Bethany Gardens Skilled Living Center

Based on observation, record review and interviews during the recertification survey conducted 9/5/2024 - 9/11/2024, the facility failed to consult with the physician when there was a significant change in the resident's physical status for 1 of 4 residents (Resident #79) reviewed. Specifically, Resident #79 had a continuing, unplanned weight loss and the medical provider was not notified.
Findings include:
The facility policy, Change in a Resident's Condition or Status, revised 05/2017 documented the nurse would notify the resident's attending physician or physician on-call when there had been a significant change in the resident's physical, emotional, or mental condition.
The facility policy, Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol, revised 9/2017 documented nursing staff would monitor and document the weight in a format which permitted comparisons over time, and nursing staff would report to the physician significant weight gains or losses.
Resident #79 had diagnoses including vascular dementia with other behavioral disturbance, gastro-esophageal reflux disease (stomach acid flows back up into the esophagus), and dysphagia (difficulty swallowing). The 8/7/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required set-up or clean-up assist for eating, weighed 126 pounds, had a weight loss of 5% or more in 1 month or 10% or more in 6 months, was not on a physician-prescribed weight loss regimen, was on a mechanically altered diet and had no swallowing disorder.
Nurse Practitioner #7 medical orders documented:
- 10/20/2023 regular diet, thin liquids, mechanical soft with ground meat consistency.
- 3/6/2024 push fluids every shift.
- 4/26/2024 weekly weights.
- 5/10/2024 180 milliliters Med Pass 2.0 (a nutritional health shake supplement) three times a day during medication pass.
The resident's weights were documented as follows:
- 1/1/2024 154.4 pounds
- 2/1/2024 146.6 pounds (5% loss in 1 month)
- 3/1/2024 145.5 pounds
- 4/1/2024 141 pounds
- 5/6/2024 138.6 pounds
- 6/3/2024 137.4 pounds
- 7/1/2024 133.8 pounds (13% loss in 6 months)
- 8/5/2024 126.4 pounds
- 9/2/2024 125.4 pounds (19% loss since 1/1/2024)
The Comprehensive Care Plan, with a start date of 11/22/2022 and edited on 8/8/2024, documented the resident was at increased risk for alterations in nutritional status and malnutrition secondary to a diagnosis of dementia and significant, unplanned weight loss at 1/3/6 months. The resident's weight continued to trend downward. A long-term goal, edited on 8/9/2024, documented the resident would maintain a current body weight of 154 pounds, plus or minus 5 pounds. Interventions, edited on 5/15/2024, included provide current diet as ordered; provide supplements as indicated; assess intakes, labs, and weights; and monitor weight status at least monthly if stable; and update medical of significant changes.
There was no documented evidence the resident had not met their comprehensive care plan goal weight.
Medical provider progress notes by Nurse Practitioner #7 and the Medical Director from 5/8/2024 - 9/3/2024 did not document the resident's unplanned weight loss.
Nursing progress notes from 5/7/2024-9/9/2024 did not document the resident's unplanned weight loss.
Registered Dietitian #8 documented:
- on 5/10/2024 at 1:48 PM the resident's weekly weight was 138.6 pounds. The resident's gradual weight loss had resulted in a 26.8 pound loss over the last 6 months. The plan included the resident walked with an extra sandwich, and Med Pass 2.0 was increased to 180 milliliters three times a day.
- on 5/15/2024 at 12:55 PM the resident's weekly weight was 134.4 pounds, a 4.2 pound loss from the previous week. The Interdisciplinary Care Team was informed of the weight loss. The plan was to provide an 8-ounce Health Shake (nutritional supplement) and extra sandwiches three times a day at meals. Cookies and ice cream and a 4-ounce Health Shake were added as between meal snacks.
- on 7/3/2024 at 9:44 AM the resident's most recent weight had been 133.8 pounds, a loss of 1.6 pounds in 1 week, 3.6 pounds in 1 month, 7.2 pounds in 3 months and 20.24 pounds in 6 months. The Interdisciplinary Care Team was informed of the weight loss. The resident received fortified cereal at breakfast and fortified mashed potatoes with gravy at lunch and supper. Fortified orange juice was added to breakfast. Would request for medical to evaluate if an appetite stimulant would be appropriate.
- on 7/24/2024 at 4:44 PM the resident's weekly weight was 132 pounds and the gradual decline continued. Increasing supplements was not indicated at that time.
- on 7/31/2024 at 4:42 PM the resident's weekly weight was 128.6 pounds. This was an ongoing, gradual weight loss despite multiple interventions. Weight loss had been significant. Interdisciplinary Care Team, including medical, were aware of the resident's nutritional status.
There was no documented evidence the medical provider evaluated the resident for an appetite stimulant (per the 7/3/2024 at 9:44 AM Registered Dietitian #8's progress note) or that medical was made aware of the resident's nutritional status/significant weight loss (per the 7/31/2024 at 4:42 PM Registered Dietitian #8's progress note).
The resident was observed:
- on 9/5/2024 at 12:29 PM standing next to their bed. They turned around suddenly, got back into bed, and pulled the blankets over their head. At 12:53 PM lying in their bed. Certified Nurse Aide #12 was nearby and stated they offered the resident their lunch tray but, they flopped back down in bed. Certified Nurse Aide #12 stated breakfast was usually the resident's best meal.
- on 9/6/2024 at 10:30 AM lying in bed. When their name was called, they sat up quickly and proceeded to walk out of their room and down the hall. At 10:43 AM Certified Nurse Aide #12 stated the resident had eaten well for breakfast that morning.
- on 9/9/2024 at 11:16 AM walking continuously around the entire unit.
During an interview on 9/10/2024 at 9:08 AM, Nurse Practitioner #7 stated they expected nursing or dietary to inform them if a resident had a weight loss. There was usually a group electronic mail from the registered dietitian about residents with weight loss so they could come up with a plan. If they were told about a resident with weight loss, they would write a progress note right away. Nurse Practitioner #7 reviewed their electronic mail and provider notes and stated they did not see any documentation regarding Resident #79's significant and continuing weight loss. They stated there were no further interventions they could do, and the current plan remained.
During an interview on 9/10/2024 at 9:59 AM Licensed Practical Nurse Unit Manager #4 stated dietary usually notified them of a resident's weight loss and they or dietary would notify the medical provider. They thought the Interdisciplinary Team knew about Resident #79's continuing weight loss trend. The resident's weight loss was discussed at the last few care plan meetings and the family was aware. The resident did not sit down for long at meals. Medical should be notified of weight loss because they did not want the resident to lose weight so rapidly. They must have dropped the ball on the resident's weight loss because they had seen the resident continuing to lose weight ever since they came from another unit and the resident's weight loss was talked about and a known fact. They were surprised the registered dietitian did not notify medical of the weight loss.
During an interview on 9/10/2024 at 11:19 AM Registered Dietitian #8 stated they brought weight changes of residents to morning report. They discussed weight changes, reviewed with nursing, then nursing would bring it to the attention of medical. Resident #79 was on every possible supplement, nourishment, extra sandwiches, and finger foods. This was discussed during care plan meetings. Medical providers did not attend care plan meetings. They brought the resident's weight loss to the attention of Licensed Practical Nurse Unit Manager #4 who should have notified medical.
During an interview on 9/11/2024 at 9:08 AM the Medical Director stated they were not aware of Resident #79's continuing downward weight loss over the past year and expected the Nurse Manager to inform them. If they knew of a resident's weight loss, they looked for non-pharmacological solutions first. Family representatives would be included in solutions to weight loss. With dementia residents they asked families what expectations they had for their resident's plan of care and nutrition. If all the non-pharmacological solutions were looked at and weight loss continued, then they might trial mirtazapine (an anti-depressant medication sometimes used as an appetite stimulant).
During an interview on 9/11/2024 at 10:05 AM, the Director of Nursing stated Licensed Practical Nurse Unit Managers could notify medical about a resident's weight loss. There was also a communication book on the unit and things rarely got missed. Licensed Practical Nurse Unit Manager #4 edited resident care plans with approval from a registered nurse. The nutrition care plan for Resident #79 was written by Registered Dietitian #8 so they would be the one to update the care plan. Resident #79's weight loss was discussed in care plan meetings with the resident's family and medical notification must have slipped through the cracks.
10 NYCRR 415.3(e)(2)(ii)(b,c)

Based on record review and interview during the recertification survey conducted 9/5/2024-9/11/2024, the facility did not ensure residents were screened for a mental disorder or intellectual disability prior to admission for 1 of 18 residents (Resident #52) reviewed. Specifically, there was no documented evidence Resident #52 had a Preadmission Screening and Resident Review (PASARR, New York State Department of Health form 695) completed by a qualified screener within the required time frame prior to admission to the facility.
Findings include:
The undated facility policy, Screens, documented every admission would have a completed screen prior to being accepted and arriving to the facility. The admission department would obtain the completed screen and the social worker would ensure it was in the medical record. The Admissions Department would ensure that if a Level II evaluation was required, that the necessary information was completed and processed. The Director of Admissions would conduct a quarterly audit to ensure compliance.
Resident #52 had diagnoses including anxiety, depression, and Post Traumatic Stress Syndrome. The 12/25/2022 admission Minimum Data Set assessment documented the resident had intact cognition, had depression and Post-Traumatic Stress Disorder, and received an antidepressant daily.
The 8/23/2022 Preadmission Screening and Resident Review from a different facility admission documented Resident #52 could not receive restorative services within the community. The resident did not have a screen done prior to the current 12/2022 admission.
The 1/2/2023 admission Comprehensive Care Plan documented the resident resisted care, was a lateral transfer from another facility, needed assistance with activities of daily living, preferred activities that identified with prior lifestyle, and had slight confusion. Interventions included educate, notify physician or social worker of any changes in mood/behavior, assist with activities of daily living as planned, provide activities calendar, and provide early interventions as needed.
During an interview on 9/10/2024 at 1:50 PM, the Director of Admissions stated each resident should have a screen done prior to admission to the facility and the screen had to have been done within 90 days prior to admission. Resident #52's screen was from the previous facility and exceeded the 90-day window. The resident did not have a significant psychiatric history and was not developmentally disabled. The Admissions Department was responsible for ensuring the screen was obtained and within regulations. They must have made an error calculating the date at admission time.
During an interview on 9/10/2024 at 2:00 PM, the Director of Social Services stated the purpose of the screen was to identify if a resident had a significant mental illness or delay that required special services. Th Admissions Department was responsible for obtaining the screen and notifying social services if a Level II was needed/done signifying what special services were recommended. All residents required a Level I screen to determine if a Level II was required. The screen should be done within 90 days prior to admission. Random audits were done within the facility to ensure compliance. Somehow, Resident #52's screen was missed and was not within the required time frame prior to admission. The resident had no significant issues and did not need specialized psychosocial care. The resident's care was also monitored by an outside agency on a routine basis due to post-traumatic stress syndrome.
10NYCRR 415.11(3)

Based on observation, record review, and interviews during the recertification survey conducted 9/5/2024-9/11/2024, the facility did not ensure residents who required dialysis (a process that filters blood for the kidneys) received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #42) reviewed. Specifically, Resident #42 did not receive ongoing assessment of their condition and monitoring for complications before and after dialysis treatments, or ongoing communication and collaboration with the dialysis facility.
Findings include:
The undated facility policy, Dialysis, documented residents going out of the building for hemodialysis should take communication sheets with them to allow for ease of communication between facilities; changes in resident status should be communicated to nephrology (kidney specialists) staff in a timely manner.
Resident #42 had diagnoses of end-stage renal (kidney) disease and dependence on renal dialysis. The 5/13/2024 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, and required hemodialysis treatments.
The Comprehensive Care Plan initiated 8/16/2022 and revised 8/16/2024 documented the resident had end-stage renal disease and required dialysis. Interventions included assess the resident for mental status/general condition, review communication book upon resident's return from the dialysis center, assure resident took communication book with them to the dialysis center, check hemodialysis access site and monitor for signs and symptoms of bleeding/infection or any abnormality and notify the physician, and monitor vital signs and dialysis as scheduled.
Physician orders documented:
- on 1/31/2024 hemodialysis catheter, ensure no drainage to bandage, covered at all times, dialysis only to touch.
- on 3/4/2024 documented the resident was to receive hemodialysis on Mondays, Wednesdays, and Fridays from 7:00 AM- 3:00 PM; dialysis notes on every dialysis day on Monday, Wednesday, and Friday.
The 9/1/2024-9/9/2024 Treatment Administration Record documented hemodialysis catheter, ensure no drainage to bandage, covered at all times, dialysis only to touch, with a start date of 1/31/2024. The Treatment Administration Record had x's from 9/1/2024-9/3/2024 for days, evenings, and nights; and for 9/4/2024 days and evenings.
Nursing progress notes dated 8/8/2024-9/6/2024 did not include assessments of the resident's dialysis access site or monitoring for signs and symptoms of bleeding.
There were no pulses, respirations, or blood pressures documented from 8/9/2024-9/9/2024.
The 9/2024 resident care instructions documented dialysis per schedule and assure resident took communication book with them to dialysis.
The resident's dialysis communication book was unable to be located in their room or on the nursing unit.
The last dialysis communication sheet in the electronic medical record was dated 6/23/2023. The dialysis center flowsheets scanned into the resident's electronic medical record documented the resident's vital signs and weights were obtained at the dialysis center.
A 9/10/2024 at 1:37 PM email received from the Administrator documented there were no Registered Nurse assessments or staff education for dialysis.
During an observation and interview on 9/5/2024 at 11:06 AM, Resident #42 was sitting in their room in a wheelchair. They stated they received dialysis. A dry sterile bandage was on the Resident's right upper chest wall.
During an observation and interview on 9/9/2024 at 9:25 AM the resident was sitting in their wheelchair in the front lobby. They stated they were going to dialysis, they did not have a dialysis communication book, and staff were supposed to check their heart rate and other vital signs before they went. This was only done occasionally.
During an interview on 9/9/2024 at 11:21 AM Certified Nurse Aide #14 stated the resident required assistance to get up and dressed on dialysis days and the night shift staff got the resident up before they arrived. Certified Nurse Aide #14 stated they were unsure if the resident needed anything or was required to bring anything with them to dialysis.
During an interview on 9/9/2024 at 11:24 AM Licensed Practical Nurse #15 stated Resident #42 went to dialysis on Monday, Wednesday, and Fridays. They thought the resident had a sheet the dialysis center filled out. Dialysis weighed the resident, and the nurses recorded it when the resident returned. Licensed Practical Nurse #15 stated they were unsure if staff were required to do anything else when the resident returned except for administering their evening medications.
During an interview on 9/9/2024 at 1:44 PM with Registered Nurse Unit Manager #13, they stated they did not know where the resident's communication book was and thought Licensed Practical Nurse #16 took care of the book. They stated the resident was not assessed by them when they returned from dialysis, they were unaware an assessment had to be completed. They thought licensed practical nurse #16 weighed the resident when they returned and took vital signs when they were needed.
During an interview on 9/10/2024 at 10:00 AM, the Director of Nursing stated they were familiar with Resident #42, and they received dialysis treatments three days per week. They were unaware a dialysis resident required an assessment when they returned and thought if the resident had complications, that dialysis would let them know.
10 NYCRR 415.12(k)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 9/5/2024-9/11/2024, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service in the facility's main kitchen. Specifically, in the main kitchen, food was not stored at safe temperatures in the walk-in cooler, there were uncleanable floor surfaces, the toaster was not clean, and the dishwasher instructions were not clean and legible.
Findings included:
The facility policy, Cleaning and Sanitation of Food Service Areas, revised 10/2022 documented staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.
The facility policy, Food Receiving and Storage, revised 5/2024 documented foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerated foods must be stored below 41 degrees Fahrenheit unless otherwise specified by law and refrigerated food will be stored in such a way that promotes air circulation around food storage containers.
Improper Cooling:
During an observation and interview on 9/5/2024 at 4:03 PM, a large hotel pan (6 inch deep) of cooked pasta covered in plastic wrap, located on the lower shelf just inside to the right of the walk-in cooler, measured at 65 degrees Fahrenheit. The Food Service Director stated the pasta was cooked about two hours ago. They cooked the pasta, drained it, rinsed it with cool water, added ice, and let the pasta set out for an hour. [NAME] the pasta was below 70 degrees Fahrenheit, it was placed into the walk-in cooler. They stated they were familiar with the cooling requirements and the cook who made that pasta was new and should not have put the pasta in that deep of a pan and should have used a shallow pan to help the pasta cool quicker. Cooling was supposed to be documented and checked in the logbook. The cooling logbook was reviewed, the logbook was blank, and there was no entry for pasta cooling.
Uncleanable surfaces and equipment in disrepair:
During an observation on 9/5/2024 at 9:48 AM, the kitchen floor by the main oven had unclean areas on the left side below the oven. The toaster had food debris on it and was not clean. The floor tiles in the main dish washing area were missing and there were stains on the walls above the main dish washing area.
During an observation on 9/6/2024 at 3:56 PM, there were broken floor tiles in front of the 3 bay sink area. The wall above the sinks had missing tiles and the wall was unclean.
During an observation and Interview on 9/6/2024 at 1:25 PM, Dietary Aide #11 stated they knew how to power on the dish washer and the minimum temperatures for the wash and rinse cycle were posted on the wall outside of the dish machine area. They were not aware there were instructions on the machine. and that the instructions should be easily read. They received training on how to use the dish machine. They stated it was important to know the required washing temperature to ensure the dishes were sanitized properly and prevent germs on the dishes.
During an interview on 9/9/2024 at 3:36 PM, the Food Service Director stated the kitchen had a cleaning schedule that included the dirtiest use areas. The floors should be cleaned every night with mop and broom. The dish person was responsible to clean the dishwashing area floor and walls. They stated the broken floor tiles should be replaced, they cannot clean them properly, and dirt could get trapped in the area where the tile was missing. They stated they would put in a work order to get the tiles replaced. The toaster should be cleaned every day. The parts that were able to be removed should be run through the dishwasher to remove any food debris to ensure food does not build up and cause a fire within the toaster. They were not aware that the specifications and instructions for the dish machine were in an area that staff were unable to read it. The director stated the instructions were not easily seen, as the area was worn and dirty.
10NYCRR 415.14(h)
Based on observation, interview, and record review during the recertification survey conducted 9/5/2024-9/11/2024, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service in the facility's main kitchen. Specifically, in the main kitchen, food was not stored at safe temperatures in the walk-in cooler, there were uncleanable floor surfaces, the toaster was not clean, and the dishwasher instructions were not clean and legible.
Findings included:
The facility policy, Cleaning and Sanitation of Food Service Areas, revised 10/2022 documented staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.
The facility policy, Food Receiving and Storage, revised 5/2024 documented foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerated foods must be stored below 41 degrees Fahrenheit unless otherwise specified by law and refrigerated food will be stored in such a way that promotes air circulation around food storage containers.
Improper Cooling:
During an observation and interview on 9/5/2024 at 4:03 PM, the lower shelf, just inside the walk-in cooler, had a large hotel pan (6 inches deep) of plastic wrap covered, cooked pasta. The pasta's temperature was measured at 65 degrees Fahrenheit. The Food Service Director stated a cook made the pasta about three hours ago. They cooked the pasta, drained it, rinsed it with cool water, added ice, let it sit out for an hour until it was below 70 degrees Fahrenheit, and placed it into the walk-in cooler. It had been there for about two hours. They stated they were familiar with the cooling requirements and the cook who made that pasta was new and should not have put the pasta in that deep of a pan. They should have used a shallow pan to help the pasta cool quicker. They stated cooling was supposed to be documented in the logbook, however, the logbook was blank, and there was no entry for cooling the pasta. They stated the covered pan of pasta was not meeting with cooling requirements because it had only dropped about 5 degrees in the last two hours.
Uncleanable surfaces and equipment in disrepair:
During an observation on 9/5/2024 at 9:48 AM, the kitchen floor by the main oven had unclean areas on the left side below the oven. The toaster had food debris on it and was not clean. The floor tiles in the main dish washing area were missing and there were stains on the walls above the main dish washing area.
During an observation on 9/6/2024 at 3:56 PM, there was some food, debris, and grime under the cooking equipment. The toaster had cooked on food debris inside the unit, and some burn marks on the housing (not smooth and easily cleanable surfaces). The dish machine specifications could not be read because of the grease and grime on the specification plate. The exterior of the machine was coated with a dusty greasy build up of grime.
During an observation on 9/6/2024 at 3:56 PM, there were broken floor tiles in front of the 3 bay sink area. The wall above the sinks had missing tiles and the wall was unclean.
During an observation and Interview on 9/6/2024 at 1:25 PM, Dietary Aide #11 stated they knew how to power on the dish washer and the minimum temperatures for the wash and rinse cycle were posted on the wall outside of the dish machine area. They were not aware there were instructions on the machine. The instructions should be easily read. They received training on how to use the dish machine and it was important to know the required washing temperature to ensure the dishes were sanitized properly and to prevent germs on the dishes.
During an interview on 9/9/2024 at 3:36 PM, the Food Service Director stated the kitchen had a cleaning schedule that included the dirtiest use areas. The floors should have been cleaned every night with a mop and broom. The dish person was responsible to clean the dishwashing area floor and walls. The broken floor tiles should have been replaced, they could not be cleaned properly, and dirt could get trapped in the area where the tile was missing. The toaster should be cleaned every day. The parts that were able to be removed should be run through the dishwasher to remove any food debris to ensure food did not build up and cause a fire within the toaster. They were not aware that the specifications and instructions for the dish machine were in an area that staff were unable to read them, and the instructions were not easily seen, because the area was worn and dirty.
10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted [DATE]-[DATE], the facility failed to provide a safe, clean, comfortable, and homelike environment on 5 of 5 resident units (Units 2, 3, 4, 5, and 6) reviewed. Specifically, there were stained ceiling tiles, non-working overhead lights, faucets that did not shut off, an exhaust fan that did not work, stained window blinds, a leaking sink, a stained chair, damaged and soiled walls, an unclean window, a broken window screen, a clogged sink, a damaged cabinet, and uncomfortable/incorrect sized mattresses.
Findings include:
The facility's undated Inservice for Daily/Weekly Cleaning documented the objective of daily cleaning was to ensure cleanliness and safety. Resident rooms should be cleaned in a clockwise manner, the housekeeper should clean and dust all windowsills, tables, chairs etc.; and clean all spot, spills, or scuff marks on vertical surfaces such as walls, doors, and over bed table stands. In the hallways all high touch areas, including handrails, elevator buttons, doorknobs were to be wiped with disinfectant daily. The resident lounge was to be cleaned after each meal.
The facility's undated daily housekeeping checklist included the room numbers and bathrooms, walls, window curtains, and did not include the resident lounge.
UNIT 2:
The following environmental issues were observed on Unit 2 on [DATE]:
- at 9:55 AM, resident room [ROOM NUMBER] had a stained ceiling tile and resident room [ROOM NUMBER] had a light over the resident bed that was not working.
- at 10:15 AM, resident room [ROOM NUMBER] had a stained ceiling tile.
- at 10:38 AM, resident room [ROOM NUMBER] bathroom had a stained ceiling tile.
- at 10:43 AM, resident bathrooms [ROOM NUMBERS] had faucets that would not shut off.
- at 12:25 PM, the Unit 2 dirty utility room exhaust fan was not working.
- at 12:36 PM, resident room [ROOM NUMBER] had two stained ceiling tiles.
- at 12:40 PM, the hall outside resident room [ROOM NUMBER] had a stained ceiling tile.
During additional observations on Unit 2 on [DATE] at 2:59 PM and [DATE] at 11:44 AM the same environmental issues observed on [DATE] remained the same.
During an interview on [DATE] at 3:55 PM, both the Facility Director and Maintenance Director stated that they were not aware that the exhaust fan was not working in the Unit 2 dirty utility room and this fan was required to provide negative pressure air flow to prevent odors from entering the hallway.
UNIT 3:
On [DATE] The following environmental issues were observed on Unit 3:
- at 10:22 AM, resident room [ROOM NUMBER] window ledge had a section of wall Formica (laminated composite countertop material) that was missing.
- at 10:39 AM, resident room [ROOM NUMBER] window blinds were stained/unclean.
- at 12:05 PM, resident room [ROOM NUMBER] had two stained ceiling tiles.
- at 12:10 PM, the resident lounge had water leaking under the sink into a puddle on the floor below the sink, and there were 5 fruit flies near this sink.
- at 12:11 PM, the resident lounge had a stained/dirty chair.
- at 12:11 PM the resident lounge window ledge had a section of wall Formica that was peeling. There were multiple dead bugs in between the window screens and the windows, and two of the window screens had small holes.
- at 12:22 PM, resident bathroom [ROOM NUMBER] had a clogged sink.
During an interview on [DATE] at 12:10 PM the Facility Director stated they were not aware of the leaking sink in the Unit 3 resident lounge or the clogged sink in resident room [ROOM NUMBER] bathroom.
During an observation on [DATE] at 8:25 AM, resident room [ROOM NUMBER] had a window ledge with a section of wall Formica that was missing.
During an interview on [DATE] at 9:40 AM, housekeeper #12 stated they were assigned to Unit 3 and would cover other units as directed. They were responsible for cleaning everything on the unit, including the floors, walls, bathrooms, emptying trash, and dusting the dining room when residents were not there. Deep cleaning of the rooms was not on a routine schedule. Deep cleaning would take place when a resident expired or went out on pass for the day. Deep cleaning included cleaning and sterilizing the bed and wiping down all items in the room including the window blinds. Housekeeper #12 stated when furniture was dirty it was to be taken out of the resident area and brought downstairs for a deep clean. They stated they did not complete any task sheets or daily cleaning worksheets, but their supervisor would check in with them routinely to monitor the unit's cleanliness. They were aware of the dirty areas in the dining room but were unable to clean them because there were always residents in the area.
During observations on [DATE] at 3:14 PM and 3:20 PM resident room [ROOM NUMBER] blinds remained unclean. The resident lounge window ledge had a section of wall Formica that was peeling and the multiple dead bugs in between the window screens and the windows remained, and two of the window screens had small holes in them. The resident room [ROOM NUMBER] window ledge had a section of wall Formica that was missing.
During an interview on [DATE] at 3:31 PM, the Facility Director stated they were not aware the 3rd floor resident lounge/ kitchenette sink had a water leak. They stated that they were not aware that the sink in resident room [ROOM NUMBER] bathroom was blocked by a small cap and stated once the cap was removed the sink was working. Previously there had been other clogged resident room sinks, and they had always been fixed via word of mouth without a work order being completed.
UNIT 4:
During observations on Unit 4 on [DATE] at 10:45 AM, and on [DATE] at 3:06 PM, the resident lounge cabinet was soiled with a brown substance, and there were crumbs and miscellaneous debris on the cabinet shelf. Additionally, on [DATE] at 3:06 PM there were 2 fruit flies observed in the cabinet.
UNIT 5:
On [DATE] the following environmental issues were observed on Unit 5:
- at 10:52 AM, resident room [ROOM NUMBER] had a stained ceiling tile.
- at 10:58 AM, resident room [ROOM NUMBER] had a stained ceiling tile.
- at 11:04 AM, resident room [ROOM NUMBER] had a wall near the resident bed with a 2-foot x 1-foot unpainted patch.
- at 11:45 AM, resident room [ROOM NUMBER] had two square patches of wall with spackle and were unpainted.
- at 11:50 AM, resident room [ROOM NUMBER] had 6 stained ceiling tiles.
- at 11:56 AM, the resident lounge had four stained ceiling tiles.
During an observation on [DATE] from 2:49 PM-2:59 PM, the stained ceiling tiles and unpainted walls remained.
During an interview on [DATE] at 3:31 PM, both the Facility Director and the Maintenance Director stated they were not aware of any of the stained ceiling tiles observed in the facility. Stained ceiling tiles should be replaced immediately after being reported. There was no written documentation that maintenance would have completed this task. They stated the facility used paper format for work orders and after work orders were corrected it would be initialed, dated and filed. The Facility Director stated that the facility had a dedicated painter who would patch and paint the walls.
During an interview on [DATE] at 9:20 AM, the Maintenance Director stated that the daily housekeeping checklist had only been completed by some of the housekeeping staff, and that all staff were aware of their responsibilities. Resident rooms would be deep cleaned after a resident passed away or left the facility. Deep cleaning would include wiping down beds, mattresses, nightstands, windows, and anything else that was needed. The Maintenance Director stated that if something was found broken during the deep cleaning process it should be immediately repaired by maintenance. After a deep clean was completed, social services would be notified the room was ready for a new resident. They stated that the housekeeping department was responsible for keeping resident rooms clean. Most resident rooms on Unit 6 were rehabilitation short term rooms, and that there was no set frequency schedule for the deep cleaning of resident rooms. Housekeeping staff could not clean in dining rooms when residents were in the room. Dining rooms should be cleaned monthly, and this was not consistently documented. The Maintenance Director stated that each housekeeper had their own scheduled floor, except for their day off in which the other 4 housekeepers would clean 5 rooms each and then work on their floor.
During an interview on [DATE] at 12:46 PM, the Facility Director stated they were not aware of the findings on Units 2, 3, 4 and 5 and there were no current work orders for the environmental issues. They stated the facility was the home of these residents and they should have a comfortable, homelike environment.
UNIT 6
During an interview on [DATE] at 11:54 AM, Resident #13 stated they were uncomfortable in their bed and was unable to extend their feet and legs due to the curving of the mattress against the footboard. They stated that they had notified staff several times about this problem.
During observations on [DATE] at 9:48 AM, [DATE] at 9:26 AM, and [DATE] at 10:57 AM Resident #13 had an oversized mattress on the bed frame and the mattress did not fit. The mattress was too long and rolled up at the footboard. The tag on the mattress documented it was a standard 80-inch x 36-inch mattress, which was used throughout the facility. When measured by the Facility Director it measured 84 inches long. The Facility Director stated they could not find any work orders requesting a change in mattress.
During an interview on [DATE] at 10:54 AM, CNA #9 stated that ensuring a proper mattress for a resident was a team effort, and that if staff saw something wrong, they should tell maintenance. They stated a mattress should not be too big or too small, and that a proper sized mattress could prevent resident falls. CNA #9 stated that the mattress in Resident #13's room was too long for the bed and could make the resident's feet curl up or their head bend forward.
During an interview on [DATE] at 11:10 AM, LPN #10 stated that a maintenance request work order should be completed for any bed issues, and that any staff that entered a resident room was responsible for observing bed safety. They stated that the mattress fitting properly on the bed was important. The mattress in Resident #13's room was too long for the bed. LPN #10 stated that oversized beds could prevent proper positioning of residents' feet and was not sure how long the oversized mattress had been on that bed. They stated that no staff had made them aware of the oversized mattress in Resident #13's room and they had not noticed the mattress.
During an interview on [DATE] at 11:17 AM, the Facility Director stated that the oversized mattress in Resident #13's room could create pressure sores as the resident may not be able to stretch out and this could make the resident uncomfortable. They stated that they were not aware of the large mattress, could not think of any reason why this mattress would have been placed on this bed frame, and that prior to survey the facility had already stopped buying mattresses from this company.
During an interview on [DATE] at 12:05 PM, registered nurse (RN) Unit Manager #11 stated resident bed safety was the responsibility of all staff. If a CNA observed a problem, they should let a supervisor know, and then a work order should be created to replace a mattress in a resident room. They stated that a proper fitting mattress could help prevent injury and enhance comfort for the resident. A mattress that was too long for the bed could be a safety issue and could cause the resident discomfort and effect skin integrity.
10 NYCRR 415.29(j)(1)

Based on observation, interview and record review during the recertification survey conducted 9/8/22-9/13/22, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents # 7) reviewed. Specifically, Resident #7 was not assisted with shaving and was observed with long facial hair on multiple days.
Findings include:
The facility policy, Activities of Daily Living (ADL) dated 7/2017 documented all residents would receive assistance as needed for their activities of daily living (ADL's), an accurate care plan would be developed, and if a resident's preference was contrary to the plan of care, e.g., shaving, the facility would develop a non-compliant plan of care for the resident and staff would reapproach them within a reasonable amount of time.
Resident #7 had diagnoses including dementia without behavior disturbances, transient ischemic attack (TIA, mini stroke), and cerebral vascular accident (CVA, stroke). The 5/20/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and was totally dependent for ADLs.
The comprehensive care plan, (CCP) initiated 5/20/20 documented the resident had ADL deficits. Interventions included assistance of 1 with bathing, toileting, grooming and dressing.
The 9/8/22 revised care instructions documented the resident required extensive assistance of 1 with bathing, dressing, and grooming. Shower days with weekly skin checks were scheduled on Mondays during the 7:00 AM-3:00 PM shift.
The certified nurse aide (CNA) ADL record did not include documentation ADLs were completed on 9/8/22 for all shifts.
The resident was observed:
- on 9/8/22 at 10:53 AM, sitting in a wheelchair in their room. The resident had facial hair on their chin approximately 1 inch long and on their upper lip approximately ½ inch long.
- on 9/9/22 at 8:24 AM, sitting in their wheelchair with facial hair approximately 1 inch long on their chin and facial hair approximately ½ inch long on their upper lip.
- on 9/9/22 at 1:53 PM, sitting in the dining room with facial hair approximately ½ inch long on their upper lip. The chin hair appeared shorter than 1 inch.
- on 9/12/22 at 11:26 AM, sitting in their room in a wheelchair with facial hair approximately ½ inch long on their upper lip.
During an interview on 9/8/22 at 10:53 AM, Resident #7 stated they preferred to have their facial hair shaved.
During an interview on 9/9/22 at 2:50 PM, CNA #3 stated that Resident #7 needed assistance with their ADL's which consisted of washing, dressing, grooming, and shaving if needed. CNA # 3 stated that facial hair on a resident should be shaved if it was visible and they would assist with shaving.
During an interview on 9/13/22 at 9:19 AM, CNA # 4 stated Resident #7 required assistance with their ADLs including shaving. CNA #4 stated they cared for Resident #7 on 9/8/22, gave them a bed bath and did not shave them. CNA # 4 stated that facial hair should be removed if it was visible and ½ inch in length or longer. CNA # 4 stated that they shaved residents when time allowed. They were the only CNA on the unit that morning and was not able to shave the resident.
During an interview on 9/13/22, registered nurse (RN) # 5 stated they were responsible to ensure direct care staff completed their assignments regarding Resident #7's ADL care. Resident #7 needed assistance with shaving and their AM care involved washing, personal grooming, and shaving. RN #5 stated rounds were not performed to ensure care was completed unless they observed a resident with care not completed. A female resident should not have facial hair. It was unacceptable and a dignity issue unless that resident preferred to have facial hair. RN #5 stated they were aware, at the time of this interview, that Resident #7 currently had facial hair.
During an interview with the Director of Nursing (DON) on 9/13/22 at 11:44 AM, they stated that female residents should not have facial hair unless it was their preference and were care planned to have it. They expected direct care staff to remove facial hair and ask for assistance if needed.
10NYCRR 415.12 (a)(3)

Based on observation, record review, and interview during the recertification survey conducted 9/8/22-9/13/22, the facility failed to ensure food and drink was palatable, attractive, and at safe and appetizing temperatures for 3 of 3 meal test trays. Specifically, 1 breakfast tray and 2 lunch trays had hot and cold food items that were not maintained at safe temperatures and the food did not taste appetizing or palatable.
Findings include:
The facility's Meal Service/Tray Service Times posting revised on 5/2/22, documented that meal service for Unit 2 lunch was scheduled for 11:35 AM, and Unit 5 breakfast was scheduled for 8:00 AM.
The facility's undated Meal Rounds quality audit forms documented that there had been hot food items and cold food items that had been out of range, and that some of these food items had been addressed by the Food Service Director.
The undated facility policy Food and Nutrition Services documented that each resident would be provided with a nourishing, palatable, well-balanced diet. The facility would employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service.
The facility's Production Tally Sheet documented on 9/3/22 and 9/12/22 that all hot food item temperatures in the main kitchen measured over 140 degrees Fahrenheit (F), and all cold food item temperatures in the main kitchen were measured under 45 F.
During a resident council meeting on 9/9/22 at 11:00 AM, multiple anonymous residents stated the food delivery was late and that the hot food was cold.
1) Unit 2 Lunch Tray
During an observation on 9/9/22 at 11:58 AM, the meal cart arrived on Unit 2 and at 12:05 PM a meal tray was delivered to Resident #2. This tray was used for testing and a replacement was provided to the resident. The chicken patty was not hot to taste; and the diced pears, the diced peaches and the cottage cheese were not cold to taste and not palatable.
The following temperatures were measured:
- the chicken patty was 129 degrees F;
- the diced pears were 53 F;
- the diced peaches were 59 F; and
- the cottage cheese was 50 F.
2) Unit 5 Breakfast Tray
During an observation on 9/12/22 at 8:46 AM, the meal cart arrived on Unit 5 and at 9:34 AM a meal tray was delivered to Resident #56. This tray was used for testing and a replacement was provided to the resident. The egg sandwich on the test tray was 103 F and was not palatable.
During an interview on 9/12/22 at 10:16 AM, Resident #92 stated that breakfast was cold and as a result they ate only one of the two eggs provided.
3) Unit 2 Lunch Tray
During an observation on 9/12/22 at 11:39 AM, the meal cart arrived on Unit 2 and at 12:03 PM a meal tray was delivered to Resident #198. This tray was used for testing and a replacement was provided to the resident. The hamburger, beans and peas were not hot to taste, and the diced pineapples were not cold to taste.
The following temperatures were measured on the unit:
- the hamburger was 106 degrees F;
- the beans were 100 F;
- the peas were 95 F; and
- the diced pineapples were 75 F.
During an interview on 9/12/22 at 12:38 PM, the Food Service Director stated that hot food items were supposed to be served above 140 F, and cold food items were supposed to be served below 45 F. They stated that the current process for cold items (i.e., the diced pineapple, the diced pears, the diced peaches, and the cottage cheese) was placing a food container into the walk-in refrigerator the night before it was to be used. The food was taken out the next day during food preparation for the specific meal, the container opened, and the food items placed into individual dessert bowls. The bowls were then placed back into the walk-in refrigerator. The bowls were taken out of the refrigerator and placed in an ice bath prior to plating and sending food to the resident units. The Food Service Director stated that it was not acceptable for the hot food items to be served under 140 F, or the cold food items to be served over 45 F. They stated that they did test trays at least twice a week, and that this was documented. The Food Service Director stated that this process included putting a test tray in the cart with a resident name on it, waiting until a staff person brought the tray to the resident room, and then doing temperature checks of the food. They stated that when there was adequate staffing on resident floors the test tray temperatures were within range, and when there was not adequate staffing on resident floors the temperatures were out of range. The Food Service Director stated that residents had not identified issues with cold and unpalatable foods during food committee at resident council.
During an interview on 9/13/22 at 12:45 PM, certified nurse aide (CNA) #16 stated that it was their responsibility to pour the drinks for meal service, check trays for accuracy of consistency and preferences, assist with cutting food as needed, and deliver the meals. They stated that this typically took approximately 20 minutes when there were two CNAs on, but alone the process took much longer. They stated that they were alone once or twice a week.
During an interview and observation on 9/13/22 at 1:23 PM, Resident #49 stated the vegetable they had for lunch did not appear appetizing. The vegetable mix was observed and consisted of cut green beans, carrots, corn nibblets, and peas which were shriveled and unappealing.
10NYCRR 415.14(c)

Based on observation, record review, and interview during the recertification survey conducted 9/8/22-9/13/22, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen) reviewed. Specifically, the main kitchen had a leaking handwash sink, and the floor and wall near the stove and preparation area was unclean.
Findings include:
The facility was unable to provide documentation to verify the last time the floor and wall in the vicinity of the stove and cook preparation area had been cleaned, or a kitchen cleaning policy.
An undated Cleaning Task for AM Staff did not include the stove and preparation area.
The following observations were made in the main kitchen on 9/8/22:
- at 10:15 AM, the handwash sink was dripping water from part of the sink pipe onto the floor. The pipe plumbing was loose and not secure.
- at 10:20 AM, the wall behind the stove and cook preparation area was stained and unclean. The floor below this area was unclean and had miscellaneous debris on it.
During an interview on 9/8/22 at 10:30 AM, the Food Service Director stated that they were not aware of the leaking sink, or of any work order for the leaking sink.
During an observation on 9/12/22 at 11:15 AM, the wall behind the stove and cook preparation area remained stained and unclean.
During an interview on 9/12/22 at 11:15 AM, the Food Service Director stated that the floor under cook area was pressure washed and cleaned monthly. There was no documentation to verify this.
During an interview on 9/13/22 at 10:02 AM, the Food Service Director stated that it was important to keep the kitchen clean and in good repair to keep pests out and have an environment safe for cooking food.
10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey conducted 9/8/22-9/13/22, the facility failed to 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 1 of 3 residents reviewed (Resident #83). Specifically, Resident #83 had an infected Stage 4 pressure injury (full thickness tissue loss with exposed bone, tendon, or muscle) on their sacrum (the bone at the base of the spine) requiring intravenous (IV) antibiotics, and a wound vacuum (vacuum assisted closure, application of negative pressure to assist with healing). During an observed wound vacuum dressing change, infection control practices were not maintained.
Findings include:
The undated facility policy Wound Care documented:
- Use disposable cloth (paper towel is adequate) to establish a clean field on the resident's overbed table.
- Place all items to be used during procedure on the clean field.
- Arrange the supplies so they can be easily reached.
- Wash and dry your hands thoroughly and put on exam glove.
- Loosen the tape and remove the dressing.
- Pull glove over dressing and place in appropriate receptacle.
- Wash and dry your hands thoroughly and put on gloves.
The facility Wound Vac Policy dated 1/27/2014 documented:
- Cut the black foam dressing (placed in the wound) to a size that is appropriate to the wound.
- Do not trim the foam over or around the wound site to help prevent fragments from the dressing from falling into the wound.
- Place the foam in the wound site.
Resident #83 had diagnoses including osteomyelitis (infection of bone), pressure ulcer of sacrum, and diabetes. The 8/3/22 Minimum Data Set (MDS) comprehensive assessment documented the resident had moderately impaired cognition, required extensive assistance of 2 with bed mobility, had active diagnosis of septicemia (infection in the blood stream), did not have a wound infection, had one Stage 3 (full thickness tissue loss) pressure ulcer present on admission, received pressure ulcer care including application of non-surgical dressing and ointment/medication.
The hospital Discharge summary dated [DATE] documented the resident was hospitalized [DATE]-[DATE] with a diagnosis of severe sepsis secondary to infected pressure ulcer. Discharge recommendations were to continue ceftriaxone (antibiotic given by IV) for a total of 6 weeks due to multiple microorganisms identified from the wound culture, wound vac dressing change every Monday, Wednesday, and Friday, turn and reposition every 2 hours, and place extra padding under bony prominences.
Physician orders dated 9/7/22 documented enhanced barrier precautions (reduces transmission of resistant organisms by employing targeted gown and glove use during high contact resident care activities), ceftriaxone (an antibiotic) via peripherally inserted central catheter (PICC, intravenous access), wound vac dressing to be changed every Monday, Wednesday, and Friday (M-W-F), and wound vac set at 125 mm/Hg (millimeters of mercury).
The 9/7/22 comprehensive care plan (CCP) documented the resident had osteomyelitis with a goal of resolution with antibiotic therapy per medical order. Approaches included medication, treatment, vital signs per medical order, and to monitor for signs and symptoms of infection. The resident required enhanced barrier precautions due to wound infection with MDRO (multi drug resistant organisms).
The 9/9/22 wound management detail report, created by the Director of Nursing (DON), documented the sacral wound measured 10 centimeters (cm) X 8 cm, with tunneling (wound extending under the outer skin) measuring 10 centimeters. There was a heavy amount of serous drainage observed. The wound contained 10% slough (moist dead tissue) and 90% granulation (new pink) tissue.
During a wound care dressing change observation with RN Unit Manager #11 and certified nurse aide (CNA) #9 on 9/12/22 at 1:42 PM, the old dressing was removed, and the wound cleansed prior to the observation. RN #11 removed their gloves, performed hand hygiene, and put on new sterile gloves. CNA #9 rolled up the wet and soiled incontinence pad from under the resident and did not change their gloves or perform hand hygiene. The wound supplies were in an unopened package on the bed without a barrier. The CNA was observed applying skin prep (a skin protectant) to the wound edges wearing the same gloves used to handle the dirty incontinence pad. The RN opened the package of wound vac dressing supplies and removed the black foam to be placed in the wound. The clear plastic drape (used as a barrier for outside contaminants) dropped on the bare linen. The RN held the black foam near the wound to approximate the size needed to be cut and used scissors to trim the foam. The RN laid the scissors on the bare linen. This was repeated several times using the same scissors until the foam was the size needed. The black foam was then placed in the wound bed and covered with the plastic drape dressing. The wound vac tubing was placed and connected to the wound vac set at 125 millimeters (mm)/ mercury (Hg).
When interviewed on 9/12/22 at 2:06 PM RN Unit Manager #11 stated they considered the resident's wound a dirty wound, and a clean field setup was on the bed using packaging materials. It was a clean procedure, not sterile. They stated they used the glove wrapper as a field for putting gloves on. The rest of the supplies had no clean field setup. When they picked the foam up and cut it, the scissors should not have been placed on the bed without a barrier. A CNA could assist with wound care when overseen by an RN.
When interviewed on 9/13/22 at 10:59 AM CNA #9 stated they assisted with the wound vac dressing on 9/12/22 with the RN Unit Manager and was in the room since the beginning of the treatment. They helped reposition the resident, cleanse the wound with wound spray, and rolled up the soiled pad. The RN asked the CNA to apply skin prep around the outer edge of the wound to help the dressing stick. They did not think they changed their gloves or performed hand hygiene before applying the skin prep. They stated they thought of it afterward and should have to help prevent infection.
When reinterviewed on 9/13/22 at 12:11 PM, RN #11 Unit Manager stated that before the surveyor entered the room, the resident was repositioned with the assistance of CNA #9. The old dressing was removed, and the wound was cleansed with normal saline. The CNA then rolled the soiled pad out of the way for the new dressing to be placed. There was no clean field setup, the scissors should not have been placed on the bedding as it could have bacteria present that could contaminate the dressing. They asked the CNA #9 to put skin prep on wound edges, but did not notice if hand hygiene or a glove change was performed before the CNA applied the skin prep. The RN stated they were not sure if hand hygiene was needed by the CNA prior to applying the skin prep.
When interviewed on 9/13/22 at 12:57 PM, nurse practitioner (NP) #13 stated they went on wound rounds weekly to see pressure areas. Dressing change technique was important to prevent infection during wound care, which included hand hygiene and glove changes. Resident #83 had recently been in the hospital with sepsis due to the sacral wound infection. A wound vac dressing change was a clean technique, and they would expect a clean field for supplies to be setup. Hand hygiene and glove changes should always take place between removal of the dirty dressing and application of the new dressing.
When interviewed on 9/13/22 at 1:15 PM, the Infection Control Nurse stated nurse competencies were done on hire including wound care. The setup for wound care should have included gathering supplies, proper personal protective equipment, hand hygiene, and establishing a clean field using a barrier for supplies. The scissors that were used should not have been placed on the bed, as they could pick up germs from linen, especially for someone on transmission based precautions. The CNA should have performed hand hygiene and donned clean gloves before applying skin prep to wound edges. Staff not changing gloves and performing hand hygiene between dirty and clean tasks could increase the risk of infection.
10NYCRR 415.12(c)(2)