00 PM. The report commented that samples were received past the 48 hour hold time.-samples were collected on 12/10/2024 between 9:50 AM and 10:25 AM, received by the lab on 12/12/2024 at 10:00 AM, and processed on 12/12/2024 at 4:00 PM.-samples were collected on 03/11/2025 between 8:00 AM and 8:50 AM, received by the lab on 03/13/2025 at 10:20 AM, and processed on 03/13/2025 at 1:50 PM. The report commented that samples were received past the 48 hour hold time. During an interview on 01/08/2025 at 01/08/2026 at 1:11 PM, the Environmental Services Manager stated they were responsible for collecting the water samples and sending them out for testing. There was a company that came out to do monochloride treatments and they dealt with the vendors. They heard the facility had a Legionella issue before the monochloride system was implemented. They had only been employed by the facility since September 2025, so they did not know all the details and had only collected samples once. They were not sure how often the samples needed to be collected. There was a Legionella plan, but they were unsure of the details. They spoke with the laboratory they dropped the samples off to and was educated on the process of collecting the samples. They were told they needed to collect the samples first thing in the morning, and the laboratory needed to receive them by 9:00 AM to get them sent to the testing laboratory timely. They were not sure of the details of how long the sample was good for before testing was completed. Legionella was a hazard in the water, it was very dangerous in nursing homes, and people could get sick. During an interview on 01/08/2026 at 1:45 PM, the Director of Infection Control and Staff Development stated maintenance was responsible for collecting the water samples and they reviewed the results. Testing was completed annually per the policy. Risk assessments were completed annually, and the policy was reviewed annually. The Administrator initiated the process of reviewing and revising policies. When they had started there was a resident that had tested positive for Legionnaires' disease so there was a lot of testing that was being done, and the situation was monitored closely by the Department of Health. They were going to check on the annual risk assessments because the former Administrator was really involved, and they were sure at they were completed. They needed to be more involved as apparently, and they were not following their plan. They were working with the Administrator under a performance improvement plan on updating policies annually as that was not being done. On 01/09/2026 at 11:03 AM, the Director of Infection Control and Staff Development sent a secured electronic communication indicating they reached out to the former Administrator, and they were able to direct them to the 2025 water risk assessment. At 12:09 PM, the 01/14/2025 water risk assessment was received.During an interview on 01/09/2026 at 2:03 PM, the Administrator stated they were responsible to ensure policies were reviewed annually. They were also responsible to provide oversight with Legionella. The water system company trained their team for water sampling. The laboratory also helped with procedures. They were not sure of the window of time for samples to be sent for testing. As the Administrator they were familiar with Legionella testing but they were not an expert yet. 10NYCRR 415.19(a)(b)

Based on observations and interviews the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one (1) of four (4) shower/tub units (2 [NAME] shower/tub unit) reviewed. Specifically, four anonymous residents present at the resident group meeting stated the shower/tub floors were a mess, the drains did not work, and the tubs leaked. The shower/tub unit on 2 [NAME] was observed to have standing, discolored water underneath it for multiple days of survey.Findings include:The undated facility policy Residents' [NAME] of Rights & Responsibilities, documented the residents had the right to dignified existence. The residents had the right to receive services in the facility with reasonable accommodations of their needs and preferences.During a resident group meeting on 01/05/2026 at 2:06 PM, four anonymous residents stated the resident shower floors were a mess, the showers and tubs did not work, the drains in the shower rooms did not work, and the tubs leaked.The 2 [NAME] Maintenance Request and Requisition forms from 12/012025-01/09/2026 documented no maintenance request notifications for the tubs and/or shower roomDuring an observation on 01/07/2026 at 9:52 AM the tub in the 2 [NAME] shower room was filling. There was standing water under the top of the tub under the pipe connecting to the tub. The water was not draining anywhere. At 12:57 PM standing water remained at the head of the tub under the pipe that connected to the tub. At 2:07 PM, the puddle under the top of the tub had extended outward underneath the tub to the side and the middle. There was visible discoloration along the edges of the puddle. The water was light tan in color.During an observation and interview on 01/07/2026 at 2:10 PM, Certified Nurse Aide #18 was squeegeeing the outer most water across the shower room into the shower drain across from the tub. Certified Nurse Aide #18 stated they gave a shower next to the tub in the shower room in a shower chair because the shower in that room would flood into the hallway due to the way the floors were. The water was a light tan to brow with grayish flecks in it.During an observation on 01/08/2026 at 10:20 AM the 2 [NAME] shower room had a musty wet odor near the tub. The tub had a brownish gray puddle under the pipes under top of the tub. The tubing pipe was rusting and frayed laying in the puddle. There was a drain under the tub that was crusted with grey matter. There was gray matter floating in the water. At 12:47 PM, the greyish brown puddle was still under the top of the tub with tubing piping sitting in the water.During an interview on 01/09/2026 at 10:20 AM, Certified Nurse Aide #18 stated there was a puddle under the tub in the 2 [NAME] shower room all the time. They stated they did not know why it was there but sometimes the seal leaked on the tub when the door was shut. They stated maintenance fixed the tub seal many times.During an observation and interview on 01/09/2026 at 10:16 AM, the Environmental Services Manager stated they had not received any work orders for the standing water underneath the tub in the 2 [NAME] Shower room. The water was greyish brown and had things floating in it. They stated they were unaware of the issue, and the problem was the drain may not be draining as it should. 10NYCRR 415.29

Based on record review and interview during the abbreviated survey (NY00337472), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #3) reviewed. Specifically, Resident #3 sustained a head injury from a fall and neurological checks were not performed during the time the resident awaited transport to the hospital.
Findings include:
The Head Trauma Protocol reviewed 3/2007, documented:
- the Registered Nurse Supervisor was responsible for notifying the physician of any resident with head trauma and to follow-up as warranted.
- Neurological checks were to be performed per the instructions. The Registered Nurse was to obtain the physician's order to perform neurological checks per the policy (refer to Neurological Check policy).
The Neurological Check policy reviewed 3/2007 documented:
- any incident involving the head that resulted in an injury would initiate a monitoring schedule for neurological checks. The schedule was to be maintained for a minimum of 24 hours. Following the initial Registered Nurse assessment, monitoring and neurological assessments could be conducted by licensed nursing personnel.
- If the medical provider was not in attendance, the Registered Nurse Supervisor was responsible for notifying the physician of a possible head injury and the assessment of the resident.
- A neurological assessment was to be completed and documented every 15 minutes for the first hour. If the assessment was within normal limits and there was no evidence of changes, continue with assessment, monitoring and documentation every 30 minutes for the next hour.
- The neurological assessment would include but not limited to vital signs, orientation/level of consciousness, pupil check, change in vision or speech, monitoring for nausea and vomiting, seizure activity, assessment of sensory function, change in behavior, checking motor function (ask resident to grip/release hands, push their arms against you, extend and flex both feet against resistance), and complaints of headache.
- Documentation in the nursing notes was to include response to and tolerance of assessments and the presence or absence of parameters. Documentation on the neurological check flow sheet was to be completed with each assessment. The sheet was maintained with the corresponding month's medication administration records.
Resident #3 had diagnoses including dementia and anxiety disorder. The 1/6/2024 Minimum Data Set assessment documented the resident had moderate cognitive impairment and required supervision for transfers. The resident had no falls since the last assessment.
The 3/24/2024 at 4:30 AM Licensed Practical Nurse #16's progress note was documented as a late entry and noted the resident was found on the floor and the Supervisor was notified. Vital signs and neurological checks were done. The resident had a large bump above and next to their left eye with a small cut and a large bump on the side of their knee. The resident was sent to the hospital.
The 3/24/2024 Incident Report completed by Registered Nurse Supervisor #15 documented:
- at 4:40 AM, the resident was observed by staff to be on the floor in their room near their bed.
- The resident had a large hematoma (collection of blood under the skin) to the left forehead and left side of the eye that measured 5 inches by 2 inches, and a hematoma with severe pain to the touch on the lower thigh that measured 2.5 inches by 2.5 inches.
- The fall was unwitnessed.
- The physician was notified at 5:00 AM and the resident was to be sent to the hospital for evaluation and treatment.
-There was no documentation of neurological checks being completed. The resident's blood pressure, pulse, and respirations were noted on the incident report.
The 3/24/2024 at 6:07 AM Registered Nurse Supervisor #15's progress note documented the resident was observed lying on their back next to the bed. They had a large hematoma to the left forehead extending down the left side of their eye measuring 5 inches by 2 inches and a hematoma to the left lower thigh area measuring 2.5 inches by 2.5 inches that was very painful to touch. Range of motion on all 4 extremities was at baseline. Neurological checks were at baseline. Ice was applied and acetaminophen was given. The on-call medical provider was notified and gave a new order was received to transfer the resident to the hospital for evaluation and treatment. Emergency Medical Services was called, and the resident left the facility via stretcher without incident.
The Emergency Medical Service Patient Care Record documented they arrived to the resident at 6:46 AM. The resident had a fall out of bed, had a bump on their head, and possible hematoma and leg fracture. The resident was transported to the hospital and arrived at 7:21 AM.
There was no documented evidence of neurological checks every 15 minutes for the first hour and every 30 minutes the next hour, following the initial assessment (approximately 5:00 AM) until emergency services arrived at 6:46 AM.
During an interview on 5/15/2024 at 4:18 PM, Registered Nurse Supervisor #15 stated on 3/24/2024, they were called to the unit to assess Resident #3 following a fall. They called the physician and received the order to send the resident to the hospital and then called the resident's representative at approximately 5:15 AM for hospital of choice. The Supervisor called the Emergency Medical Services company directly. The Supervisor stated after that they went to the office to print the transfer paperwork and brought it to the unit, then returned to their office to do end of shift tasks. Registered Nurse Supervisor #15 was called back to the unit (unsure of the time) due to increased swelling of the area on the resident's head. They reassessed the resident at that time and directed staff to monitor the resident. They then returned to the office and was not made aware that Emergency Medical Services had not arrived to transport the resident. Approximately 45 minutes later, the Supervisor was on the unit and observed the resident was still in their room. They immediately called Emergency Medical Services again and they arrived shortly after.
During an interview with Licensed Practical Nurse #16 on 5/23/2024 at 7:43 AM, they stated after a fall with head injury, neurological checks were done for 24 hours. They were to be recorded on a paper neurological flow sheet for 24 hours. The Licensed Practical Nurse was not sure of the time intervals to complete the neurological checks and would refer to the neurological check sheet. When Resident #3 fell, Registered Nurse Supervisor #15 responded to the unit and did an initial assessment and neurological check. Licensed Practical Nurse #16 stated they monitored the resident while waiting for Emergency Medical Services to arrive and did not complete a neurological check flow sheet due to the resident being sent to the hospital. They stated they documented neurological checks in the progress notes and on the incident report. During the time they waited for Emergency Medical Services, they did not notify the Registered Nurse Supervisor when they did not arrive but when the Supervisor came back to the unit, the Licensed Practical Nurse stated Emergency Medical Services had not arrived and the Supervisor called them again.
During an interview with the Director of Nursing on 5/23/2024 at 11:52 AM, they stated post-fall protocol for residents who hit their head included initiation of neurological checks immediately. Neurological checks should be completed and documented every 15 minutes for the first hour, every 30 minutes for the next hour, and then every hour, and ongoing increments for a full 24 hours. If the resident was being sent to the hospital, the neurological checks should be completed per the protocol until Emergency Medical Services arrived. Neurological checks included vital signs, pupil reactions, hand grips, sensory function, and mobility/gait and should be fully documented for each increment of time according to the neurological flow sheet. The Registered Nurse who completed the initial assessment should document the first neurological assessment and subsequently, it could be the Registered Nurse or unit nurse. Documentation of the neurological assessment in progress notes without any details was acceptable as long the assessment was fully documented on the neurological flow sheet. If there was no flowsheet, the Director of Nursing expected the assessment to be documented in the progress note. The Director of Nursing was not aware that there were no neurological checks in the resident's record and stated it should have been documented to ensure monitoring of the resident's condition prior to emergency services arrived.
10 NYCRR 415.12

Based on observation, record review, and interviews during the recertification and abbreviated (NY00290651, NY00310705, and NY00312631) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure residents were treated with respect and dignity for 3 of 5 residents (Residents #26, #38, and #110) reviewed. Specifically, Resident #26 had soiled clothing and an unclean wheelchair; Resident #38 was assisted with eating by registered nurse #9 and licensed practical nurse #10 who stood over them while feeding; and certified nurse aide #17 was observed speaking loudly about Resident #110's colostomy care and could be heard by anyone in the vicinity.
Findings include:
The facility policy, Accommodation of Resident Needs revised 9/2008 documented staff should call the resident by their first or last names and not honey, sweetie, dear; introduce yourself and explain all procedures to the resident and allow them to tell you what their needs are; review the care plan before providing assistance and always give the Resident a means to call for assistance by placing a call bell or tap bell within easy reach.
The undated facility admission agreement packet documented as a resident of the facility, residents have the right to a dignified experience, self-determination, respect, full recognition of their individuality, consideration and privacy for personal needs and communication with and access to persons and services inside and outside of the facility.
1) Resident #26 had diagnoses of dementia with psychosis, Parkinson's Disease (a progressive neurological disorder), and depression. The 11/07/2023 Minimum Data Set assessment documented the resident had moderate cognitive impairment, required partial/moderate assistance of 1 for bathing and upper body dressing, substantial/maximum assistance of 1 for lower body dressing, and used a walker and a wheelchair.
The comprehensive care plan, initiated 8/22/2022, documented Resident #26 had an activities of daily living deficit related to confusion, impaired balance, limited mobility, and Parkinson's Disease. Interventions included limited assistance of 1 for bathing/dressing and limited assistance of 1 for personal hygiene.
Resident #26 was observed:
- on 1/8/2024 at 10:23 AM sitting in their wheelchair dressed in a blue shirt, gray pants, and a gray hooded sweatshirt. There was a white stain on their shirt, a red food substance stain on the left sleeve of their jacket, and the left side of their wheelchair armrest and seat cushion had food stains.
- on 1/9/2024 at 1:45 PM dressed in a green shirt, blue pants, and a white jacket. The left jacket sleeve had a red food substance on it and the left wheelchair armrest and seat cushion had food stains.
- on 10/10/2024 at 10:00 AM sitting in their wheelchair. The left arm rest and seat cushion had food stains.
During an interview on 1/10/2024 at 12:00 PM certified nurse aide #3 stated housekeeping was generally responsible for cleaning wheelchairs but if staff noticed a dirty chair, they should either wipe it down with bleach wipes or they could take the chair into the tub room and use the spray hose on it. They stated Resident #26's wheelchair was dirty and it was not dignified for the resident to sit in an unclean wheelchair.
During an interview on 1/12/2024 at 9:14 AM licensed practical nurse #4 stated housekeeping usually cleaned wheelchairs but there was no set schedule. It was not dignified for Resident #26 to sit in a dirty wheelchair or to wear soiled clothing. Licensed practical nurse #4 stated staff should change the resident's clothes when they were soiled and should wipe down the wheelchair.
During an interview on 1/12/2024 at 9:25 AM registered nurse #5 stated they were the charge nurse and was familiar with Resident #26. They stated Resident #26 required intermittent assistance with care and could feed themselves. Registered Nurse #5 stated the resident should be provided a clothing protector if they wanted one and it was not dignified for them to have clothing soiled with food. They expected staff to change the resident's clothing if it was soiled. The resident should sit in a dirty wheelchair as it was undignified.
During an interview on 1/12/2024 at 9:56 AM the Director of Nursing stated they expected staff to assist Resident #26 with changing clothes when they were soiled and expected staff to wipe down dirty wheelchairs. They stated it was not dignified for a resident to remain in soiled clothing or to sit in a dirty wheelchair.
2) Resident #38 had diagnoses including Parkinson's disease (a progressive neurological disorder), and dementia. The 12/13/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition and required substantial/maximum assistance for all activities of daily living.
The comprehensive care plan revised 10/26/2022 documented the resident had an activities of daily living self-care performance related to Parkinson's disease. Interventions included being fed by staff, providing a sippy cup with handles, and using an insulated mug with a lid.
The following observations were made of Resident #38 during meals:
- on 1/8/2024 at 12:36 PM, registered Nurse #9 assisted the resident with their meal in their room while standing.
- on 1/9/2024 at 8:46 AM, registered nurse #9 assisted the resident with their meal in their room while standing.
- on 1/9/2024 at 12:56 PM, registered nurse #9 assisted the resident with their meal in their room while standing.
- on 1/10/2024 at 1:14 PM, licensed practical nurse #10 assisted the resident with their meal while standing. A chair was observed within reach.
During an interview 1/9/2024 at 3:10 PM, certified nurse aide #12 stated they usually helped Resident #38 with their dinner. They stated they could either sit or stand with the resident when feeding them. The appropriate fashion to feed a resident with dignity was to stand and feed them.
During an interview 1/10/2024 at 10:07 AM, certified nurse aide #8 stated the policy was to sit while feeding residents to be at their eye level. The resident's wheelchair was tall, so to keep at their level when assisting with eating, they had to stand. The facility did not provide tall stools or tall chairs to use with Resident #38. Dignified care was to be on the resident's level when assisting with meals.
During an interview on 1/11/2024 at 9:32 AM, registered nurse #9 stated they had worked with Resident #38 for years. They did not have a preference on whether a staff member stood or sat down while assisting at mealtime. Registered nurse #9 stated it was important to provide residents with dignity. They stated staff should be at eye level with the resident when they were feeding and sitting would be more dignified. The registered nurse stated they always had to be moving and that was the reason they stood when they assisted the resident with eating.
During an interview on 1/11/2024 at 9:55 AM, the Director of Nursing stated the dignified manner of feeding a resident was to sit. The resident should be care planned for their feeding requirements to ensure their dignity was maintained while assisting with mealtime. Staff should be seated when assisting the resident with feeding.
3) Resident #110 had diagnoses of diverticulitis of the intestines (inflamed pouches), colostomy status (a surgical opening from the large intestine to the outside to redirect stool), and gastro-intestinal bleeding. The 12/23/2023 Minimum Data Set assessment documented the resident was cognitively intact, had a colostomy, required assistance of 1 with toileting, and partial/moderate assistance for toileting hygiene.
The 12/16/2023 physician order documented colostomy care every shift and as needed and colostomy supplies of a one-piece drainable ostomy pouch (holds stool from the colostomy).
The comprehensive care plan initiated 12/27/2023 documented the resident had an activities of daily living self-care deficit related to activity intolerance. Interventions were partial/moderate assistance with toileting.
The 1/2024 bowel and bladder elimination for colostomy care documentation was not completed on the evening and night shifts from 1/5/2024-1/7/2024.
During an observation on 1/8/2024 at 11:19 AM, certified nurse aide #17 entered Resident #110's room, slammed the door, asked the resident if they wanted their colostomy bag emptied or changed, stated they did not know how to change a colostomy bag and would get someone to assist them in 15 minutes. Certified nurse aide #17 talked loudly and could be heard from the hallway.
During an observation and interview on 1/8/2024 at 12:22 PM, Resident #110's colostomy bag was half full of fecal matter and air. The resident stated their ostomy bag exploded or leaked due to staff telling them to wait for it to be emptied and not returning for an hour. The resident stated it resulted in wet pants and the need for a clothing change which embarrassed them.
During an interview on 1/10/2024 at 11:38 AM, certified nurse aide #25 stated certified nurse aides received colostomy care training in their classes. They were familiar with the resident and stated staff should check their colostomy bag every hour because it filled fast and would burst due to accumulated gas. Certified nurse aide #25 stated aides were trained to burp the colostomy bags and to empty them. They should not yell loudly about a resident's ostomy, and it would embarrass the resident. They stated the resident knew how to do their ostomy care, but they were in the facility for care and should be assisted. If the certified nurse aide did not know how to perform the task, they should ask the nurse quietly to explain the process to them.
During an interview on 1/10/2024 at 1:41 PM certified nurse aide #17 stated they were not assigned to Resident #110 on 1/8/2024 and had answered their call bell. Certified nurse aide #17 stated they had ostomy care training in their class and had no hands-on training and they did not know how to care for a colostomy. They stated they should not have yelled loudly about the resident's ostomy because it could embarrass the resident and they should have asked another aide or a nurse for help.
During an interview on 1/11/2024 at 9:22 AM certified nurse aide #24 stated they were familiar with Resident #110, they had a colostomy, and they helped empty it when needed. They stated they learned about ostomy care in certified nurse aide class by reading and return demonstration. They stated due to the Health Information Portability and Accountability Act (protects private health information), staff should not yell out loud that they did not know how to perform the ostomy care, it would embarrass the resident, it was a private matter and when asked, the nurse would always help them.
During an interview on 1/11/2024 at 12:14 PM licensed practical nurse #26 stated the nurses were responsible for changing colostomy bags weekly during skin assessments and nurses and certified nurse aides could empty them and document the amount. They stated the certified nurse aides should not be discussing a resident's care loudly and if the aide did not know how to perform the care, they should ask another aide, or the nurse and they would walk them through the steps.
During an interview on 1/12/2024 at 11:26 AM, the Director of Nursing stated that if a certified nurse aide was not sure how to perform colostomy care, they should ask the nurse on the unit. The staff should never say they cannot or do not know how to do the care in a loud voice, the resident would lose faith in the staff ability to care for them and this was a dignity issue if the conversation could be heard in the hallway.
10NYCRR 415.3(c)(1)(i)

Based on observation, record review, and interview during the recertification survey conducted 1/8/2024-1/12/2024, the facility did not develop and implement a comprehensive person-centered care plan for each resident to meet medical and nursing needs for 1 of 1 resident (Resident #46) reviewed. Specifically, Resident #46 had a physician order to elevate their legs when out of bed and the order was not implemented.
Findings include:
The facility policy Baseline Care Plan, reviewed 3/2023, documented the care plan included instructions needed for staff to provide effective and person-centered care and physician's orders. The baseline care plan would be evolved into the comprehensive plan of care by the care team and subsequent assessments.
Resident #46 had diagnoses including Alzheimer's disease, hypothyroidism (underactive thyroid gland), and hyperlipidemia (elevated fat levels in the blood). The 12/13/23 Minimum Data Set assessment documented the resident had severely impaired cognition, did not exhibit behaviors, had functional limitation in both legs, and was dependent for most activities of daily living.
The 12/14/2027 physician's order active through 1/11/2024 documented to elevate the resident's legs when out of bed as much as possible.
The comprehensive care plan, revised 9/17/2019, documented the resident had an activities of daily living self-care performance deficit related to Alzheimer's dementias and limited range of motion. Interventions included the resident was to be in a positioning wheelchair with a foot bucket (a solid one piece footrest to assist with leg support and positioning) when out of bed, was to utilize bilateral soft knee-high offloading boots unless bathing and laundering, and they required maximal assistance of 2 with a mechanical lift.
The comprehensive care plan initiated 1/21/2016 documented the resident had impaired circulation related to dependent edema (swelling) and elevated cholesterol. Interventions included to have legs elevated when resting and to inspect the foot, ankle, and calf skin daily for changes.
The January 2024 resident's care instruction did not include instructions to elevate the resident's legs.
The skin risk assessments dated 11/27/2023 and 12/18/2023 documented the resident had a risk factor of edema.
The following observations were made of Resident #46:
- on 1/8/2024 at 12:18 PM, their feet were positioned dependent on the positioning wheelchair foot bucket and were not elevated.
- on 1/9/2024 at 8:10 AM, their feet were positioned dependent on the positioning wheelchair foot bucket and were not elevated. At 1:05 PM, their right foot was on the foot bucket and their left foot was on the floor, both feet were dependent and not elevated. At 1:41 PM, both feet were dependent in the foot bucket and not elevated. At 2:43 PM, their feet were dependent on the wheelchair foot bucket and not elevated.
- on 1/10/2024 at 11:16 AM, both legs were dependent on the foot bucket of the wheelchair and were not elevated. At 1:28 PM, 2:35 PM and 4:57 PM, both legs were dependent on the foot bucket of the wheelchair with the chair slightly tilted so their legs were elevated less than 45 degrees.
- on 1/11/2024 at 8:45 AM, eating with their positioning chair slightly tilted back with both legs dependent on the foot bucket of the wheelchair. At 9:59 AM, asleep, positioned with the wheelchair slightly tilted back and both legs were dependent on the foot bucket of the wheelchair. At 12:36 PM, eating with their positioning chair slightly tilted back and both legs dependent on the foot bucket of the wheelchair.
During an interview on 1/11/2024 at 1:37 PM, certified nurse aide #14 stated if a resident had an order for their legs to be elevated whenever possible, their legs should be elevated by the staff. They would know if a resident had an order for their legs to be elevated by their plan of care. A resident's legs were considered elevated at 90 degrees or more from a dependent position of their feet flat on the floor or on footrests. They stated they knew Resident #46 was to wear the bilateral soft knee-high offloading boots but was unaware that their legs were to be elevated.
During an interview on 1/11/2024 at 1:45 PM, licensed practical nurse #15 stated they would usually elevate a resident's legs in a recliner or in their bed. If the resident was in a wheelchair that reclined, they would tilt the chair backwards and use a pillow to assist with propping the legs. They stated staff would use a pillow or recline Resident #46's wheelchair. At 3:44 PM, licensed practical nurse #15 stated they checked the electronic medical record and Resident #46's order to elevate their legs as much as possible when out of bed was under other order, no documentation. The order did not populate for the nurses to see on the medication administration record or the treatment administration record where the nurses could see the order and record it was completed.
During an interview on 1/11/2024 at 3:45 PM, registered nurse Care Coordinator #16 stated they had reviewed the order for Resident #46 to elevate their legs whenever possible out of bed. They stated they believed the order was put in when the resident was in a different kind of wheelchair. The order was discontinued today. They stated nursing staff should follow the orders in the computer and the orders should be put into the computer, so they populated for the nurses to be aware of them and to document on them.
10NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the recertification and abbreviated (NY00310705, NY00312631, NY00313972, and NY00328391) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure sufficient nursing staff was provided for nursing care to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 12 of 12 anonymous residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner. Specifically, during a confidential group meeting (resident council) 12 residents stated they had long wait times for receiving assistance with care. Additionally, deficiencies related to staffing were identified in the areas of Posted Nurse Staffing Information (F732), Resident Rights (F 550), and Infection Control (F 880).
Findings include:
The facility policy Staffing of Nursing Personnel dated 6/22/2009 documented all residents' needs were always met in a timely manner. The Director of Nursing set the staffing level for each unit and shift. The staffing levels/rosters were prepared for the nursing supervisor for each shift. If staffing needs fell below the anticipated needs, the nursing supervisor was to contact as many on duty and off duty personnel to find coverage. If adequate nursing personnel was not obtained, the nursing supervisor was to contact the Director of Nursing or Administrator, who might request assistance from other departments.
The 10/2023 Facility Needs Assessment documented the facility's average daily bed census was 130, with a total bed capacity of 160. The facility's population served both long-term nursing and short-term rehabilitation. The staff plan included the following positions with the desired number total for the facility, by shift: Resident assistants, desired number for day shift 5; evening shift 4, none desired for night shift. Certified nurse aides, desired number for day shift 15; evening shift 15; and night shift 6. Licensed practical nurses, desired number for day shift 6; evening shift 4.5; and night shift 4. Nurse Care Coordinators, desired number for day shift 5. Nursing supervisors, desired number for evening shift 1.5; and night shift 1.
The facility daily staffing schedule documented the following nursing schedule for 1/8/2024 through 1/12/2024 (there were 4 nursing care units; 1W, 1E/1EE, 2W, and 2E/2EE):
Day shift/first shift (7:00 AM to 3:00 PM) Monday 1/8/2024 staffing documented the following schedule for 115 residents.
- Unit 1W: 2 registered nurses (1 worked 11:00 AM-3:00 PM), 2 licensed practical nurses (1 worked 11:00 AM- 3:00 PM), 2 certified nurse aides, and 1 resident assistant.
- Unit 1E/1EE: 1 registered nurse, 2 licensed practical nurses (1 worked 6:30 AM-2:30 PM), 3 certified nurse aides (1 worked 9:00 AM-1:30 PM), and 3 resident assistants.
- Unit 2W: 1 registered nurse, 1 licensed practical nurse, 2 certified nurse aides, and 1 resident assistant
- Unit 2E/2EE: 1 registered nurse, 2 licensed practical nurses, 2 certified nurse aides (1 worked 6:00 AM-2:00 PM), and 3 resident assistants
Evening/second shift (3:00 PM to 11:00 PM) Monday 1/8/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 2 licensed practical nurse (1 worked 3:00 PM-7:00 PM), 1 certified nurse aide, and 2 resident assistants (1 worked 3:00 PM-9:00 PM).
- Unit 1E/1EE: 2 registered nurses that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, respectively (acted in the licensed practical nurse role), 1 licensed practical nurse, 1 certified nurse aide (another staff orienting to the certified nurse aide position), and 2 resident assistants (1 worked 3:00 PM-9:00 PM).
- Unit 2W: 1 licensed practical nurse, 1 certified nurse aide, and 2 resident assistants
- Unit 2E/2EE: 1 registered nurse (acted in the licensed practical nurse role), 2 licensed practical nurses that splint the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, respectively, 2 certified nurse aides that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, and 2 resident assistants.
Overnight/third shift (11:00 PM to 7:00 AM) Monday 1/8/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 2 licensed practical nurses (1 worked in the certified nurse aide role), 1 certified nurse aide (another staff member orienting to the certified nurse aide position from 3:00 AM-7:00 AM), and 1 resident assistant.
- Unit 1E/1EE: 2 licensed practical nurses, and 2 certified nurse aides.
- Unit 2W: 1 licensed practical nurse, and 2 certified nurse aides.
- Unit 2E/2EE: 2 licensed practical nurse (1 worked 11:00 PM-3:00 AM, in the certified nurse aide role), and 2 certified nurse aides.
Day/first shift (7:00 AM to 3:00 PM) Tuesday 1/9/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 2 registered nurses, 1 licensed practical nurse, 2 certified nurse aides that split the shift 7:00 AM-8:40 AM, and 8:40 AM-3:00 PM, respectively, (another staff orienting to the certified nurse aide position), and 1 resident assistant.
- Unit 1E/1EE: 1 registered nurse, 2 licensed practical nurses, 3 certified nurse aides (1 worked 7:30 AM-3:00 PM), and 3 resident assistants.
- Unit 2W: 1 licensed practical nurse, 2 certified nurse aides (1 worked 6:00 AM-2:00 PM, 2 other staff orienting to the certified nurse aide position), and 1 resident assistant.
- Unit 2E/2EE: 3 registered nurses (2 registered nurses split the shift 7:00 AM-12:00 PM and 12:00 PM-3:00 PM, and worked in the licensed practical nurse role), 1 licensed practical nurse, 4 certified nurse aides (1 worked 7:00 AM-8:40 AM, and another staff member oriented to the certified nurse aide position), and 3 resident assistants
Evening/second shift (3:00 PM to 11:00 PM) Tuesday 1/9/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 2 licenses practical nurse (worked 3:00 PM-7:00 PM, and 2:00 PM-11:00 PM, respectively), 2 certified nurse aides (1 worked 7:00 PM-11:00 PM), and 3 resident assistants (2 worked overtime 4:30 PM-7:30 PM and 3:30 PM-5:30 PM, respectively).
- Unit 1E/1EE: 3 licensed practical nurses (2 split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM), 3 certified nurse aide, and 2 resident assistants (another staff member oriented to the resident assistant position).
- Unit 2W: 1 licensed practical nurse, 2 certified nurse aides, and 1 resident assistants
- Unit 2E/2EE: 2 registered nurses (worked 3:00 PM-7:00 PM in the licensed practical nurse role), 2 licensed practical nurses worked 7:00 PM-11:00 PM, 3 certified nurse aides (2 worked 2:00 PM-11:00 PM and 7:00 PM-11:00 PM, respectively) and 1 resident assistant.
Overnight/third shift (11:00 PM to 7:00 AM) Tuesday 1/9/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 2 licensed practical nurses (1 worked in the certified nurse aide role), 2 certified nurse aides split the shift 11:00 PM-3:00 AM and 3:00 AM-7:00 AM.
- Unit 1E/1EE: 2 licensed practical nurses, and 2 certified nurse aides.
- Unit 2W: 2 licensed practical nurses (1 worked in the certified nurse aide role from 11:00 PM- 3:00 AM), and 2 certified nurse aides.
- Unit 2E/2EE: 2 licensed practical nurses, 4 certified nurse aides (2 worked 11:00 PM - 3:00 AM, and another staff member oriented to the certified nurse aide role), and 1 resident assistant.
Day/first shift (7:00 AM to 3:00 PM) Wednesday 1/10/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 2 registered nurses, 2 licensed practical nurses, 3 certified nurse aides, and 2 resident assistants (1 worked 7 AM-1 PM).
- Unit 1E/1EE: 1 registered nurse that worked 11 AM-3 PM, 2 licensed practical nurses, 3 certified nurse aides (1 worked 9:00 AM-1:30 PM), and 2 resident assistants.
- Unit 2W: 2 licensed practical nurses, 2 certified nurse aides, and 2 resident assistants.
- Unit 2E/2EE: 1 registered nurse, 2 licensed practical nurses, 3 certified nurse aides (1 worked 6:00 AM-2:00 PM, and another staff member oriented to the certified nurse aide position), and 3 resident assistants
Evening/second shift (3:00 PM to 11:00 PM) Wednesday 1/10/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 1 license practical nurse (with a registered nurse oriented to the licensed practical nurse position), 2 certified nurse aides, 1 resident assistant worked overtime from 4:30 PM-7:30 PM.
- Unit 1E/1EE: 1 registered nurse worked in the licensed practical nurse, 2 licensed practical nurses that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM), 2 certified nurse aide, and 1 resident assistant (another staff member oriented to the resident assistant position).
- Unit 2W: 2 licensed practical nurses that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, 2 certified nurse aide, and 1 resident assistants.
- Unit 2E/2EE: 2 registered nurses (1 worked 3:00 PM-7:00 PM in the licensed practical nurse role), 1 licensed practical nurse worked 7:00 PM-11:00 PM, 3 certified nurse aides (1 worked 7:00 PM-11:00 PM), and 1 resident assistant.
Overnight/third shift (11:00 PM to 7:00 AM) Wednesday 1/10/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 1 licensed practical nurse, and 2 certified nurse aides.
- Unit 1E/1EE: 2 licensed practical nurses, and 2 certified nurse aides.
- Unit 2W: 1 licensed practical nurse, 3 certified nurse aides (2 split the shift 11:00 PM-3:00 AM and 3:00 AM-7:00 AM), and 1 resident assistant.
- Unit 2E/2EE: 2 licensed practical nurses, and 2 certified nurse aides (another staff member oriented to the certified nurse aide role).
Day/first shift (7:00 AM to 3:00 PM) Thursday 1/11/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 2 registered nurses, 2 licensed practical nurses (1 worked 7:00 AM-2:00 PM), 3 certified nurse aides, and 2 resident assistants (1 worked 7:00 AM-2:30 PM).
- Unit 1E/1EE: 1 registered nurse, 2 licensed practical nurses, 3 certified nurse aides, and 3 resident assistants.
- Unit 2W: 2 licensed practical nurses, 3 certified nurse aides (1 worked 6:00 AM-2:00 PM), and 2 resident assistants.
- Unit 2E/2EE: 1 registered nurse, 3 licensed practical nurses, 2 certified nurse aides (1 worked 6:00 AM-2:00 PM, and another staff member oriented to the certified nurse aide position), and 3 resident assistants.
Evening/second shift (3:00 PM to 11:00 PM) Thursday 1/11/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 1 license practical nurse, 3 certified nurse aides (2 worked 3:00 PM-5:00 PM and 8:30 PM-11:00 PM, respectively), and 2 resident assistants (1 worked overtime 4:30 PM-7:30 PM).
- Unit 1E/1EE: 3 licensed practical nurses (2 split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM), 2 certified nurse aides, and 1 resident assistant (another staff member oriented to the resident assistant position).
- Unit 2W: 2 licensed practical nurses that split the shift 3:00 PM-7:00 PM, and 7:00 PM-11:00 PM, 2 certified nurse aides (1 worked 3:30 PM-7:30 PM, and 1 resident assistants.
- Unit 2E/2EE: 2 registered nurses (1 worked 3:00 PM-7:00 PM in the licensed practical nurse role), 1 registered nurse worked in the licensed practical nurse role 7:00 PM-11:00 PM, 1 licensed practical nurse worked 7:00 PM-11:00 PM, 2 certified nurse aides, and 1 resident assistant.
Overnight/third shift (11:00 PM to 7:00 AM) Thursday 1/11/2024, staffing documented the following schedule for 115 residents.
- Unit 1W: 1 licensed practical nurse, and 3 certified nurse aides (2 split shift 11:00 PM-3:00 AM and 3:00 AM-7:00 AM).
- Unit 1E/1EE: 2 licensed practical nurses, and 2 certified nurse aides.
- Unit 2W: 1 licensed practical nurse, 2 certified nurse aides (1 worked 3:00 AM-7:00 AM), and 1 resident assistant.
- Unit 2E/2EE: 2 licensed practical nurses (1 worked 11:00 PM-3:00 AM), and 2 certified nurse aides (another staff member oriented to the certified nurse aide role).
The undated facility census, provided on 1/8/2024 documented 115 residents resided in the facility.
The undated resident roster documented that Unit 1W had 11 of 26 residents, unit 1E and 1EE had 15 of 38 residents, unit 2W had 14 of 28 residents, and unit 2E and 2EE had 12 of 36 residents that required assistance of 2 or more for activities of daily living.
Staffing for mealtime assistance:
During an observation on 1/8/2024 at 11:43 AM lunch trays were delivered to Unit 1EE. Multiple residents were served their trays while seated in the hallway outside their rooms.
During an observation on 1/8/2024 at 11:54 AM, Resident #107 was being fed by certified nurse aide #8 in their room. The staff member remained standing during mealtime. Upon return to Resident #107's room at 12:06 PM (12 minutes later), the resident's tray was removed from the resident with 50-75% of food remaining on the tray.
On 1/8/2024 at 12:26 PM, licensed practical nurse #10 was overheard asking where everyone was, as there was no staff at the nurse's station to help pass lunch trays.
During a telephone interview on 1/08/2024 at 2:28 PM, Resident #107's family stated that the resident required assistance with eating and had to be fed as they were unable to feed themselves. They were not sure there were enough staff to assist the resident, as the resident's food was often cold when they had a chance to help them. The family stated that due to the resident's level of assistance, only certain trained staff could assist at mealtime.
During an interview on 1/10/2024 at 12:41 PM, certified nurse aide #8 stated that they fed Resident #107 on 1/8/2024. Certified nurse aide #8 stated they were quite rushed on 1/8/2024, as they were the only certified nurse aide for the unit on that day. The person assisting with mealtime feeding should engage the resident and be seated at the level of the resident.
During an interview on 1/11/2024 at 9:32 AM, registered nurse #9 stated that the residents on the long-term care units of the first floor used to be transported to the second-floor dining room for every meal before COVID-19. This practice took about 3 hours every meal. They were unsure how many staff members it took to transport the residents to the second floor, but they worked as a team to move residents for meals. All staff assisted with this move daily. They also needed staff to remain on the first floor as not all residents went to the dining room for meals. The facility was no longer able to use the second-floor dining room due to facility restrictions.
During an interview on 1/11/2024 at 9:55 AM, the Director of Nursing stated it was difficult to help all the residents that needed assistance during mealtime because at times the number of residents that required assistance was more than the number of staff they had. They assisted Resident #107 for dinner meals at times.
During a telephone interview on 1/11/2024 at 4:33 PM, certified nurse aide #8 stated they did not feel there was enough staff no matter how many people they had. They stated they believed the expectation of their job duties had risen. They were expected to do more with less. In addition to being short staffed at times, there were a high number of staff who called in, which made things more difficult. There were approximately 7 residents on the units that needed assistance during mealtimes. They stated staff were very frustrated and angry when the 2 units combined into 1 unit, because there was not enough staff for all the residents, but they worked together to help one another and made things work.
Staffing for activities of daily living
During an interview on 1/8/2024 at 10:14 AM, Resident #52 stated that call bells could be turned off by staff at the desk and were not answered. They stated they had an incontinent episode due to long call bell wait time. They activated their call bell for assistance to the bathroom, they could hear the call bell turn off and had to reactive it several times. This incident occurred during the overnight shift. There were occasions they were unable to get assistance to exit the bathroom for 45 minutes due to call bell wait times. This was painful and uncomfortable due to placement of wounds and the shape of the toilet.
During a confidential group meeting on 1/8/2024 at 1:58 PM, 12 residents reported the evening shift typically had 2 certified nurse aides, while the overnight shift typically only had 1 certified nurse aide for 42 residents. Residents stated they waited 2-3 hours for assistance, especially, if they did not get what they needed in the window of time between supper and getting other residents to bed. Residents were left on the toilet for 15-20 minutes because the certified nurse aide was assisting someone else. The aides did not always have two people to operate the resident mechanical lifts on the overnight shift. They did not like to wait an extended period because the aide was assisting someone with a bath. All department heads attended the resident council meetings, except for nursing.
A review of resident council minutes from June 2023 to January 2024, documented there was not a category in the meeting minutes to discuss nursing care concerns. Areas of discussion in the meetings included dietary, administration, social work, and activities.
During an interview on 1/8/2024 at 2:27 PM, the Ombudsman stated the concerns from the former Ombudsman for the facility included call lights and staffing.
During an interview on 1/8/2024 at 3:52 PM, licensed practical nurse #40 stated the registered nurse supervisor #39 had to come to unit 2EE to help with medication administration, because they were short staffed for nurses this shift.
During an interview on 1/9/24 at 7:58 AM, licensed practical nurse #18, stated they were the only nurse on the unit for 26 residents, and they usually only had 1 licensed practical nurse and one certified nurse aide. They should have had 2 licensed practical nurses and 2 certified nurse aides. They stated to prevent the spread of infection, the COVID section of the unit (where current COVID-19 positive residents were located) should have had their own nurse and aide.
During an interview on 1/9/2024 at 8:23 AM, resident assistant #41 stated they were the resident assistant for Unit 1E, and there was another resident assistant for 1EE, but normally they were the only resident assistant covering both units.
During an interview on 1/9/2024 at 8:43 AM, certified nurse aide #6 stated all staff had to remain in the facility until the next shift showed up. No call ins were accepted without medical notice. They stated this was a no mandate facility, but this was how the facility ensured they had staff for the residents. They were not technically mandated, but they also could not leave.
On 1/9/2024 at 9:07 AM, certified nurse aide #8 was overheard stating they worked 3 units all alone on Sunday.
On 1/9/2024 at 12:38 PM, during the lunch meal, an unidentified certified nurse aide was overheard stating to registered nurse #45, they had to shave a resident, still had 3 baths to give, and 2 rooms to move.
During an interview and observation on 1/9/24 at 12:44 PM, certified nurse aide #21 stated they did not have an assigned unit and was floated to the COVID-19 unit (unit 1 West) today. The unit used to have 7 residents and now it had 26 residents with the same number of staff. With the new admission and the COVID-19 resident rooms it could get very confusing. All the resident care was behind today, staffing was tough, and they had a certified nurse aide go home at the start of the shift for health reasons. This left them alone until another aide got there and now, they were trying to catch up on their care. The unit assignment was doable with two aides but not one aide. They had 3 late baths to do after lunch.
During an interview on 1/9/2024 at 12:48 PM, certified nurse aide #21 stated they worked 72 hours in the last 5 days because they had staff call out of work. They felt bad leaving the residents without enough help. They stated they had several residents that required two staff for mechanical lifts and sit to stand lifts, and if they did not have enough staff, the resident would have to wait for care. They should always have at least two certified nurse aides on a unit with 26 residents.
During an interview on 1/9/2024 at 3:02 PM, certified nurse aide #12 stated 1E/1EE was considered one unit. They had two licensed practical nurses, three certified nurse aides, two resident assistants, and an additional staff member orienting to the position of resident assistant. Certified nurse aide #12 stated this was not a common staffing roster, they never had this many staff members on the evening shift. They stated the previous night they worked a double, which meant they were the only certified nurse aide for both 1E and 1EE. The overnight shift was lucky if they had a second certified nurse aide working. There was a list of residents that got up in the morning on the overnight shift. If the resident on the get-up list needed a mechanical lift or required assistance of two, the certified nurse aide would either ask for help from the licensed practical nurse on shift or had to go to another unit to ask for a certified nurse aide to help.
During an interview on 1/10/2024 at 11:28 AM, certified nurse aide #42 stated they worked full time day shift on the 1E/1EE units which had a low census lately, and they were moved to the 1W unit for the day. Typically, they worked solo on the east unit, during the week, and had one additional staff member on the weekends. Second and third shift typically had one certified nurse aide for both the east units. The unit had 6-7 residents that required assistance of two, and they had to get assistance from the nurse on the unit to help transfer and move residents. There were times that residents were not toileted in time. The west unit (Unit 1 West) was difficult for them today, as it was not their typical unit, the pace was faster, and the needs of the residents were different.
During an interview on 1/10/2024 at 12:00 PM, certified nurse aide #3 stated they had worked in the facility for 8 years. A typical shift would be when they were the only certified nurse aide on the unit with 24 beds. The facility combined 2E and 2EE to try to help with staffing, but they only had 1 certified nurse aide on that unit too. The overnight shift had a list of 6-7 resident that wanted to get up early, so the day shift only had 7-8 residents to get up for the day. The unit had 4 residents that used mechanical lifts, which required 2 staff to operate safely, the shift nurse helped when needed. The certified nurse aide would get the lift set up and if the nurse was busy, they had to go to the other unit to get someone to assist them.
During an interview on 1/10/2024 at 1:51 PM, certified nurse aide #17 stated they did not have an assigned unit and worked between units. The nursing office door had a schedule and they reported to the unit they were listed on. They would sometimes get moved to another unit during the shift if someone did not show up for work. The nurse aide was a crucial position, and they needed adequate staff to care for residents. One certified nurse aide was not enough, they should have two resident assistants, two certified nurse aides, and two licensed practical nurses on the rehabilitation and COVID unit. The staffing was low, but they had good staff and worked well as a team. It was important to have adequate staff to ensure the resident needs were met and they were taken care of.
During an interview on 1/10/2024 at 4:11 PM, certified nurse aide #43 stated they were assigned 13 residents for this shift. They used chair alarms because several residents stood up and fell. They had chair and bed alarms so they knew if a resident tried to get up, they could hear them. They checked on residents about every 2 hours for bathroom use and knew if a resident tried to get up because the bed alarms would go off.
During an interview on 1/11/2024 at 9:05 AM, registered nurse #44 stated their unit was all the COVID residents from the facility, The unit usually only had 15 or 16 residents, so now having 26 residents was a lot. They can get up to 32 residents, but with new admissions, rehabilitation residents, and COVID residents it was a lot to handle.
During an interview on 1/11/2024 at 2:27 PM, registered nurse #11 stated they only sometimes had enough staff, but it was tough to get enough staff especially just before and just after the weekend. Mondays and Fridays they had to use mostly float staff to ensure they had enough staff, and it was slower to get the residents' needs met. The staff became upset when they could not do extra things for the residents, such as paint nails, or style a resident's hair.
During an interview on 1/12/2024 at 9:43 AM, registered nurse #45 stated Unit 1West was a short term rehabilitation unit and the designated COVID unit. Registered nurse #44 and registered nurse #45 usually worked 7:00 AM- 3:00 PM but tended to stay late to help with resident care and admissions. Staffing on the day shift was 1 licensed practical nurse, sometimes 2 on the larger units, 1-2 certified nurse aides, and a resident assistant when they had 10-15 residents. All the new admissions and readmissions came to Unit 1West for a 10-day quarantine. There was an increase in COVID residents. The facility provided more staff this week because, one aide was acceptable with 13 residents, but not with 26. They had a lot of residents with 2 assist requirements and mechanical lifts. Acuity went up on the unit in general, as the unit provided hospital type acute care to the residents. The last 5-6 years had been more stressful and busier with the quarantines. The census increased and with the COVID outbreak they went up to 2 nurses, but they did not get extra aides. There were many residents that required assistance of two. The best staffing with a census of 26 would be 2 licensed practical nurses, 3 certified nurse aides, and 2 resident assistants, as a minimum for the unit. The 2 registered nurse supervisors on evenings 12:00 PM-12:00 AM tried to help with medication passes on the evening shift.
During an interview on 1/12/2024 at 9:56 AM, the Director of Nursing stated they were responsible for managing all of nursing staff, policies, procedures, and staffing issues. The expectation for resident care was that staff should provide assistance with bathing, morning care, grooming, assistance with meals, toileting, transferring, and walking for those that could walk.
During an interview on 1/12/2024 at 11:26 AM, the Director of Nursing stated staffing for the long-term care units was done based on a set number of a full unit and what the unit would like to have on their unit. The rehabilitation unit had a frequently changing census, the staffing needs for that unit changed on a day-to-day basis. The rehabilitation unit normally had 12-15 residents but had an influx of admissions and currently had 24 but could hold up to 32 residents. That unit had not been at full census in 3 years, because they did not have the staff. Safe staffing for the acuity of the rehabilitation unit with 24-26 resident was 2 licensed practical nurses, 2-3 certified nurse aides, and a resident assistant, during the day. The evening would have 1 licensed practical nurse and 2-3 certified nurse aides with the current census. The long-term care units were 24 bed units, they had 1 licensed practical nurse on each extension, and 2-3 certified nurse aides between the 2 units. The aides work between units, as the goal was to have more certified nurse aides. The staffing sheets had blanks where they would like to have those positions filled. They had a nurse aide class finish in mid-December. It was important to have enough staff to provide the best care and quicker response to the residents, and to meet the needs of the resident. Most of the registered nurses stayed late and passed medications in the evening or picked up extra time on the night shift. There had been times when they had 1 aide and 1 nurse, due to calls in, staff not showing up for their shift, sickness, or preapproved time off. If there was one aide, the nurse should help the aide. They should call the nursing supervisor to help if they were available. They could call staff from another unit to help with the residents who required assistance of 2. This was not ideal staffing, but they worked together. New certified nurse aides worked with an experienced certified nurse aide for approximately 2-3 weeks but could be adjusted if they needed more help.
During an interview on 1/12/2024 at 11:51 AM, scheduler #13 stated the staffing needs were determined by the actual staffing sheets that were created by the Director of Nursing. Unit 1 [NAME] needed more staff currently because they had all the new admissions and had more residents than normal. The staffing needs right now for each unit were 2 licensed practical nurses, 3 certified nurse aides, and 2 resident assistants for days. The evening shift was to be scheduled with 1 licensed practical nurse, 2 certified nurse aides, and 1 resident assistant. The evening shift was the shortest shift and needed more coverage. They would call staff to come in on days off or stay late. They handled call ins by pulling staff from another unit and if they did not have enough staff, they would call staff on their day off to see if they would come in. If they were unable to find the coverage, they would go to the Director of Nursing to see if anyone would stay late from day shift or come in early from night shift.
During an interview on 1/12/2024 at 1:02 PM, the Administrator stated staffing played a role in facility quality measures. They had an Assistant Administrator that was tracking the staffing. The staffing person tracked what they needed and worked on recruitment. They had an outpour of staff retire and were trying to recruit. They staff for the census, and they would like more staff, but the staff they had was doing well. Recruitment was done with an outside recruitment agency, posters in the laundry mats, and social media connections were used to find the types of staff they needed.
10NYCRR 415.(a)(1)(i-iii)

Based on observation and interview during the recertification and abbreviated surveys (NY00310705 NY00312631, NY00313972, and NY00328391) conducted 1/8/2024-1/12/2024, the facility did not post on a daily basis at the beginning of each shift, the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent location readily accessible to residents and visitors for 4 of 5 days. Specifically, the current daily resident census and nurse staffing schedules were located on the Unit 1 [NAME] nursing office door that was not easily accessible to visitors or residents.
Findings include:
The daily resident census and nurse staffing information was observed posted on the nursing office door outside of Unit 1 [NAME] across from the elevator:
- on 1/8/2024 at 2:21 PM.
- on 1/9/2024 at 7:50 AM.
- on 1/10/2024 at 12:03 PM.
- on 1/11/2024 at 9:27 AM.
The posting was not legible, did not include the daily census, and was not readily accessible to residents or visitors.
During an interview on 1/8/2024 at 4:00 PM, the Administrator stated the main entrance to the facility was on the ground level near the outpatient clinics; the nursing home was located on floors 1 and 2 and the upper-level entrance had been closed since the COVID-19 pandemic and was not going to be re-opened.
During an observation on 1/10/2024 at 12:03 PM, signs that directed visitors to use the ground level entry were posted near the social services office and entrance to Unit 1 West. There were no daily staffing or census posted.
During an interview on 1/12/2024 at 11:51 AM staff scheduler #13 stated the staffing schedule was posted per shift outside of Unit 1 West, across from the elevator on the nursing office door on the 2nd level of the nursing home on the 1st floor. They stated it was not always legible and was for the day shift only. They were not aware the daily staffing needed to include all shifts for 24 hours and should be posted in an area visible to all visitors upon entrance.
10 NYCRR 415.13

Based on observation, record review, and interviews during the recertification and abbreviated (NY00328391) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure a resident who displays or is diagnosed with dementia receives the appropriate treatment and services to attain and or maintain their highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #45) reviewed. Specifically, Resident #45 who had a diagnosis of dementia, made suicidal statements that were not addressed by the facility.
The facility policy Suicide Precautions reviewed 03/2023 documented immediate protective response would be provided, physically and emotionally, to any resident that expressed suicidal plans, thoughts, or attempts. Any employee who became aware that a resident had expressed suicidal thoughts, plans, or attempts would immediately notify the charge nurse on the resident's unit. The resident would be under direct supervision until a plan of care for the resident was determined. The registered nurse Supervisor, Director of Nursing, social services, Administrator, and physician would all be notified. If the resident was on psychiatric services, the provider of those services would be notified. If they were not, an evaluation would be requested.
Resident #45 had diagnoses that included depression, anxiety disorder, and unspecified dementia. The 12/20/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, did not have depression, had no behavioral symptoms, and was on anti-psychotic and anti-depressant medications.
The comprehensive care plan revised 04/2023, documented the resident had a history of behavior problems related to their dementia which included being weepy and inconsolable. The resident was to have psychiatric consults as needed. Interventions included to monitor behavior episodes to determine cause and to encourage the resident to express their feelings. The comprehensive care plan, initiated 09/11/2020, documented the resident had impaired cognitive function related to dementia. The interventions included to report any change in mental status or cognitive function.
The 12/2/2023 at 9:28 PM licensed practical nurse #36 nursing note documented the resident had been yelling and singing all shift and was impossible to redirect. The resident was also making comments that they wished they were dead, and they were going to jump in front of a bus. The plan was to monitor. There was no documented evidence a nursing supervisor or medical provider were notified of the resident's comments.
The 12/5/2023 at 9:10 PM licensed practical nurse #36 nursing note documented the resident was singing/screaming/swearing all shift. The resident was and stated they were going to jump out the window when the nurse asked the resident not to sing. There was no documented evidence a nurse Supervisor or medical provider were notified of the resident's comments.
There was no evidence of social services or medical provider notification or interventions regarding the resident's statements of self harm.
The following observations were made of Resident #45:
- on 1/9/24 at 1:41 PM, singing out loudly a wordless tune in their room. At 1:54 PM, they were still singing wordless tune loudly in their room.
- on 1/10/24 at 1:19 PM, singing loudly in their room. At 4:49 PM, they were in the hallway singing Candy, Candy, where are you loudly and appeared distressed. An unidentified certified nurse aide informed the resident that they just had to sit another resident down and then they would take the resident back to their room to call their family. Resident #45 was agreeable and stopped singing. At 5:17 PM, they were singing loudly in their room.
During an interview on 1/10/2024 at 4:33 PM, the Director of Social Services stated they should be notified of depressive or suicidal statements or ideations made by residents so they could assess the resident. Resident #45 had been followed in their psychotropic medication monitoring rounds due to an increase in behaviors and a decline in their cognitive status related to dementia. There were no reports from the resident or staff the resident was having increased depression. They stated they were not informed of the statements made by the resident on 12/2/2023 and 12/5/2023. They would have done a safety assessment to ensure the resident was okay.
During an interview on 1/11/2024 at 1:37 PM, certified nurse aide #14 stated if a resident appeared more depressed or had made depressive comments, they would inform the nurse and the Nursing Supervisor.
During an interview on 1/11/2024 at 1:45 PM, licensed practical nurse #15 stated if a resident had made suicidal or increased depressive statements, they would chart on it and notify the Nursing Supervisor. They would also document that they informed the supervisor and what the supervisor implemented for the resident. The Nursing Supervisor would notify the nurse practitioner or the physician. They stated that if they did not report the statements and the resident ended up hurting themselves, it would be a safety issue.
During an interview on 1/11/2024 at 3:45 PM, registered nurse Care Coordinator #16 stated if a resident made a suicidal ideation statement, they expected the nurses or any staff member to bring it to their attention. The facility had resident assistants who could sit with the resident while they assessed the situation, and they brought it to the Director of Nursing and the medical providers. The resident would be assessed to see if an evaluation by a hospital was warranted. They were unaware of any suicidal statements made by Resident #45.
During an interview on 1/11/2024 at 4:09 PM, the Director of Nursing stated registered nurse supervisor #39 worked on the evening of 12/2/2023 and registered nurse supervisor #38 worked on the evening of 12/5/2023. They stated the actions put into place if a resident made suicidal ideation statements would depend on the resident and the resident's history. They stated the facility took every resident statement seriously. If the statements were not a normal behavior for the resident, they would immediately put a one-to-one (safety watch) in place and notify the provider. Supervisors were to be notified of any resident that made suicidal ideation statements.
During an interview on 1/11/2024 at 4:14 PM, registered nurse supervisor #39 stated if a licensed practical nurse was informed a resident made a suicidal ideation, the nurse should immediately report it to them so the resident could be assessed, and the information passed up the nursing chain of command. They could not recall being notified of any resident in the facility making a suicidal ideation statement. They stated they should have been informed of Resident #45's statements so interventions could be put into place as the resident could have acted on their thoughts.
During an interview on 1/11/2024 at 4:22 PM, registered nurse supervisor #38 stated they expected to be contacted immediately if a resident made a suicidal ideation statement so that they could assess the resident and their ability to act on a plan. If a resident had a psychiatric history with previous attempts and would act on a plan, the resident would be placed on one-to-one immediately and the Director of Nursing and medical provider would be contacted. They stated they could not recall being informed of any resident in the facility making a passive suicidal comment. They had never been informed of Resident #45 making statements. They knew Resident #45 could get frustrated with their dementia. They stated they should have been informed and it was important to report those statements so the resident could be investigated and monitored.
During an interview on 1/12/2024 at 10:40 AM, licensed practical nurse #36 stated their procedure for a resident that had made a depressive or suicidal ideation statement was to let the supervisor know and document what the resident stated. Sometimes they would talk to the resident to calm them down or contact the resident's family to assist with calming them down, but they did not have a lot of time to sit and spend with a resident. They could not recall if they notified the supervisor on 12/2/2023 and 12/5/2023. They tried to document when they let their supervisor know but that they sometimes let the supervisor know thirty minutes or so after the resident had made the comments so the note may have already been written. They stated they did not believe there were any negative side effects in the delayed supervisor notification because they would sometimes bring the resident out to the nurse's station to be within sight or had a resident assistant sit with the resident. Resident #45 had made some suicidal ideation statements but that it was a behavior that reoccurred at random, so they did not always let the supervisor know.
10 NYCRR 415.12

Based on observation, record review, and interview during the recertification survey conducted 1/8/2023-1/12/2023, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in 1 of 1 main kitchen. Specifically, the mechanical dishwasher was not maintained, clean utensils were not properly stored, uncleanable surfaces were present in the walk-in cooler, and the walk-in cooler was soiled.
Findings include:
The undated facility policy, Kitchen Cleaning documented all kitchen staff were responsible for cleaning and sanitizing the kitchen. Specifically, cooks were responsible for cleaning and maintaining their work area, steamers, fryers, sinks, slicers, stove tops, and general work areas; dietary aides were responsible for cleaning their tray line areas, walk-in cooler, refrigerator and dessert carts and dishwashers were responsible for cleaning the dishwashing area and cleaning/mopping floors. Garbage was removed by maintenance.
1) Mechanical dishwasher
The mechanical dishwasher's specifications were not documented on the machine.
During an observation on 1/12/2024 at 10:06 AM, dishwashing staff were observed washing, putting away and stacking wet dishes. The dishwashing machine temperatures were observed at 125 degrees Fahrenheit (F) for washing and 170 F degrees for rinsing and temperature logs were not documented at the proper temperatures.
The facility's Dishwasher Temperatures log documented the required wash temperature as 150 degrees and the rinse temperature as 180 F degrees or above. The log dated January 2024 documented the following temperatures recorded by dietary aide #33:
-1/2/2024: 169 F degrees for washing, 170 F degrees for rinsing;
-1/3/2024: 150 F degrees for washing, 172 F degrees for rinsing;
-1/4/2024: 154 F degrees for washing, 160 F degrees for rinsing;
-1/5/2024: 149 F degrees for washing, 175 F degrees for rinsing;
-1/8/2024: 152 F degrees for washing, 173 F degrees for rinsing;
-1/10/2024: 147 F degrees for washing, 176 F for rinsing;
-1/11/2024: 163 F degrees for washing; 152 F degrees for rinsing.
The log dated December 2023 had the following temperatures recorded by various staff:
-12/7/2024: 125 F degrees for washing, 172 F degrees for rinsing;
-12/8/2024: 115 F degrees for washing, 175 F degrees for rinsing;
-12/17/2024: 125 F degrees for washing, 150 F degrees for rinsing;
-12/25/2024: 149 F degrees for washing, 170 F degrees for rinsing;
-12/26/2024: 146 F degrees for washing, 188 F degrees for rinsing;
During an interview on 1/12/2024 at 10:08 AM, dietary aide #33 stated dishes were pre-washed and then put through the dish washing machine. After the dishes went through the machine, they should be left to drip, some to dry, and bowls should be placed face down to let dry. They stated there was a temperature range to look for and they documented the machine's temperature on a log. They stated the dishwashing machine temperatures under 150 degrees for washing and 180 degrees for rinsing were not appropriate. The logs were sent to the Supervisor; but they were not sure if temperature logs for the dishwasher were reviewed.
During an interview on 1/12/2024 at 10:18 AM, Dietary Supervisor #34 stated dishes should be left to air dry and not stacked wet. They stated they were not sure of the mechanical dishwasher's required temperatures, but thought they were 100 degrees for washing and 180 degrees for rinsing. They stated they collected the logs, but they did not review them, only saved them in a file. After reviewing the log for January 2024 and December 2023, Dietary Supervisor #34 stated the temperatures recorded below the 150 for wash and 180 for rinse were not acceptable. They stated they should have called maintenance, but they did not know the machine was not at the correct temperature and did not alert maintenance.
During an interview on 1/12/2024 at 10:35 AM, the Director of Dietary stated the mechanical dishwasher required temperatures were 165 for wash and 185 or higher for rinse. They stated those temperatures were checked and documented twice daily, but occasionally the night shift did not remember to do so. Staff were supposed to notify supervisors if it was not at the correct temperature, and they would alert maintenance or their vendor. They stated the dietary supervisors were supposed to collect and periodically check the logs. The Director of Dietary stated the temperatures recorded on the logs for December 2023 and January 2024 that were below 150 for wash and 180 for rinse were not acceptable. They stated they were not sure if anything was done or if anyone had contacted maintenance.
2) Utensil storage/Uncleanable surface/Walk-in cooler floor
During observations on 1/9/2024 at 11:28 AM, 1/10/2024 at 12:19 PM, and 1/12/2024 at 10:18 AM ice scoops were on top of the ice machine which was soiled with debris.
During an observation on 1/9/2024 at 12:11 AM the shelving in the dairy walk-in cooler was very rusty, not smooth, and uncleanable.
During observations on 1/9/2024 at 12:13 AM, 1/10/2024 at 12:19 PM, and 1/12/2024 at 10:18 AM the meat and produce walk-in cooler had a small puddle of yellowish liquid under the wire racks on the right side of the cooler.
During an interview on 1/12/2024 at 10:18 AM, Dietary Supervisor #34 stated the person assigned as the pot and pan washer was responsible for cleaning the walk-in coolers and those should be swept and mopped daily. They stated they were not sure what the liquid on the floor of the cooler was but should have been cleaned. They stated the ice scoops were stored on top of the ice machines and they thought the top of the ice machines were cleaned weekly.
During an interview on 1/12/2024 at 10:35 AM, the Director of Dietary stated the walk-in coolers should be cleaned daily, or as needed, and a spill should not have remained on the floor of the cooler for multiple days. They stated the rusty shelving was not smooth, or easily cleanable. The Director of Dietary stated the ice scoop should not be stored atop the ice machine.
10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during the recertification and abbreviated (NY00328391) surveys conducted 1/8/2024-1/12/2024, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 staff members (certified nurse aides #17 and #28, and food service worker #18) observed. Specifically, certified nurse aide #17 did not don and doff personal protective equipment as required when entering and exiting rooms with COVID-19 positive residents, did not perform hand hygiene, and placed an unclean face shield on a kitchenette counter; certified nurse aide #28 removed a dinner tray from a COVID-19 positive resident room and placed the tray on top of the dinner cart with unserved meal trays; and food service worker #18 entered the closed COVID-19 area with a lunch cart. Additionally, Resident #45 had extended spectrum beta lactamase resistance (an enzyme produced by bacteria that are resistant to many antibiotics) and was not placed on enhanced precautions as planned.
Findings include:
The facility policy COVID-19 Management dated October 2023 documented all staff were to adhere to hand hygiene, contact precautions and/or enhanced barrier precautions were to be used when caring for residents with COVID-19. In order to reduce transmission in shared rooms personal protective equipment was to be changed and hand hygiene performed before and after each resident interaction.
The undated facility policy Coronavirus- Surveillance Plan for Residents/ Staff documented personnel caring for the resident would need to wear an N-95 mask, disposable gown and goggles, or a face shield.
The facility policy Precautions- Droplet - Transmission Based revised 8/2023 documented in addition to standard precautions, anyone caring for the resident should wear a mask, gown, and gloves if they were within three feet of the resident. The infection control staff or nursing staff would place the appropriate Centers for Disease Control transmission- based, isolation signage for droplet precautions outside the resident's room. A cart with personal protective equipment would be placed outside the resident room door for use. The attending physician, infection control nurse or supervising registered nurse may make the determination to place a resident on both, droplet, and contact precautions. When removing food trays from the precaution room, the tray would be wrapped in a clear plastic bag and brought out to the carts. The bag would serve as a barrier as well as a warning for dietary so they would know the tray was from a room on precautions.
The facility policy Enhanced Barrier Precautions dated 1/2023 documented enhanced barrier precautions was to be used when providing care for the residents with an infection or colonization (presence of a microorganism on/in a host without interaction between host and organism) with a multi-drug resistant organism, when contact precautions do not apply. Gloves and gowns should be worn when providing high contact care such as bathing, dressing, care of indwelling devices and wound care. The Enhanced Barrier Precautions sign should be placed outside of the resident room.
The Infection Control staff education COVID Precautions, Signs, PPE dated November 2023 documented COVID-19 rooms would have three signs, droplet, contact and a sign that stated what the staff must wear inside the COVID-19 positive rooms and COVID-19 exposure room. Additionally, directions prior to entering the COVID positive/exposure room included: perform hand hygiene, remove face mask, and put in trash, perform hand hygiene, before entering room, put on all personal protective equipment that included gown, N95, face shield, gloves. The way to exit the COVID-19 room documented to remove all personal protective equipment properly, N95 mask were to go into a brown paper bag and back on the cabinet; cleanse the face shield with alcohol wipes and perform hand hygiene and put on regular face mask. The education included diagrams with the proper way to don and doff the personal protective equipment.
The 12/8/2023 facility line list for COVID-19 documented positive COVID-19 resident rooms included Unit 1 [NAME] rooms 113, 114, 115, and 116.
During an observation on 1/8/2024 at 10:29 AM, there was no signage posted on the left side of Unit 1 [NAME] closed double doors that notified visitors this was a COVID-19 cohorted area.
Observations on 1/8/2024 of certified nurse aide #17 on Unit 1 [NAME] included:
- at 10:58 AM, walking down the hallway with a pen and paper in their hand entering and exiting rooms [ROOM NUMBER] which had signage on the doors for contact, droplet, and enhanced precautions. After exiting room [ROOM NUMBER] wearing a yellow gown, face shield, and a surgical mask and walked toward room [ROOM NUMBER]. They did not enter room [ROOM NUMBER] and walked back to the nursing station area where they took off their yellow gown next to a round table where there were boxes of N95 masks. They removed their face shield, and while holding the used face shield, they walked around with the gown balled up in their right hand. They placed their face shield on the kitchenette counter near the sink/eye wash station and entered the soiled utility room. They came back to hallway without the yellow gown and left the face shield on the kitchenette counter.
- at 11:05 AM, the face shield remained on the kitchenette counter next to the eye wash station.
- at 11:06 AM, they entered room [ROOM NUMBER] without any personal protective equipment on and the signage outside of the door documented contact, droplet, and enhanced barrier precautions.
- at 11:07 AM, they entered room [ROOM NUMBER], a COVID-19 positive room without wearing the posted personal protective equipment and exited the room without performing hand hygiene.
- at 11:08 AM, rooms [ROOM NUMBERS] call bells were ringing and were lit up above the door. They entered room [ROOM NUMBER], without personal protective equipment.
- at 11:10 AM, they exited room [ROOM NUMBER]. They performed hand hygiene and entered room [ROOM NUMBER] without wearing the personal protective equipment listed on the sign outside the door.
- at 11:15 AM, they exited room [ROOM NUMBER], wearing a N95 mask and walked to the dirty utility room.
- at 11:25 AM, they went back to room116 where the call bell was on. They stopped in front of the personal protective equipment bin and put on gloves and a yellow gown, then walked to the nurse's station with a yellow gown on and walked back to room [ROOM NUMBER]. They had a N95 mask on and entered the room.
- at 11:28 AM, they exited room [ROOM NUMBER], and with the same yellow gown on entered room [ROOM NUMBER].
- at 11:29 AM, they exited room [ROOM NUMBER] without a yellow gown on, wearing the N95 mask and entered room [ROOM NUMBER]. They did not put on new personal protective equipment and did not perform hand hygiene. They exited room [ROOM NUMBER] and they went back into room [ROOM NUMBER], with no gown on and did not complete hand hygiene. They exited room [ROOM NUMBER], and then walked down the hallway while removing their gloves.
During an interview on 1/8/2024 at 11:35 AM, Unit 1 [NAME] Secretary #27 stated rooms 113, 114, 115, and 116 were COVID-19 positive rooms. The hallway divider at room [ROOM NUMBER] was placed as it was to create a designated COVID-19 cohorted section of the unit.
During an observation on 1/8/2024 at 11:58 AM, the wall outside of room [ROOM NUMBER] had signage that documented to enter the room staff should wear a gown, gloves, an N95 mask, and a face shield. The resident was on contact precautions, droplet, and enhanced barrier precautions. The was no personal protective equipment bin outside of the room.
During an observation on 1/8/2024 at 12:00 PM, the face shield that certified nurse aide #17 removed at 10:58 AM was observed on the kitchenette counter near the eye wash station.
During an observation on 1/8/2024 at 2:25 PM, certified nurse aide #17 was walking around the unit with their yellow gown on, went to the dirty utility room with a bag of trash, went to the nurse's station to get a new N95 mask and then entered the COVID-19 cohorted area.
During an interview on 1/9/2024 at 7:58 AM, licensed practical nurse #18 stated the residents that were new admissions should be on full precautions and quarantine for 10 days and the staff should follow the directions on the signs outside of the door. When there was not a personal protective equipment supply bin outside of the room, they should use the next closet bin. They stated they were not sure what the recent facility COVID-19 protocol included and said it was very confusing. They thought the staff should don a gown and a new N95 mask when they were in the COVID-19 positive rooms. The staff should not be wearing a used yellow gown walking around the units, and they should change their N95 mask when they came out of a COVID-19 room. They should use the hand sanitizer that was on the walls or outside of the rooms in the personal protective equipment bin. They stated they were the only nurse on the unit for 26 residents, and they usually only had 1 licensed practical nurse and one certified nurse aide. They stated to prevent the spread of infection, the COVID-19 cohort section should have their own nurse and certified nurse aide.
During an interview on 1/9/2024 at 8:06 AM, resident aide #20 stated they were floated to Unit 1 [NAME] in the morning and did not routinely work the unit. They stated there were COVID-19 rooms on the unit and staff should wear N95 mask and remove the mask when exiting the room, perform hand hygiene, and leave the gown in the bins in the room. The gowns and gloves should be changed between residents to prevent the spread of infection.
During an interview on 1/9/2024 at 9:17 AM, the Administrator confirmed there were 2 infection prevention nurses and Unit 1 [NAME] was where the COVID-19 residents were cohorted.
During an observation on 1/9/2024 at 12:15 PM, on the nurse's station desk on 1 [NAME] there was an electronic mail memo that was dated 1/9/2024 at 10:52 AM, from registered nurse Infection Control Director regarding personal protective equipment requirements for the new admissions. The face shields should be worn in new admission rooms and all face shields should be wiped down between uses.
During an observation on 1/9/2024 at 12:32, food service worker #18 entered 1 [NAME] through the closed double doors on the COVID-19 side of the unit. They pushed the cart up to room [ROOM NUMBER] and staff told food service worker #18 they needed to exit and enter the unit on the other side of the unit due to the COVID-19 restricted area.
During an observation on 1/9/2024 at 12:36 PM, certified nurse aide #21 was overheard asking the Director of Nursing if they had to completely gown up every time, they entered a room to deliver a meal tray. The Director of Nursing nodded their head yes and was overheard telling the aide every single time you take a tray in the room you need to gown up.
During an interview and observation on 1/09/24 at 12:44 PM, certified nurse aide #21 stated they did not have an assigned unit and was floated to the COVID-19 unit today. Unit 1 [NAME] used to have 7 residents and now they had 26 residents with the same number of staff. They stated the required personal protective equipment for the COVID-19 rooms was listed on the signs on the wall and they needed to make sure the room doors were closed. At 12:48 PM, they were wearing a gown, face shield, and a N95 mask holding a lunch tray to bring into room [ROOM NUMBER] W. They stated the staff should remove the gown in the resident rooms, the face shield needed to be sanitized outside of the room with alcohol, and the mask should not be worn in and out of different rooms. At 1:02 PM, during the interview they entered and exited room [ROOM NUMBER], and went to get another lunch tray from the other side of the unit and kept their N95 mask on. They stated they should have taken off the N95 off before getting the meal tray for the roommate (116 D) near the door. Staff should not exit the resident room with a yellow gown on, the gown should be removed prior to exiting the room, and left in the designated bin. It was important to remove the gown and change the mask so not to spread germs from one resident to the next. They had seen staff wearing their yellow gown in the hallway between rooms and would usually remind them, but it was not really their place to tell them what to do. The signs outside of the rooms told the staff what personal protective equipment to wear, and basically the entire unit was on precautions. With the new admissions and the COVID-19 resident rooms it was confusing about what precautions to maintain.
During an interview on 1/9/2024 at 3:56 PM, registered nurse Infection Control Director #22 and registered nurse Infection Preventionist #23 stated 1 [NAME] had certain rooms that were designated for COVID-19. The rooms were from 113 to 116. They tried to cohort the COVID-19 positive residents on the left side of the unit. The right side of the hallway was for new admission residents. This was not a new thing for the facility to place the new admission on full precautions for 10 days. They sent an electronic memo to the Unit Managers to let staff know what residents had COVID-19. There was also a new sign on the outside of the 1 [NAME] left side door, notifying staff and visitors that was a COVID-19 area. They stated there was a sign, but it must have fallen off because there was not a sign on the door when entering the COVID side of the unit on Monday (1/8/2024).
During an interview on 1/10/24 at 1:27 PM, certified nurse aide #17, stated they just became a certified nurse aide and did their training at the facility. They were in the October 2023 class, and just received their certification a couple weeks ago. They had worked in the facility as a resident aide since June 2023. They stated the residents on COVID-19 precautions were on 1 [NAME] and were in rooms 113-116. The personal protective equipment required for COVID-19 was gloves, gown, a N95 mask, and not a surgical mask. When entering a COVID-19 room a gown should be put on before going in the room and taken off before coming out of room. For residents on enhanced precautions, staff could keep the gown on between residents because the resident did not have COVID-19. The enhanced precautions were just extra precautions. Staff should always wash their hands before putting on gloves and after gloves were removed and any times they were soiled. They should put on their N95 mask before going in the COVID-19 rooms and take it off before leaving the room. It was important to do this to avoid spreading the germs around to other residents. There was a bin in the resident rooms for the gowns to be disposed. They stated they received training about infection control and the expectation for COVID-19 rooms. They stated they were aware that they did not wear the required personal protective equipment in rooms where it was required, and a couple times went room to room with the same gown and mask. They stated it was important to follow the posted steps for personal protective equipment for every room. The gowns should be changed, when walking from the COVID-19 cohort unit to the new admission side/precautions and should not be carried in their hands in the hallway after being worn in a COVID-19 positive room.
During an interview and observation on 1/10/2024 at 5:55 PM, certified nurse aide #28 placed a tray that was removed from room [ROOM NUMBER] W (a COVID-19 positive room) on the meal cart of trays that had not been served to residents. During an interview at 5:57 PM, certified nurse aide #28 stated the tray was eaten from and was from a COVID-19 room. They stated they would sometimes put the used meal trays in the cart with the new unserved trays. They said they thought the COVID-19 resident trays could potentially contaminate the unserved trays.
During an interview on 1/11/2024 at 12:23 PM, food service worker #18 stated they delivered the food cart on the wrong side of the hallway on Monday and Tuesday. They forgot that side of 1 west was for the COVID-19 residents, and they should not have brought the cart on that side.
During an interview on 1/12/2024 at 11:00 AM, the registered nurse Infection Preventionist #22 documented they started in the role October 2023. The first COVID-19 outbreak was in September 2023. Staff had received the bare minimum of infection control training when they were hired. They continued to reinforce education regarding personal protective equipment. They had completed an in-service training in December 2023 about personal protective equipment documentation and the signage that was posted outside of the resident rooms. They stated to prevent the spread of COVID-19 to other residents and staff they encouraged proper personal protective equipment. There was posted signage at each room, so everyone knew what to wear in the rooms. They had not done an education for the staff on the proper donning and doffing of personal protective equipment. Staff should not be walking from resident room to resident room with the same gowns and N95 masks on as that violates their policy. They stated they do the best they can to keep the same staff on the COVID-19 unit to prevent the spread of the infection.
During an interview on 1/12/2024 at 11:42 AM, the Director of Nursing stated they educated staff on the importance of hand hygiene and the use of personal protective equipment to prevent the spread of infection.
PRECAUTIONS NOT IMPLEMENTED
Resident #45 had diagnoses that included urinary tract infection, extended spectrum beta lactamase resistance, and unspecified dementia. The 12/20/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, was taking antibiotics, was frequently incontinent of urine, and required moderate assistance for toileting.
The 12/15/2023 progress note by nurse practitioner #29, documented the resident had an extended spectrum beta lactamase resistance urinary tract infection and would be treated with antibiotics. The resident was placed on contact precautions indefinitely due to the extended spectrum beta lactamase resistance infection.
Physician orders after 12/15/2023 did not include contact precautions.
The comprehensive care plan, revised 12/18/2023, documented the resident had reoccurring urinary tract infections which included an extended spectrum beta lactamase resistance urinary tract infection on 12/16/2023. Interventions included to check and change the resident every two hours, give antibiotics as ordered, and to monitor for signs and symptoms of a urinary tract infection. There was documented evidence contact precautions were added to the care plan after nurse practitioner recommendations on 12/15/2023.
Nursing progress notes dated 12/15/2023-12/20/2023 did not document the resident was on contact precautions.
Nursing notes dated 12/21/2023 at 1:25 PM and 12/28/2023 at 12:30 PM, documented contact precautions maintained for extended spectrum beta lactamase in the urine. There was no documentation of contact precautions from 12/29/2023-1/8/2024.
The resident's room was observed to have no contact precaution signage posted prior to entering the room from 1/9/2024 through 1/11/2024.
During an observation and interview on 1/9/2024 at 2:35 PM, licensed practical nurse #30 stated the precaution isolation signs were placed on the wall outside the resident's room to identify who was on precautions. If the precaution sign was above the room number sign outside the door, the resident in the bed by the door was on precautions. If the precaution sign was below the room number sign outside the door, the resident in the window bed was on precautions.
During an interview on 1/11/2024 at 3:45 PM, registered nurse Care Coordinator #16 stated the miscellaneous notes were not always reviewed as the providers would usually put in any orders that were needed after seeing the resident and would speak to the Nurse Supervisor directly. If it was not communicated directly or put in an order, any follow up in the miscellaneous note would not be seen. They were unsure how a provider's direction to put someone on indefinite precautions got communicated if it was in a miscellaneous note. They stated that if a resident tested positive for an extended spectrum beta lactamase resistance urinary tract infection, there would be ongoing precautions unless a culture was obtained that stated the resident no longer had extended spectrum beta lactamase resistance. Registered nurse Care Coordinator #16 stated if a resident had previously tested positive for extended spectrum beta lactamase resistance and the resident was not on precautions, there was a risk of spreading extended spectrum beta lactamase resistance to other residents.
During an interview on 01/11/2024 at 3:59 PM, Quality Assurance and Safety/Certified Nurse Aide #31 stated an infection control memo went out via email to all managers. They stated the infection control personnel updated the list daily and the precaution information and what it required for each resident would be on that list. They stated the most recent infection control memo that came out did not have Resident #45 included on it for precautions.
During an interview on 1/12/2024 at 9:11 AM, nurse practitioner #29 stated if a resident had tested positive for an extended spectrum beta lactamase resistance urinary tract infection the precautions would be indefinite. They stated residents who had tested positive for an extended spectrum beta lactamase resistance were to be on enhanced barrier precautions. It was their understanding that the nurses and Nurse Managers read the miscellaneous note assessments where they recorded their provider notes. They stated the precautions would be put in place automatically by the infection preventionist in the building and they had a morning report daily where they discussed residents on precautions. They were not aware that Resident #45 was not on precautions and the resident should be on precautions indefinitely.
10 NYCRR 415.19(a)(b)

Based on observation, record review and interview during the recertification survey conducted 11/15/21-11/18/21, the facility failed to ensure all residents were provided an ongoing program to support residents in their choice of activities and designed to meet their individual needs based on the comprehensive assessment and care plan and the preferences of each resident for 1 of 3 residents (Resident #10) reviewed. Specifically, Resident #10 was not provided meaningful activities as care planned.
Findings include:
Resident #10 had diagnoses including glaucoma, legal blindness, and heart failure. The 8/12/21 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required extensive to total assistance with most activities of daily living (ADLs). The resident considered choice of listening to books on tape, listening to television, and listening to music important.
The comprehensive care plan (CCP) initiated 8/18/21 documented the resident was alert and able to make leisure choices, enjoyed listening to books on tape, music, and television (genre not specified). The resident enjoyed 1:1 visits, required assistance to activities, and preferred listening to television or books on tape in their room.
The care instructions dated 11/18/21 documented the resident was to be encouraged to participate in a program that accommodated the resident's sensory abilities. The resident's preferred activities were listening to television (genre not specified), religious music or books on tape in their room.
The activity progress notes documented there were no activities provided to the resident 28 of 31 days in 10/2021 and from 11/1-11/17/21.
The resident was observed:
- on 11/15/21 at 2:06 PM lying in bed sleeping. There was no television, music, or talking books playing.
- on 11/16/21 at 1:31 PM, sitting by the nursing station.
- on 11/17/21 at 9:48 AM, in bed with a drink. The television was off and there was no music or talking books playing.
- on 11/17/21 at 12:04 PM lying in bed. The television was off and there was no radio or talking books playing.
During an interview with activities nurse #27 on 11/18/21 at 11:22 AM, they stated they knew what the residents' interests were by talking with them. They would talk to the resident, about their father and the residents daughters. The resident would tell them what they liked. The activities nurse stated if they had provided interaction/activities with the resident it would have been recorded.
When interviewed on 11/18/21 at 11:00 AM, certified nurse aide (CNA) #25 stated that most of the time the unit CNAs did not do activities with the residents because they did not have time. The resident liked to listen to books on tape; however, the resident had the same 5 books on tape the last year and a half and they did not have any others to play for them.
During an interview with the Director of Activities on 11/18/21 at 1:23 PM, they stated they had not been asked to order more books on tape for the resident. If staff knew what the resident's interests were, they would expect them to be provided as much as possible, and they should be documented in the resident's record. If they did not document activities, then nothing was done.
10NYCRR 415.5(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated surveys (NY00284242) conducted from 11/15/21- 11/18/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents for 2 of 4 residents (Residents #75 and #113) reviewed. Specifically, Resident #75 was provided a hot beverage that had been microwaved by staff, the resident spilled the beverage and the resident sustained burns to their abdomen and thigh. Resident #113 was provided hot water by a staff person without ensuring proper temperature before serving. This resulted in actual harm to Resident #75 that was not an immediate jeopardy.
Findings include:
The facility policy Hot Food/Beverage Temperatures of Microwaved Food dated 2/2016 documents hot foods and/or beverages heated in the microwaves must not be served to residents at a temperature greater that 165 degrees Fahrenheit (F) to ensure staff are preparing and serving hot food/beverages in a safe manner to residents. It is the responsibility of the charge nurse to temp all food/beverages prior to serving to ensure temperatures are not greater than 165 degrees Fahrenheit. On every nursing unit a hot food/beverage temperature log will be maintained in the medication room for one year. It is the responsibility of the charge nurse to temp all food/beverages prior to serving to ensure temperatures are not greater than 165 degrees Fahrenheit.
Resident #75 had diagnoses including diabetes with diabetic neuropathy (nerve damage) and chronic venous hypertension (increased pressure inside veins). The 7/10/21 Minimum Data Set (MDS) documented the resident had intact cognition and was independent with eating.
The comprehensive care plan (CCP) initiated 12/19/20 documented the resident had activities of daily living (ADLs) deficits and was able to feed self independently after set-up. The resident had poor circulation and diabetes with interventions including to monitor/document/report signs and symptoms of infection to any open areas: redness, pain, heat, swelling or pus formation.
The 10/1/21 at 1:00 AM registered nurse (RN) #10 progress note documented the licensed practical nurse (LPN) communicated that the resident assistant (RA) on the previous shift reported the resident spilled a hot drink on themself at about 10:30 PM. When the LPN checked the resident, there were burn marks on the resident's mid lower abdomen and upper right thigh near the groin. The lower mid-abdominal area had two 4-centimeter (cm) x 4 cm open reddened blisters with a small amount of clear drainage. The resident's right upper thigh near the groin had an 8 cm x 2 cm reddened area with an intact blister. The areas were left open to air. The resident stated their pinky caught the cup and caused it to spill on them.
An RN #17 10/1/21 nursing progress note documented an assessment of the resident's burns from spilled hot chocolate last night. There were two popped blisters to the mid-lower abdomen and one to the right upper thigh. The areas were cleansed with Normal saline (NS) and dried. Bacitracin (antibiotic ointment) and dry dressing applied. Orders placed to be changed every day. The resident had no complaints of pain but stated some slight discomfort to the upper area as their shirt rubbed against it.
The 10/1/21 incident report documented the LPN observed burn areas on Resident #75's mid-abdomen and left upper thigh near the groin. The LPN stated the resident spilled a hot drink on themself at about 10:30 PM on 9/30/21. The resident was assessed by an RN and had 2 open blisters about 4 cm each on the lower mid-abdomen and an 8 cm x 2 cm blister on the right thigh near the groin. The resident told staff their hot chocolate spilled when the resident's pinky finger caught the cup. The resident stated a staff member had heated the hot water. The incident report documented certified nurse aide (CNA) #11 worked on 9/30/21 from 5:00 PM-9:00 PM and CNA #11 stated they did not give the resident any hot water. RA #12 had worked on the unit and was asked by the resident to get more hot water after the hot chocolate was spilled on the resident. RA#12 reported the spill to the oncoming night shift nurse. An investigation was done, and LPN #13 did not recall giving the resident hot water that night but had in the past.
The temperature logs for 9/30/21 did not document recorded temperatures for Resident #75's hot water provided on that date.
A 10/5/21 after visit summary from the wound care center documented the resident was seen for non-pressure chronic ulcer of the right calf and blisters with epidermal loss due to burn (second degree) of abdominal wall. Instructions included to apply Silvadene cream and cover with non-stick pad and change daily.
The 10/6/21 physician order documented to apply to abdomen and right groin Silvadene cream 1% (topical antibiotic) topically and cover with nonstick dressing every day shift for burns with an end date of 10/27/21.
The 10/2021 treatment administration record (TAR) documented to cleanse open burns on mid/low abdomen and right upper thigh with normal saline and pat dry. Apply thin layer of bacitracin, cover with Telfa and tape daily. The treatment had a start date of 10/1/21 and a discontinue date of 10/6/21. The treatment was signed for on 10/1, 10/2, and 10/3 and was not signed for as being done on 10/4 and 10/5 as scheduled.
The 10/2021 medication administration record (MAR) documented apply Silvadene cream 1% to abdomen and right groin topically every day shift for burn and cover with nonstick dressing.
During an observation on 11/15/21 from 2:15 PM the kitchenette area by room [ROOM NUMBER] had a white microwave with signs on the wall to the right of the microwave listing directions for using the microwave and another listing solid food group temperatures. There was a sign on the cabinet above the microwave documenting please make sure all food/drinks have a temperature no greater than 165 F. A thermometer should be with the medicine cart. The LPN/RN will do this for you. The same signs were above a black microwave in the kitchenette near room [ROOM NUMBER]. There were white microwaves in the kitchenettes near rooms [ROOM NUMBERS] that only had a yellow sign on the microwave door Please see nursing staff before using the microwave.
During an observation on 11/16/21 at 12:57 PM, the kitchenette across from RM [ROOM NUMBER] had a 700 [NAME] (W) white microwave, there was no food temperature log in the kitchenette, there was a white sign documenting food/drinks not to be over 165 F and another sign describing microwave use and a food thermometer was in the medicine cart. The kitchenette across from RM [ROOM NUMBER] had a 1050 W black microwave with 2 white signs describing microwave use and meat temperatures, a food thermometer was on top of the microwave, and there was no food temperature log. The kitchenette across from RM [ROOM NUMBER] had a 700 W white microwave with a yellow sign documenting to see nursing staff before using the microwave. There was no food thermometer or food temperature log observed in the kitchenette. The kitchenette across from RM [ROOM NUMBER] had a 1050 W black microwave with 2 white signs describing microwave use and meat temps, a food thermometer was on top of microwave, a yellow sign on the microwave door documented to see a nurse before using microwave, and there was no food temperature log.
When interviewed on 11/15/21 at 12:12 PM, Resident #75 stated their bedtime snack was usually hot chocolate and crackers. The resident stated the night the hot chocolate spilled on them, a staff member brought them a cup of hot water and the resident added hot chocolate powder. The resident was watching TV in a straight back chair, forgot to take the spoon out of the cup, reached for a cracker, and a pinky finger caught the end of the spoon spilling the hot chocolate onto them. The hot chocolate caused a couple of blisters on their abdomen and right groin. The resident stated they cleaned the hot chocolate off themself and the floor using a towel. The resident informed staff of the spill and staff assessed the burns. The resident stated they did not remember which staff member had heated the water. The resident's abdomen was observed and there were two areas purple in color about 2.5 centimeters (cm) x 1 cm on the abdominal middle and middle-right quadrants.
During an interview on 11/16/21 at 1:21 PM with licensed practical nurse (LPN) #14, the food temperature log and food thermometer were observed stored on a shelf in the 1W medication room. The LPN stated there was no policy on microwaving resident food. The LPN stated education was done after the incident occurred with Resident #75 on 2W. The education included the policy which stated that only the nurse was to temp the food/liquid prior to serving to the resident and the food temp was to be 135 F or less. There were signs by each microwave to see the nurse to temp the food.
When interviewed on 11/16/21 at 1:27 PM, certified nurse (CNA) #15 stated heating resident food/drink education was done about a year ago by completing a read and sign. CNAs could microwave the resident's food or drink, but the nurse had to take the food temperature prior to serving the resident. The food or drink temperature could not be above 165 F when giving it to the resident. The CNA stated if someone was unsure of what to do, there were signs by each microwave.
When interviewed on 11/16/21 at 1:38 PM, physical therapy aide (PTA) #16 stated they had been asked in the past to heat up a resident's food or drink while passing meals, and they were unaware of a microwaving policy. The PTA had tested the temperature of the item by touching the item with a gloved hand. If the item was too hot, the item was left standing until cool enough to serve. The PTA stated there were signs by each microwave explaining the procedure of microwaving resident items. The PTA stated they did not receive formal education about microwaving resident items.
When interviewed on 11/16/21 at 1:52 PM, RN Manager #17 stated unit staff could microwave resident food, the food or drink had to be temped when done after microwaving and before serving a resident. The RN stated the CNAs could temp the food but was it usually done by a nurse. Families were not allowed to heat the food/drink. The nurse was supposed to log the heated items in the temp log and the temp log was supposed to be with the microwave. The RN stated the food thermometers were to be kept in each medication room and every unit had at least 1 microwave. The RN Manager did not remember being educated on microwave use prior to the incident but staff were recently reeducated by a read-and-sign education. The RN stated maximum food or drink serving temperature was 165 F.
When interviewed on 11/16/21 at 2:02 PM, RA #18 stated they were unaware if they could microwave food or drinks but had in the past. The RA had checked food or drink temperature in the past and reported it to the nurse. The RA stated they would test the food by placing a drop on the back of their hand like they would to test baby formula. The RA stated they did not use a thermometer. If the item was too hot, the RA would set it aside until lower than the maximum allowed temperature. The RA was not educated on microwave procedure until after Resident #75 was burned.
When interviewed on 11/16/21 at 4:08 PM, LPN #13 stated they worked night shift and had not had any microwave use training prior to the incident with Resident #75. The LPN stated the resident used to have hot chocolate every night about 9:00 PM and staff always heated the hot water. The LPN stated the night the resident spilled hot chocolate; RA #12 had heated the water for the resident when the LPN was on another unit. The LPN stated they were unaware of a policy to temp microwaved items. The LPN stated they were made aware of the incident with Resident #75 upon returning to the unit to provide report to the oncoming nurse. The LPN stated the resident preferred their water microwaved for about 4 minutes, but staff never heated it for that long as it would be too hot. There would be no way knowing how hot the water was because staff never checked the temperature.
When interviewed on 11/16/21 at 4:30 PM, RA #12 stated staff could microwave a resident's food, but a nurse had to take the temperature of the food prior to giving it to the resident. The RA stated that policy started about a month ago. The RA was not aware of any microwave policy prior to the incident and temps of the fluids were not taken prior to bringing them to the resident. The RA stated they checked the temps of the microwaved item by putting a little on wrist to determine if it was too hot. The RA stated they had worked on a different unit that evening shift when the resident spilled hot chocolate and burned themself. The RA stated they had gone to the resident's unit and was working the unit alone from about 10:15 PM until 11:00 PM. The RA stated another staff member, believing it to be LPN #13, had microwaved the resident's hot chocolate and left it with the resident. The RA stated LPN #13 was the only staff member on that unit from 9:00 PM until about 10:15 PM when the RA got there. The RA stated LPN #13 had to go to another unit, had heated the hot chocolate prior to 10:00 PM. RA #12 stated Resident #75's call bell went off, the RA responded, and the resident gave them their T-shirt that had hot chocolate all over it. The resident was bare chested, and the RA noticed the resident had some redness on their stomach. The resident told the RA that they spilled hot chocolate on themself. The resident asked the RA to heat up more water for some more hot chocolate. The RA stated more water was heated in the microwave for about 30 seconds. At that time, LPN #13 and LPN #19 were on the unit and the RA told them about the resident's redness/burns.
When interviewed on 11/17/21 at 9:50 AM, the Administrator stated microwave use policy education was completed when the policy was first in effect and then again after Resident #75's burn.
On 11/17/21 at 10:16 AM, the microwave policy and sign in sheets documented the only dates of education on microwave use were 12/2020 and 10/2021. LPN #13 or RA #12 had not signed for the 12/2020 education. The RN Educator had completed the training for the 10/2021 microwave education.
When interviewed on 11/18/21 at 12:23 PM, the Director of Nursing (DON) stated there was a microwaving policy in place prior to the resident getting burned. At the time of the incident, staff should have been taking the temperatures of the food and documenting it. If the food or drink item was over the specified temp, it should not have been given to the resident. Reeducation of the policy was completed by the RN Educator after the resident was burned. There were regular microwave use in-services completed prior to the resident getting burned but the DON was unsure how often. The facility was unable to determine who microwaved the resident's hot water prior to the incident on 9/30/21. The DON stated only a nurse could check food/drink temperatures prior to being served to a resident. The DON stated Resident #75 was harmed due to the sustained burns caused from spilling the hot beverage.
When interviewed on 11/18/21 at 1:02 PM, RN Educator #21 stated an LPN or RN only were to temp microwaved food items and that policy had been in effect since at least 2015. The RN Educator stated almost 100% of unit staff were in-serviced at the beginning of October. Unit staff could microwave the item, but the nurses had to document the resident's name, food item, temperature, date and who checked the temperature. The temperature log was to be kept in the unit medication room and the thermometer should be in the medication cart, but it was acceptable for the food thermometer to be in the cabinet above the microwave.
When interviewed on 11/18/21 at 1:26 PM, nurse practitioner (NP) #22 stated they were unaware the resident received a burn. Upon review of Resident #75's chart, the NP stated the resident sustained a burn from the hot chocolate and the hot liquid caused harm to the resident as the resident needed a treatment for those injuries.
2) Resident #113 had a diagnosis including complete paraplegia (paralysis of the lower part of the body). The 10/22/21 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, was independent with eating, and had no impairments to the upper extremities.
The comprehensive care plan (CCP), updated 11/2/21, documented the resident fed self after meal set up in their room and staff was to provide coffee at bedtime (HS) per resident request.
The care instructions, active 11/17/21, documented staff was to provide coffee at HS per resident request. The resident was able to feed self after set up and ate in their room.
During an observation on 11/17/21 at 12:56 PM, CNA #6 was carrying the resident's lunch tray to the resident in their room and stated they had heated your hot water. There was a brown mug with a lid on the tray. The CNA left the tray in the room and exited.
During an interview with CNA #6 at 12:56 PM, they stated they heated the water up in the microwave in the unit kitchenette. The microwave had a yellow sign that said, before you use the microwave seek assistance from nursing staff. They stated they did not seek assistance from nursing staff. Another CNA had told them to heat the resident's water for 30 seconds, it was the normal process for Resident #113's water, and they did not feel it was necessary to get the nurse to heat up the water as they were following normal protocol. The CNA stated they would hand the water to the resident who would pour it into their French press (non-electric coffee brewer). They stated they had received education regarding microwaving and the thermometer was used so a resident would not get burned. The CNA opened the cabinet at the kitchenette and displayed a thermometer.
During an interview with registered nurse (RN) Unit Manager #8 on 11/18/21 at 11:15 AM, they stated to avoid an accident, the CNA should have sought out a RN or LPN to check the temperature of the hot water after microwaving and before giving it to the resident. They said the CNAs had been educated on this and there were signs on the microwaves so the temperature should be checked first. The water should have been temped to ensure it was not above 160 degrees Fahrenheit (F.). The resident liked to have their water warmer and usually requested it at lunch and sometimes dinner times. They wanted the water so they could put it in their French press.
10 NYCRR 415.12(h)(1)(2)

Based on observation, interview, and record review during the recertification survey conducted 11/15/21-11/18/21 the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional standards, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 unit medication rooms (Unit 2EE) and 1 of 4 medication carts (medication cart #8) reviewed. Specifically, the Unit 2EE and medication cart #8 had stock medications that were expired or outdated beyond the opened date.
Findings include:
The facility policy Storage and Maintenance of Medication dated 6/2016 documented medication should be checked regularly for expiration dates and deterioration. Expired medications are removed from use and destroyed.
During an observation of the 2EE medication room on 11/16/21 at 9:54 AM, there was a vial of influenza vaccine with an expiration date of 6/30/20 and a handwritten date on the box labeled 12/2, and an open of box of bisacodyl suppositories (laxative) with an expiration date of 11/2020. Medication cart #8 contained an opened bottle of aspirin 325 milligram (mg) with an expiration date of 6/2021 and an opened date of 7/20/21, and an opened bottle of bisacodyl 5 mg with an opened date of 4/1/19 and an expiration date of 3/2021.
When interviewed on 11/16/21 at 9:56 AM, licensed practical nurse (LPN) #9, stated they were unsure if there was an assigned person to check for expired meds. The LPN stated each nurse should check the expiration date prior to giving medications.
When interviewed on 11/18/21 at 11:26 AM, registered nurse (RN) Unit Manager #8 stated the expectations was that staff would date the medication bottle when opened. The stock vials were good for 30 days after being opened and staff were expected to date the box with open date. The 11-7 shift was expected to check medications in the medication cabinets, the medication carts, and the refrigerator weekly. The RN stated each nurse should check the expiration date of each medication before administration. When a medication was discontinued the nurse should pull the medication and put it in a designated location for pharmacy pick-up. The RN stated the medications that were expired should have been discarded prior to use.
When interviewed on 11/18/21 at 12:10 PM, the Director of Nursing (DON) stated the expectation was each nurse should check for expiration dates prior to medication administration and the 11-7 nurse should check twice a week for expired medication in the medication room, the refrigerator, and the medication carts. The medication should be discarded when it expired. The date opened should be written on the vial or the box. Once opened immunization vials should be good for 28 days depending on what it was.
10NYCRR 415.18(d)(e)(2-4)

Based on observation and interview during the recertification survey conducted 11/15/21-11/18/21, the facility failed to ensure each resident received food and drink that was palatable and at a safe and appetizing temperature for 2 of 2 meal trays (lunch and dinner) tested. Specifically, food was not served at a safe and appetizing temperature for a lunch and dinner meal.
Findings include:
The facility policy for Food Temperatures was requested and was not received.
During an interview with Resident #50 on 11/15/21 at 1:42 PM, they stated food was generally served cold.
During an interview with Resident #21 on 11/15/21 at 4:45 PM, they stated the food was served lukewarm or ice cold.
During the resident group meeting on 11/17/21 at 10:00 AM, 1 anonymous resident stated their hot food items at meals were not always served hot.
During an observation on 11/15/21 at 5:17 PM, the meal cart arrived at the Unit 2 Extension. At 5:22 PM, Resident #18 was served, and their dinner tray was used for temperature measurement and taste testing with a replacement provided. At 5:24 PM, the following food temperatures were measured:
- coffee 115 degrees Fahrenheit (F)
- Spanish rice 130 degrees F
- shredded pineapple 56 degrees F
- milk 53 degrees F
- cranberry juice 56 degrees F
- salad 67 degrees F
The shredded pineapple, milk, cranberry juice, and salad tasted warm and were not palatable.
During an observation on 11/17/21 at 11:46 AM, the lunch trays arrived at the Unit 1 Extension. At 12:03 PM, Resident #21's meal tray was used for temperature measurement and taste testing with a replacement provided. At 12:05 PM the following temperatures were measured:
- pork patty 108 degrees F
- green beans 107 degrees F
- hot water for tea was 125 degrees F
- Ensure (oral nutritional supplement) 60 degrees F
- pears 57 degrees F
- Lactaid (lactose-free) milk 50 degrees F
- cranberry Juice was 56 degrees F.
The hot food items did not taste hot and cold did not taste cold and were not palatable.
During an interview on 11/17/21 at 12:35 PM, the Food Service Director stated the coffee and hot water for tea should be at 140 degrees F when served to the residents. Cold food items should not be above 40 degrees F and hot food should not be below 130 degrees F to 140 degrees F depending on the food items. [NAME] beans and meat patties did not hold temperature well. They stated the dinner and lunch trays were not served at palatable temperatures.
10NYCRR 415.14(d)(2)

Based on observation, record review and interview during the recertification survey conducted 11/15/21-11/18/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 8 unit pantry refrigerators (Units #1 East and 2 West) and 1 kitchen tray line refrigerator observed. Specifically, air temperatures were not maintained for Unit #1 East and 2 [NAME] pantry refrigerators at 40 degrees Fahrenheit (F) or lower. Additionally, the kitchen tray-line refrigerator air and food temperatures were not maintained.
Findings include:
The facility policy Proper Refrigeration Temperatures dated 11/2011 documents the following:
- All dining room and nourishment pantry refrigerators will be maintained to standards set for proper storage of cold foods and beverages. The dietary aide/server will take temperatures of each refrigeration unit in dining room pantries on the day shift and record on the log sheet. The cook will take the temperature of each refrigerator in the kitchen and record on the log sheet.
- If a refrigerator temperature is found to be above 42 degrees Fahrenheit (F) or below 34 degrees F, staff will immediately notify the Food Service Manager or the Dietary Supervisor. The Dietary supervisor will temp all items in the cooler and if deemed above 42 degrees F, they will be discarded. A maintenance request for repair will be completed and forwarded to the Maintenance Department.
- Refrigerators in the unit kitchenettes are not to be used for potentially hazardous foods (food that requires time/temperature control for safety to limit the growth of pathogens). Daily temperatures of the refrigerator are taken by dietary staff and recorded on the log sheet, which is posted inside the cupboard. If a refrigerator temperature is above 50 degrees F or below 30 degrees F, staff were to notify the Food Service Director or Supervisors, and Maintenance.
On 11/15/21 at 11:24 AM, the Unit 2 [NAME] pantry/kitchenette was observed. The refrigerator temperature log was last signed on 10/28/21 and there were no temperatures for 10/29-10/31/21 and 11/1-11/15/21 documented. The refrigerator had a sign that documented no meat or dairy were to be in the refrigerator. Inside the refrigerator, there were multiple individual packets of butter, non-dairy liquid creamer, and a half empty 48-ounce container of applesauce. The thermometer inside the refrigerator door was observed to be 50 degrees F.
On 11/15/21 at 5:24 PM, the following temperatures were obtained from a test tray:
- Shredded pineapple 56 degrees F
- Milk 53 degrees F
- Cranberry juice 56 degrees F
- Salad 67 degrees F
On 11/17/21 at 12:05 PM, the following temperatures were obtained from a test tray:
- Ensure (oral nutritional supplement) 60 degrees F
- Pears 57 degrees F
- Lactaid (lactose-free) milk 50 degrees F
- Cranberry juice 56 degrees F.
During an interview on 11/17/21 at 11:29 AM, the Food Service Director stated milk, juices, and fruit were moved from the walk-in cooler to another refrigerator near the tray line during meal service. The juices were poured in the morning and placed in the refrigerator for the lunch tray line. The pears were chilled the night before, dished that morning and put on a ladder track in the refrigerator. During the meal, the pears would be moved individually to the other refrigerator near the tray line. The refrigerator door was held open throughout food service. Temperatures of refrigerators in the main kitchen were checked daily in the morning before breakfast service started. The Dietary Department was responsible for checking temperatures in the pantry refrigerators on the units. The temperatures were done at different times of the day.
On 11/17/21, the following was observed with the Food Service Director:
- At 1:13 PM, the 1 East pantry refrigerator read 56.1 degrees F; the refrigerator contained thickened orange juice measured at 57 degrees F and pineapple chunks measured at 54 degrees F.
- At 1:18 PM, a 2 [NAME] pantry refrigerator had a temperature of 50 degrees F.
- At 1:34 PM, the trayline refrigerator had a temperature of 54 degrees F.
During an observation of the kitchen trayline refrigerator on 11/17/21 at 3:18 PM, there was a temperature log on the side of the refrigerator that was initialed on 11/17 with no time. The tray line Supervisor stated that the trayline refrigerator had been replaced since the previous observation at 1:34 PM. The Supervisor stated they removed the other refrigerator and brought one from upstairs to replace it. Temperatures of items within the refrigerator were measured and included:
- red pears 52 F, when re-temped at 3:21 PM, the temperature was 51 F;
-a whole chicken salad sandwich 44 F;
-garden Salad 43 F;
-chocolate pudding was 48 F.
During an interview with the Food Service Director on 11/17/21 at 3:21 PM, they stated the refrigerator was replaced with a refrigerator from another department. The Food Service Director stated the other refrigerator was not holding temperatures. They stated the items temped were from the lunch meal and were supposed to be removed after the lunch meal. The Food Service Director stated when the refrigerators were switched, staff must have removed the items from the other refrigerator and put them into the current refrigerator. They stated they should have discarded the items from the refrigerator that was not holding temperatures. The Director confirmed the items were not acceptable temperatures. They stated the cooks took refrigerator temperatures every morning and recorded it on the logs. The refrigerator temperatures were not taken throughout the day.
During a follow-up interview on 11/17/21 at 3:33 PM, the Food Service Director stated they were not aware of any temperature issues with the kitchenette refrigerators. The items in those refrigerators should be discarded if the refrigerator was bad or if a food product in a refrigerator was out of temperature range.
During an observation of the Unit 2 [NAME] pantry refrigerator on 11/18/21 at 12:00 PM, the refrigerator had a sign reading no meats or dairy in fridge. The thermometer inside the refrigerator read 50 F. Inside the refrigerator there were two 46-ounce (oz) honey thickened waters, one 46-oz nectar thickened cranberry drink, one 46-oz nectar thickened apple juice, one 60-oz orange juice, six 4-oz yogurts, a 1 gallon storage bag with individual butter pads, 1 pudding in a blue bowl dated 11/17/21, a 236 milliliter (ml) white milk and an 8-oz cardboard container of Ensure Plus in the door and two 1 liter opened soda bottles in the back of the refrigerator. The orange juice had a measured temperature of 60 degrees.
On 11/18/21 at 12:09 PM, licensed practical nurse (LPN) #26 stated the staff were not supposed to put dairy or meat products in the pantry refrigerators as a precaution in case the refrigerator was not keeping temperature. The LPN stated they were not aware there were dairy items in the refrigerator, they did not know who put them there, and they should not be in there.
10NYCRR 415.14(h)