Every finding on record at Absolut Center for Nursing and Rehabilitation at T

Based on observations, interviews, and record review conducted during a Recertification Survey from 02/24/2025 to 02/28/2025, for four (Residents #16, #45, #79, #100) of seven residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, Resident #45 had respiratory symptoms, tested positive for Covid-19, and was not placed on enhanced droplet/contact precautions (a strategy used by nursing homes to prevent the spread of infectious diseases). Staff were observed within six feet of Resident #45 without wearing personal protective equipment (equipment used to protect against the transmission of communicable diseases/infections such as gloves, gowns, face masks, and face shields), including but not limited to, a face mask and face shield. Resident #79 was admitted with a open area to their leg and subsequently developed a pressure ulcer to their heel, was not placed on enhanced barrier precautions (a strategy used by nursing homes to decrease transmission of infectious disease), and staff were observed changing the dressing to the open heel ulcer without wearing a gown. Resident #100 had respiratory symptoms, tested positive for Covid-19, was placed on contact precautions (versus airborne) and staff were observed within six feet of the resident, touching the resident's environment without wearing appropriate personal protective equipment. Resident #104 was admitted with an unstageable pressure ulcer (a bed sore where depth cannot be seen) to their sacrum (area at bottom of the spine) and was not placed on enhanced barrier precautions. Resident #16 was on enhanced barrier precautions and staff were observed performing high-contact personal care without wearing appropriate personal protective equipment. Additionally, the facility did not ensure the Infection Prevention and Control Program policies and procedures were reviewed at least annually as required. This is evidenced by the following: 1. Resident #45 had diagnoses of polymyalgia rheumatica (an inflammatory disease that causes pain and stiffness to muscles and joints), hypertension (high blood pressure). and anxiety. The Minimum Data Set Resident Assessment, dated 02/12/2025, included Resident #45 was cognitively intact. Review of a progress note written by the Registered Nurse Educator on 02/24/2025 at 9:23 AM revealed Resident #45's family was notified Resident #45 had tested positive for Covid-19 and was on isolation precautions. During an observation and interviews on 02/24/2025 at 12:24 PM, Resident #45's room door was open and there were no visible precaution signs posted or personal protective equipment near the room. Resident #45 stated they were tested for Covid-19 due to having laryngitis (inflammation of the vocal cords) and nobody let them know their results. During an immediate interview, the Director of Social Work stated Resident #45 was tested for Covid-19 and their results were not in yet. During an observation on 02/24/2025 at 1:00 PM, Resident #45's room door was closed, there was a sign for enhanced droplet/contact precautions posted and a cart with personal protective equipment outside the room. During an observation on 02/27/2025 at 9:44 AM, Resident #45 was in their wheelchair at the threshold of their opened room door. Certified Nursing Assistant #4 was standing within six feet of Resident #45, talking with them, and was not wearing a face mask or shield. 2. Resident #100 had diagnoses of type two diabetes mellitus, stage 3 chronic kidney disease, and anxiety. The Minimum Data Set Resident Assessment, dated 12/20/2024, included Resident #100 had mildly impaired cognition. Review of a progress note written by Licensed Practical Nurse #1 on 02/22/2025 at 6:08 PM revealed Resident #100 presented with shortness of breath, was coughing, and complained of a sore throat. Review of physician's orders, dated 02/22/2025, revealed an order for Covid-19 and flu tests due to shortness of breath, cough, and sore throat to be completed the evening of 02/23/2025 for lab pick-up the morning of 02/24/2025. During an observation and interview on 02/24/2025 at 12:53 PM, Resident #100 was in their room and had a wet, harsh cough. There was a contact precaution sign posted on the door and had an x marked next to handwashing, gloves, and gowns. There was no x marked for mask or eye protection. Certified Nursing Assistant #3 put a surgical mask on, entered the room, was within six feet of the Resident #100 talking with them, picked up items, and exited the room carrying their lunch tray. During an interview at this time, Certified Nursing Assistant #3 stated they did not know why there was a contact precaution sign on the resident's door as they were not told that information. The precaution sign was reviewed with Certified Nursing Assistant #3 at that time, and they stated they only needed to wear the equipment that did not have an x marked next to them and had worn a mask (surgical) and glasses when entering Resident #100's room. During an observation on 02/25/2025 at 9:21 AM, there was a sign on Resident #100's door for enhanced droplet/contact precautions and had an x marked for handwashing, gloves, gown, eye protection, and N-95 mask. 3. Resident #79 had diagnoses including aftercare following surgery on the skin and subcutaneous tissue (layer of tissue beneath the skin), congestive heart failure, and anxiety. The Minimum Data Set Resident Assessment, dated 01/21/2025, included Resident #79 had mildly impaired cognition, was dependent on staff for care, had surgical wound(s), and required surgical wound care. Review of physician's orders, dated 01/22/2025, included to apply Aquaphor (a product applied to the skin) to donor site (right upper leg) and right graft site (right lower leg) twice daily for wound care. A physician's order, dated 02/18/2025, included to cleanse right heel with wound cleanser and apply alginate (a highly absorbent dressing) and rolled gauze daily. Review of a progress note written by Nurse Practitioner #1 on 01/27/2025 revealed Resident #79 was admitted to the facility after hospitalization for treatment of an infected hematoma (a wound causing pain and swelling) requiring a skin graft (a surgical procedure of the skin). During an observation on 02/25/2025 at 9:52 AM, Resident #79 lying in bed while the Registered Nurse Educator was holding the resident's right leg and Nurse Practitioner #2 was standing at the end of the bed. Resident #79's right heel had an open wound that was bright red in color. The Registered Nurse Educator and Nurse Practitioner #2 were not wearing gowns. There were no visible precaution signs posted or personal protective equipment near the room. During an interview on 02/28/2025 at 11:15 AM, the Registered Nurse Educator/Infection Preventionist stated they were responsible for the Infection Control Program. Staff on the units were responsible for putting up precaution signs and personal protective equipment carts outside of the resident's rooms and the Registered Nurse Educator would verify placement. The Registered Nurse Educator stated they did not realize there was no precaution sign for Resident #45 and was not aware Resident #100 had the wrong precaution sign posted on their door. The Registered Nurse Educator stated residents were supposed to be placed on enhanced droplet/contact precautions when they showed any signs and symptoms or were being tested for Covid-19. They stated staff should wear N-95 masks and a face shields in those resident rooms as Covid-19 could spread and nine staff were currently out of work due to Covid-19 illness. The Registered Nurse Educator stated the facility used enhanced barrier precautions for any resident that had significant multi-drug-resistant organisms, a device like a Foley (a medical device that helps drain urine from the bladder), a wound greater than a stage three (a deep pressure sore), or for an unhealed wound. Staff should wear personal protective equipment when providing hands on care. The Registered Nurse Educator stated Residents #79 and #104 were not on enhanced barrier precautions but should have as they had resided at the facility for a month. During an interview on 02/28/2025 at 12:42 PM with the Director of Nursing and the Regional Quality Assurance Nurse, the Director of Nursing stated enhanced barrier precautions were intended to protect the resident from acquiring other infectious diseases as well as protecting the staff from infections. The Director of Nursing stated a resident would need to be on enhanced barrier precautions if they had an indwelling catheter (a medical device that stays in place for a long period of time), were on dialysis (a treatment for people with kidney failure), or a wound that would take more than a month to heal. The Director of Nursing stated residents #79 and #104 should have been on enhanced barrier precautions as they each were admitted with wounds present for longer than a month. The Director of Nursing stated a resident should be placed on enhanced droplet/contact precautions when there was an order to test for Covid-19. The Director of Nursing stated Resident #45 and Resident #100 should have been placed on enhanced droplet precautions immediately to prevent potential exposure to others. 4. Resident #16 had diagnoses that included multiple sclerosis (a chronic neurological disorder), transient ischemic attacks (symptoms similar to a stroke), and metabolic encephalopathy (a problem with brain function due to a chemical imbalance in the blood). The Minimum Data Set Resident Assessment, dated 01/10/2025, documented the resident had severely impaired cognition. Review of urine culture results, dated 01/01/2025, revealed the presence of Extended Spectrum Beta-Lactamase (an enzyme found in urine that makes bacteria resistant to antibiotics) in Resident #16's urine. Review of Resident #16's Comprehensive Care Plan, revised 01/03/2024, revealed the resident had a multi drug-resistant organism (MDRO) and was on enhanced barrier precautions due to placement of a suprapubic catheter (a tube inserted into the lower abdomen to drain urine from the bladder) and presence of Extended Spectrum Beta-Lactamase in their urine. Interventions included, but were not limited to, staff to wear personal protective equipment (gown and gloves) when providing high contact resident care, including dressing, bathing/showering, transferring, linen change, providing personal hygiene, changing briefs, and wound care. During an observation on 02/24/25 at 10:32 AM, Certified Nursing Assistants #1 and #2 assisted Resident #16 with a mechanical lift transfer from the shower chair to bed, incontinence and catheter care, and dressing. Both certified nursing assistants were wearing only gloves while assisting with the high-contact care activities. During an interview on 02/24/2025 at 10:56 AM, Certified Nursing Assistant #1 stated Resident #16 was on enhanced barrier precautions for their catheter and they should have worn a gown. During an interview on 02/24/2025 at 10:48 AM, Licensed Practical Nurse Manager #1 stated Resident #16 was on Enhanced Barrier Precautions related to their suprapubic catheter and gloves, gown, and a mask should be worn when providing care and handling a catheter. During an interview on 02/27/2025 at 11:00 AM, the Infection Preventionist/Nurse Educator stated staff should wear gloves and a gown while providing personal care for a resident on enhanced barrier precautions. Review of the several Infection Prevention and Control Policies including Infection Prevention and Control-General Statement, Policy on Use of Criteria for Infection Identification, Antibiotic Stewardship Program, Policy on Influenza Immunization (Seasonal/H1N1), Pneumococcal Vaccination Program-Residents, and Policy on Surveillance revealed that none had been reviewed or revised in the last one year. Review of the facility policy Infection Prevention and Control-General Statement, last reviewed May 2023, included the facility's infection prevention and control program should be reviewed annually and updated as necessary. 10 NYCRR 415.19(a)(1-3)

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for one (Resident #66) of four resident reviewed, the facility did not ensure that all alleged violations involving potential abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health in accordance with state law. Specifically, the facility did not report a resident falling out of bed during care that was being provided by one Certified Nursing Assistant opposed to two Certified Nursing Assistants per the resident's person-centered Comprehensive Care Plan. This is evidenced by the following: The facility policy Accident/Incident Investigation and Prevention, dated June 2023, included in the event a resident is involved in an accident or incident in which it is reasonable to assume, based on the facts, that negligence is involved, the occurrence shall be reported to the New York State Health Department according to the Patient Abuse and Reporting regulations. Resident #66 had diagnoses including dementia (altered mental status), congestive heart failure, and atrial fibrillation (irregular heartbeat). The Minimum Data Set Resident Assessment, dated 01/23/2025, documented Resident #66 had severely impaired cognition. Review of the resident's Comprehensive Care Plan (initiated 06/02/2024) and the current Kardex (care plan used by the Certified Nursing Assistants for daily care) included Resident #66 had a self-deficit in bed mobility and required two staff for bed mobility and rolling side to side. Review of the document titled #4434 witnessed fall, dated 02/19/2025 (identified by the facility as an Incident and Accident form) and signed by Licensed Practical Nurse #3, revealed that Resident #66 had a fall out of bed during incontinence care that was provided by Certified Nursing Assistant #7. Resident #66 was care planned for two-person assist for incontinence care while in bed. Resident #66's mental status was oriented to person and situation, both Licensed Practical Nurse #3 and the night shift Supervisor Licensed Practical Nurse #5 were notified. The resident sustained a skin tear to their right knee and bruising to the right lower leg. Both Provider (medical team) and family were notified. Intervention initiated was a fall mat to left side of bed. Review of statements, all dated 02/19/2025 obtained by the facility included the following: 1. In a statement Certified Nursing Assistant #7 stated they were changing Resident #66, told Resident to roll back to them, but the resident rolled the wrong way and fell off the bed. 2. In a statement Licensed Practical Nurse #3 stated they were passing medications to another resident when Certified Nursing Assistant #7 told them Resident #66 was on floor. Licensed Practical Nurse #3 documented in their statement that the aide (Certified Nursing Assistant #7) rolled the resident out of bed. Additionally, Licensed Practical Nurse #3 documented that Certified Nursing Assistant #8 approached them to inform them another resident had complained to them that Certified Nursing Assistant #7 had been rough with them during care. Licensed Practical Nurse #3 documented that they felt Certified Nursing Assistant #7 was a detriment to the residents. 3. Resident #66's statement included that the aide rolled them onto the floor. During an interview on 02/27/2025 at 2:51 PM, Licensed Practical Nurse Manager #2 stated if an accident or incident occurred it was the nurse's responsibility to start the Accident and Incident form which included witness statements, neuro checks, vital sign sheets, and to write up findings in the resident's electronic medical record. Licensed Practical Nurse Manager #2 stated as a Nurse Manager they review Accident and Incident reports in the electronic medical records, review care plans and bring the incidents to morning meeting to discuss the situation (with the interdisciplinary team). During an interview on 02/28/25 at 10:07 AM, the Director of Nursing stated any signs of abuse or neglect with an injury should be reported to the Department of Health. The Director of Nursing stated they did not report this incident because they felt the bruise was related to a fall, so they did not need to report it. During an interview on 02/28/25 at 12:28 PM, the Administrator stated that neglect and/or mistreatment included not following the care plan. The Administrator stated they did not feel that the incident on 02/19/2025 with Resident #66 rose to the level of reporting to the Department of Health because it was not a serious injury. 10 NYCRR 415.4

Based on observations, interviews, and record review conducted during a Recertification Survey from 02/24/2025 to 02/28/2025, for one (Residents #15) of seven residents reviewed, the facility did not ensure that residents who were dependent on staff for assistance received the necessary services to maintain grooming and personal hygiene. Specifically, Resident #15 did not receive consistent assistance with nail care. This is evidenced by the following: The facility policy Nail Care, dated 04/10/2011, documented routine nail care is to be done following bath and/or shower whenever possible. Resident #15 had diagnoses including vascular dementia, congestive heart failure, and traumatic brain injury. The Minimum Data Set Resident Assessment, dated 01/04/2025, documented the resident had severely impaired cognition and was dependent with personal hygiene. Review of the Comprehensive Care Plan, last reviewed on 01/05/2025, and current Kardex (plan of care used by Certified Nursing Assistants) revealed Resident #15 required total assistance with bathing/showering and all personal hygiene including nail care on bath/shower day and/or as needed. Scheduled shower day was Monday evening shift. In a nursing progress note, dated 02/08/2025, the Licensed Practical Nurse documented that Resident #15 removes their brief and smears the bowel movement around. During an observation on 02/24/2025 at 11:45 AM, Resident #15 was in bed. Their brief (partially removed by the resident) was soaked through, their bed sheet was wet, and the resident had brown stool on back of their leg and all over their left hand, including fingers and nail beds. Review of the February 2024 Treatment Administration Record revealed Resident #15 received a weekly skin monitoring every Monday evening shift for skin integrity and was signed off as being completed on 02/24/2025. During an observation on 02/24/2025 at 12:34 PM, 02/25/2025 at 10:03 AM, and on 02/26/2025 at 4:16 PM, Resident #15 had brown debris on multiple fingers, nails, and cuticles. During an observation on 02/27/25 at 8:57 AM, Resident #15 was sitting up in bed eating breakfast with their hands. Their tee shirt, brief, and left hand had brown debris in the cuticles and under the fingernails. During an interview on 02/27/2025 at 5:49 PM, Certified Nursing Assistant #9 stated they were not assigned to Resident #9 (that day) but they have floated to that unit and care for each resident should be on the Kardex which is found in the resident's room. Certified Nursing Assistant #9 stated if a resident refused nail care, they should reapproach and tell the nurse. During an interview on 02/27/2025 at 2:51 PM, Licensed Practical Nurse Manager #2 stated nail care should be completed on the residents' shower days unless refused. Review of Resident #15's electronic medical record with the surveyor at this time revealed no documented evidence that they had refused nail care. Licensed Practical Nurse Manager stated it (the dirty nails) was a problem. During an interview on 02/28/2025 at 11:37 AM, the Director of Nursing stated nail care should be performed on shower days and that if a resident refused nail care, the nurse should be made aware, and the refusal documented in the electronic medical record and on the resident's care plan. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (Resident #51) of one resident reviewed for edema. Specifically, the facility did not ensure the resident received the highest practical, physical, mental, and psychosocial wellbeing, including ace wraps to both lower extremities. This is evidenced by the following: Resident #51 had diagnoses including congestive heart failure, atrial fibrillation (irregular heartbeat), and edema (swelling due to excess fluid in the tissues). The Minimum Data Set Resident Assessment, dated 02/07/2025, documented the resident had moderately impaired cognition. Review of Resident #51's current physician's orders revealed orders for ace wraps to both lower extremities from feet to knees as tolerated, on early AM, off in PM, as needed for edema, and to document refusals (initially ordered on 03/25/2023). Review of Resident #51's Care Plan, dated 08/05/2024, documented under skin integrity issues for staff to encourage ace wraps and document refusals. Observations on 02/24/2025 at 11:34 AM, 02/26/2025 at 4:15 PM, and 02/27/2025 at 09:00 AM revealed Resident #51 in a recliner chair, both legs were elevated and bright red with extreme edematous swelling and had multiple blisters on each leg. At no time was the resident observed wearing ace wraps. Review of Resident #51's Treatment Administration Record revealed no documentation of the ace wraps provided for the month of February from 02/01/2025 to 02/27/2025. During an interview on 02/27/2025 at 01:58 PM, Certified Nursing Assistant #9 stated they work the evening shift and do not apply the ace wraps but have removed them at times. Certified Nursing Assistant #9 stated that Resident #51 will refuse care from male caregivers, but does not refuse care from them as the resident knows them. During an interview on 02/27/2025 at 1:58 PM, Licensed Practical Nurse Manager #2 stated Resident #51 does refuse care at times. During a review of the resident's electronic medical record at this time with the surveyor, Licensed Practical Nurse Manager #2 stated there was no documented evidence of the resident's refusing the ace wraps for the past month. During an interview on 02/28/2025 at 11:37 AM, the Director of Nursing stated if a resident refused treatments or care, the Certified Nursing Assistants should let the nurses know and reapproach the resident to provide the care or have another staff member try to provide care. If a resident still refused, then the refusal should be documented by nursing. 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for one (Resident #36) of one resident reviewed, the facility did not ensure that dialysis services provided were consistent with professional standards of practice, the comprehensive care plan and physician orders. Specifically, the facility did not have evidence of consistent monitoring of the resident's ordered 24-hour fluid restriction, did not have physician's orders or a care plan for having a tunneled dialysis catheter (surgically inserted catheter into the chest wall used to perform dialysis), did not have documented evidence of monitoring the catheter and dressing for potential complications, and were not following the vascular physician's recommendations. This is evidenced by the following: Resident #36 had diagnoses that included end stage renal (kidney) disease, muscle weakness, and diabetes. The Minimum Data Set Resident Assessment, dated 02/11/2025, revealed Resident #36 was cognitively intact and received dialysis treatments. Review of a hospital Emergency Record, dated 12/31/2023, revealed Resident #36's dialysis fistula (a surgical connection between a vein and artery that helps the body create the flow of blood required to complete dialysis treatments) was clotted (not functioning) and a right-sided surgically inserted tunneled catheter dialysis port was placed (via the chest wall) to use for dialysis treatments (in place of the fistula). In a consultation note, dated 11/21/2024, the Vascular Nurse Practitioner documented that the resident required a new right arm fistula which was planned for after the holidays. Recommendations (capitalized and highlighted) included no blood draws or needle pokes in the right arm. In a consultation note, dated 01/23/2025, the Vascular Nurse Practitioner documented that Resident #36 was recommended to have a new fistula created but had a respiratory illness and they would follow up to reschedule in a few weeks. Current physician orders reviewed on 02/27/2025 documented: a. Dialysis fistula: monitor the site to the left arm for positive thrill and bruit (sounds and vibrations felt and/or heard in a fistula indicating it was functioning) every shift (ordered 01/18/2024). b. Check blood pressure upon return from dialysis, no blood pressures in the shunt (fistula) arm and check for bleeding (ordered 12/26/2023). c. Remove the pressure dressing four hours after the resident returned from dialysis (ordered 12/26/2023). d. Fluid restriction: document 24-hour totals in the electronic health record at bedtime 1500 milliliters fluid restriction/24 hours with 360 milliliters allowed for nursing and 1140 milliliters allowed for dietary (meals) for the 24-hour total (ordered 05/09/2024). The current physician's orders did not include any monitoring of Resident #36's tunneled dialysis catheter and included no blood pressures or lab draws in the left arm versus the vascular physician's recommendations referring to the right arm. Resident #36's undated Comprehensive Care Plan, reviewed on 02/26/2025, included the resident received hemodialysis three times a week with interventions as followed: a. No blood pressures or labs draws on the left side (arm) b. Monitor the shunt (fistula) for signs of infection or bleeding c. Check the shunt site for positive bruit and thrill d. A 1500 milliliters (per day) fluid restriction, at risk for dehydration and to monitor fluids daily Resident #36's care plan did not include that Resident #36 had a tunneled catheter (in addition to a fistula) or interventions for monitoring the catheter for potential complications or care of the catheter (e.g., during showers). Review of the January 2025 and February 2025 Medication Administration Records revealed that the 24-hour total fluid look back report had daily totals that ranged from zero to 60 milliliters a day to 2160 milliliters a day with an average daily fluid intake of 345 millimeters per day for the 56 days reviewed (versus 1500 milliliters). The Records also included nursing staff also signed off as completed that they removed a dressing from the residents fistula (not currently in use) after dialysis and checked it for a positive bruit and thrill. During an observation and interview on 02/25/2025 at 11:09 AM, Resident #36 had a tunneled catheter in the right chest wall covered with a dressing which was clean and dry. There was no dressing to the resident's left arm. During an interview at this time, Resident #36 stated at the time that they were on a fluid restriction when in the dining room. During a telephone interview on 02/27/2025 at 1:58 PM, the Dialysis Clinical Coordinator/ Registered Nurse stated Resident #36 was on a fluid restriction and their tunneled catheter (not their fistula) was used for their dialysis treatments. The Dialysis Clinical Coordinator stated Resident #36 had a left-sided fistula, but they were told (by medical) not to use it as the resident needed a new fistula and that the fistula (left arm) had not been in use for at least a year. The Dialysis Clinical Coordinator/ Registered Nurse stated that facility staff do not touch (remove or change) the dressing on the tunneled catheter. During an interview on 02/28/2025 at 11:28 AM, Licensed Practical Nurse #2 stated they cared for Resident #36 (approximately a week ago) and usually when caring for dialysis residents, they check the resident's fistula for a bruit and thrill, and to make sure there was no redness. Licensed Practical Nurse #2 stated dialysis access sites (catheters or fistulas) were usually listed on the care plan and the fluid restrictions were on the Medication Administration Records. Licensed Practical Nurse #2 stated they were not sure who was responsible for monitoring the resident's 24-hour total fluid intake, and did not believe Resident #36 was on a fluid restriction. Licensed Practical Nurse #2 stated they did not know anything about Resident #36's tunneled dialysis catheter. During an interview on 02/28/2025 at 12:08 PM, Licensed Practical Nurse #3 stated Resident #36 was on a fluid restriction, but did not know who was responsible for monitoring the 24-hour totals. Licensed Practical Nurse #3 stated they thought Resident #36 had their tunneled dialysis catheter as far back as a year ago. During an interview on 02/28/2025 at 12:55 PM, Licensed Practical Nurse Manager #2 stated the nurses should document the fluids used during medication administration in the electronic medical record and the Certified Nursing Assistants should document the fluid intake from meals in a separate spot. Licensed Practical Nurse Manager #2 stated a tunneled dialysis catheter should be on the care plan because it was an access site and would need to be monitored. During a review of the fluid restriction order and Medication Administration Records in Resident #36's electronic medical record with the surveyor at this time, Licensed Practical Nurse Manager #2 stated the Dietician (Diet Technician) was responsible for monitoring the 24-hour total fluid intake and that the intakes did not make sense to them (e.g., resident received 240 milliliters for the whole day) and they did not think the nurses understood how to document this. Licensed Practical Nurse Manager #2 stated they did not see any orders or interventions on the care plan for monitoring Resident #36's tunneled dialysis catheter and they thought Resident #36's fistula was being used during dialysis. They stated the Infection Prevention Nurse monitored the tunneled catheter and would look at it during the resident's showers. Review of interdisciplinary progress notes for the prior three months revealed no documented evidence that the Infection Preventionist nurse was monitoring the tunneled dialysis catheter. During an interview on 02/28/2025 at 2:03 PM, Dietary Technician #1 stated they were not aware of anyone looking at the 24-hour total fluid intake for residents on fluid restrictions and was not sure what the Look Back Report was referring to (in the fluid restriction order) and that their Registered Dietician was Corporate. During an interview with the Director of Nursing and the Quality Assurance Nurse on 02/28/2025 at 4:02 PM, the Director of Nursing stated all dialysis access sites should be monitored for bleeding and/or signs of infection. The Quality Assurance Nurse stated the evening nurse should be checking the 24-hour fluid intake since they were supposed to be documenting it. The Quality Assurance Nurse stated the resident's care plan should include monitoring the tunneled dialysis catheter. 10 NYCRR: 415.12

Based on observation, interview and record review conducted during a Recertification Survey completed on 1/13/23 it was determined that the facility did not ensure that one of two residents reviewed for vision and hearing received proper treatment and assistive devices to maintain vision and hearing abilities. Specifically, Resident #46 who has a diagnosis of glaucoma, (a disease that damages the eyes optic nerve and can cause blindness) did not receive any eye examinations since admission to the facility on [DATE] to ensure the resident maintained adequate vision without complications. The finding is: Review of the facility Policy Consultants dated 3/1/20 documented that the facility arranges for qualified professional personal to furnish specific services to the residents in the facility. Consultant services are utilized in the following areas: Optometrist, Podiatrist and Dental Services. 1. Resident #46 has diagnoses including dementia, anxiety, and glaucoma. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 12/2/22 documented Resident #46 was understood, understands and was cognitively intact. The MDS documented the resident had a diagnosis of Glaucoma. The Comprehensive Care Plan initiated 2/28/22 and revised on 3/9/22 documented Resident #46 vision was adequate and interventions included for staff to monitor vision for changes. Review of the Interdisciplinary Progress Notes dated 4/21/21 through 1/13/23 revealed no documented evidence that Resident #46 had been seen by the Optometrist (health care professional that typically provides primary eye care). Review of the documents Schedule of Residents to be seen by the Optometrist from July 2021 through December 2022, provided by the facility, revealed no documented evidence that Resident #46 had seen an Optometrist or was scheduled to see the Optometrist. During an observation and interview on 1/10/23 at 8:58 AM Resident #46 stated they have not seen an eye doctor since they were admitted to the facility and that they have problems with their eyes. The resident stated that they use reader glasses but that it is hard for them to read. During an interview on 1/13/23 at 11:57 AM Licensed Practical Nurse (LPN)/ Resident Care Coordinator (RCC) #1 stated they were unsure how often the Optometrist came to the facility but thinks it may be monthly. The LPN/RCC #1 stated that nursing received a list of residents to be seen for the visit from the Optometrist and will add any new admissions to the list. LPN/RCC #1 stated they were unsure if there was a tracking system to make sure all residents were seen. During an interview on 1/13/23 at 12:30 PM the Medical Records Director stated the Optometrist comes to the facility on ce a month usually on a Monday and that they do their own scheduling of residents for that visit. The Medical Records Director stated that They just let me know when they are coming, and I let nursing know. During an interview on 1/13/23 at 1:15 PM the Director of Nursing stated the Optometrist come in once a month, that residents should be seen every 1-2 years and that new admissions are usually seen on the next visit. During an additional interview on 01/13/23 at 01:29 PM with LPN/ RCC #1 stated they reviewed Resident #46 Electronic Medical Record and were unable to find evidence the resident had been seen by the Optometrist since admission. LPN/RCC#1 said that the Optometrist comes to the facility on Mondays and the resident is at dialysis on Mondays. During a phone interview on 1/13/23 at 1:33 PM the Optometrist stated the company they work for generates the resident list for each visit and they were unsure if the facility or the company added new admissions to the list. 10NYCRR: 415.12(3)(b)

Based on observation, interview and record review conducted during a Recertification Survey completed 1/13/23, the facility did not ensure that a resident who enters the facility without a Foley catheter (an indwelling urinary catheter inserted into the bladder to drain urine) is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary or who subsequently received one is assessed for removal of the Foley catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary. Specifically, one (Resident #361) of one resident reviewed for catheters did not have a documented valid medical justification for a continueing Foley catheter. Additionally, the Foley catheter and care of was not reflected on the resident's comprehensive care plan (CCP) and the Foley catheter tubing was observed on the floor on several observations. The finding is: The facility policy Catheter (Urinary and Suprapubic) Insertion and Removal effective March 2020 documented that prior to the insertion the Resident Care Coordinator (RCC) or designee will discuss and document the involvement of the resident/representative of the risks and benefits of the use of a catheter and removal of the catheter when criteria or indication for use is no longer present. 1. Resident #361 had diagnoses including type 2 diabetes, schizophrenia, and anxiety disorder. The Minimum Data Set (a resident assessment tool) dated 10/25/22 documented the resident understood and understands, had moderate impairment of cognitive function, required total assist of two persons with toileting use, had no indwelling catheters, and was frequently incontinent of bladder. The CCP, dated as revised on 11/3/22 documented Resident #361 had an alteration in bladder function related to bladder spasms and incontinence. Interventions included: incontinent care as needed, wears a brief, and to refer to transfer guidelines for toileting assistance. There was no CCP for a Foley catheter until after surveyor intervention and included catheter care every shift, to change the drainage bag as needed and that a leg bag to be worn during daytime hours. The CCP documented a goal that for no signs or symptoms of infection. The physician orders dated 10/1/22-1/31/23 documented an order dated 10/28/22 to ensure a Foley catheter leg strap was in place every shift for dignity and comfort and a leg bag to be used when out of bed during day and evening shift. Review of Interdisciplinary Progress Notes dated 10/21/22 through 1/11/23 documented no evidence that Resident #361 had a valid clinical indication to support the use of an indwelling catheter. In a progress note dated 10/28/22 the Registered Nurse (RN)/ RCC #1 documented that the Foley catheter was inserted without difficulty, that the resident tolerated it well, that the daughter had been updated. There were no urinary concerns or reason for Foley catheter insertion documented in the progress notes. Intermittent resident observations revealed the following: a. On 1/9/23 at 1:38 PM, Resident #361 was sitting in a wheelchair (w/c) with the Foley catheter bag under the resident's w/c seat with the tubing dragging on the floor. b. On 1/11/23 at 8:51 AM, Resident #361 was sitting in a w/c with the Foley catheter tubing on floor under the w/c. Additionally, at 3:47 PM urine in catheter tubing was cloudy in appearance. c. On 1/12/23 at 11:40 AM, Resident #361 was sitting in a w/c with the Foley catheter drainage bag hanging from the side of the w/c from a transfer sling (sling used to transfer the resident from a mechanical lift and that the resident usually sits on while in a w/c). No privacy bag covering the Foley was observed at this time. Urine in the catheter tubing and drainage bag was cloudy yellow in appearance and had an odor (sometimes an indication of a possible infection). d. On 1/12/23 at 11:46 AM, Resident #361 was transported via a w/c from their room to the dining room which was off unit for lunch. The Foley catheter drainage bag was under the w/c and the catheter tubing was dragging on floor during transport. During an interview on 1/9/23 at 1:38 PM, Resident #361 stated, they had a leaking problem, and the catheter was inserted after being admitted to the facility. Resident #361 stated they did not know why the catheter was inserted. The resident stated they had never seen a urologist and added that the catheter had not been changed since it was inserted. Additionally, on 1/12/23 at 11:40 AM, Resident #361 stated the catheter was a little invasive and embarrassing for the drainage bag not to be covered as they do not like people seeing their pee. During an interview on 1/12/23 at 11:56 AM, Licensed Practical Nurse (LPN) #2, stated they did not recall why Resident #361 had a Foley catheter inserted. Additionally, after reviewing the resident's electronic medical record (EMR), LPN #2 was unable to find any documented reason for Resident #361's Foley catheter. During an interview on 1/12/23 at 12:09 PM, RN/RCC #1 stated Resident #361 had a Foley catheter for urinary retention and neurogenic bladder (bladder with diminished sensation) as ordered by the Physician Assistant (PA). RN/RCC #1 stated they inserted the Foley catheter 10/28/22 and Resident #361 had 600 milliliters of urinary retention. RN/RCC #1 stated Resident #361 had not been seen by a urologist and had no order to see a urologist at that time. RN/RCC #1 stated the catheter tubing should not be on the floor due to the risk for a urinary tract infection (UTI). During an interview on 1/12/23 at 1:32 PM, the PA stated Resident #361 had a neurogenic bladder as they had not voided for eight hours. The PA stated they could not recall any follow-up with Resident #361 after ordering the catheter. The PA stated that if they saw a resident there should be documentation in the resident's EMR regarding the visit. PA stated they see over 200 residents, including other facilities and gives orders verbally when on call. The PA was offered the resident EMR to review the documentation and declined. The PA stated a Foley catheter would be left in for 30-60 days, then a voiding trial should be done. The PA did not know if a voiding trial had been implemented and deferred to nursing. During an additional interview on 1/12/23 at 1:45 PM, RN/RCC #1 stated Resident #361 was generally incontinent of urine and had complaints of pressure. RN/RCC #1, stated the medical providers determine when a voiding trail would be completed if a resident had a Foley catheter. Additionally, RN/RCC #1 stated Resident #361's CCP should have been updated upon insertion of the catheter, so staff were aware, and care could be done appropriately. RN/RCC #1 stated they are one person trying to do a lot of stuff, and that they honestly missed it. During a telephone interview on 1/12/23 at 2:57 PM, the Medical Doctor (MD) stated there should be documentation of the reason for a Foley catheter and the diagnosis for its continued use. After review of Resident #361 EMR, the MD stated they did not see any documentation related to the Foley catheter placement and use in the medical notes until 12/19/22. The MD stated they would expect follow up by either a mid-level provider or with themselves in deciding for removal, voiding trial, reinsertion and follow up with urology. The MD stated they would not be able to determine if a resident had a neurogenic bladder but that it would be considered urinary retention instead. The MD stated Resident #361 did not have a history of multiple sclerosis or Parkinson's Disease (diseases that may cause a neurogenic bladder) therefore they would not have determined the diagnosis of neurogenic bladder. During an observation and interview with RN/RCC #1 and Resident #361 on 1/12/23 at 3:36 PM, Resident #361 stated that the catheter was hurting. RN/RCC #1 stated urine sediment sticks to the catheter tubing and that the PA had ordered a catheter change and urinalysis (UA- a laboratory test that provides important clinical information on kidney function and potential infection). The RN/RCC #1 drained Resident #361's catheter drainage bag and stated the urine was cloudy and had an odor. During an additional interview via phone on 1/12/23 at 3:48 PM, the PA stated they had ordered a UA and catheter change for Resident #361 today based upon complaints of catheter discomfort. The PA stated the resident's catheter should have been changed every 60 days for infection control. During a combined interview with Director of Nursing (DON) and Regional Quality Assurance Nurse on 1/12/23 at 3:57 PM, the DON stated their expectation was that providers document what they are doing and why. Nursing should have been documenting on catheter care, management, and effectiveness of the catheter placement and that a care plan should have been completed. 10NYCRR: 415.12(d)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey completed on 5/3/21, it was determined that for four of four residents (Residents #34, #7, #83, and #48) reviewed, the facility did not provide food and drink that was palatable and at a safe and appetizing temperature. Specifically, the issues involved food that was unpalatable, not served at preferable temperatures and not served as ordered. Additionally, it was determined that facility equipment to keep the food warm had not been repaired or replaced as needed. This is evidenced by, but not limited to, the following: Review of the facility policy, Food Preparation, Service and Distribution, dated May 2021, revealed facility staff will serve hot foods hot and cold foods cold in accordance with resident preference. 1. Resident #34 was admitted with diagnoses including malnutrition, diabetes, and end stage [CONDITION(S)] with [CONDITION(S)]. A Minimum Data Set (MDS) Assessment, dated 4/12/21, revealed the resident was cognitively intact. When interviewed on 4/28/21 at 2:23 p.m., Resident #34 said the food is not good and is always cold as they do not have a means to keep it warm. The resident added that breakfast is served around 9:00 a.m., which is late because they can hear the announcement when the trays were delivered to the unit but then not delivered to the rooms for a while after that. Resident #34 said they have lost weight since admission and felt it was partly due to the poor food quality. 2. Resident #83 was admitted with diagnoses including diabetes, chronic kidney disease, and chronic obstructive pulmonary disease. The MDS Assessment, dated 4/12/21, revealed the resident had moderate cognitive impairments. In an interview on 4/28/21 at 12:01 p.m., Resident #83 said the food is not hot and most of the time cold and hard. 3. Resident #7 was admitted with diagnoses including diabetes, diabetic [CONDITION(S)] (nerve pain), and depression. The MDS Assessment, dated 4/15/21, revealed the resident was cognitively intact. In an interview on 4/28/21 at 2:10 p.m. and again on 4/29/21 at 1:04 p.m., Resident #7 said the meat today was so tough they could not chew it. They also said that the sausages have such a tough skin that they could not cut it with a knife. Resident #7 said they were served white rice today instead of the sweet potato that was pre-selected. When interviewed on 4/30/21 at 11:32 a.m., Cook #1 stated that staff bring the plate lowerator (a heated dish dispenser used to heat china dishware) to the tray line from the dish room for meal service. Cook #1 said that one side of the lowerator does not heat and that the plates were only lukewarm. During an interview on 4/30/21 at 11:42 a.m., the Director of Food Service (DFS) said that only one side of the plate lowerator was working so they heat the plates on low in the oven. He said that today though, due to a generator check, the ovens were unavailable. The DFS said he had put in a purchase order for a new lowerator but has not obtained one yet. The DFS added that the pellet and dome lowerator (heated metal units that are set above and below the china plate) also does not work and is out of service. In an observation and interview on 4/30/21 at 12:06 p.m., the food truck arrived on the 40-bed unit and three staff members were available to pass trays. At 12:11 p.m., the DFS asked the Nurse Manager (NM) to help pass trays as there were many to pass. At 12:19 p.m., the final tray was passed. A test tray that was held for a total of 15 minutes was tested for food temperatures by both the surveyor and the DFS thermometers and included the following temperatures: water was 60.9 degrees Fahrenheit (°F), the coleslaw was 58.9°F, the potato casserole was 118.9°F and the baked fish was 107.1°F. The DFS stated that the water was too warm and no longer ice water and that the rest of the food temperatures were too low and too cold to taste good. The DFS stated that the food trucks are old and not insulated which added to the issue of cold food. Interviews on 4/30/21 after the meal was served included the following: a. At 12:39 p.m., Resident #7 said the fish and potatoes were lukewarm. b. At 12:46 p.m., Resident #34 said their fish sandwich was not hot. c. At 12:52 p.m., Resident #83 said they had been served fish, but fish is listed as a dislike for them and they should not have gotten it. Resident #83 said the potatoes were cold and hard and they could not chew them. [10 NYCRR 415.14(d)(1)(2)]

Based on interviews and record reviews conducted during the Recertification Survey completed on 5/3/21, it was determined that one (Resident #7) of four residents reviewed for dignity, the facility did not make prompt efforts to resolve a grievance. Specifically, the resident's concerns regarding treatment received by a specific staff member were not documented, investigated, or resolved in a timely manner. This is evidenced by the following: Resident #7 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 4/15/21, revealed the resident was cognitively intact, had no behaviors or refusals of care, and required extensive assistance of two staff for activities of daily living. When interviewed on 4/28/21 at 2:07 p.m., Resident #7 said a nurse put them to bed a few months ago still in their clothes and toileting assistance was not provided all night. Resident #7 said they told another nurse and a Certified Nursing Assistant (CNA) about the incident. In an interview on 4/30/21 at 1:34 p.m., Licensed Practical Nurse (LPN) #1 said Resident #7 told her several times that LPN #2 was not nice to them and very abrupt when speaking to them. LPN #1 said that Resident #7 told her that LPN #2 was working one night when short staffed and got Resident #7 into bed earlier than preferred without asking if it was ok with them and that LPN#1 told them that the unit was short staffed and if Resident #7 did not get into bed at that time then they would not be able to go to bed later. LPN #1 said this happened approximately a week ago, but they did not report this to the Nurse Manager (NM) or Director of Nursing (DON). During an interview on 4/30/21 at 2:07 p.m., the Director of Social Work said that no one had reported Resident #7s' concerns to him, and that LPN #1 should have reported the conversation to the NM and the DON. In an interview on 4/30/21 at 2:16 p.m., the DON said LPN #1 and the CNA both should have reported the resident's concerns so that an investigation could have been initiated. When interviewed on 5/3/21 at 11:27 a.m., the involved CNA said Resident #7 had reported their concerns about LPN #2 to them but that she had not reported the event because she thought Resident #7 did get care later that night, although she did not recall the specific evening in question. [10 NYCRR415.3(c)(1)(i)]

Based on interviews and record reviews conducted during a Recertification Survey it was determined that for two of two residents, the facility did not ensure that the residents or the residents' representative were notified of the transfer or discharge and the reasons for the move in writing in a language and manner they understand. The issue involved Residents #40 and #87 who were transferred to the hospital and written notice of the transfer was not provided. This was evidenced by the following: 1. Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 2/15/21, revealed the resident had severely impaired cognition. Review of the medical record revealed that on 3/26/21, Resident #40 was transferred and admitted to the hospital. The hospital transfer form, dated 3/26/21, revealed that the representative was notified by phone of the transfer. There was no documented evidence that the resident or representative was notified in writing of the resident's transfer. 2. Resident #87 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 4/13/21, revealed the resident had moderately impaired cognition. Review of the medical record revealed Resident #87 was transferred and discharged to the hospital 3/3/21, and again on 3/23/21. Review of the hospital transfer forms dated 3/3/21 and 3/23/21 revealed that the representative was notified by phone of the transfer. There was no documented evidence the resident or representative was notified in writing of Resident #87s' transfer. In an interview on 4/29/21 at 1:31 p.m., the Licensed Practical Nurse stated that the business office provided the written notice of transfer the day after the transfer or discharge to the hospital. In an interview on 4/29/21 at 2:38 p.m., the Business Office Manager stated that the transfer/discharge summary was completed by the Director of Nursing (DON), a copy was provided to the representative and then a copy of the form is scanned into the medical record. In an interview on 4/29/21 at 2:41 p.m. and again at 3:45 p.m., the DON stated a transfer form was completed at the time of transfer to the hospital to let the business office know that the resident went out. The DON said the business office would then provide the written notice of discharge to the resident's representative. She said that a transfer and discharge form is competed and a copy provided to the resident and/or their representative prior to a discharge home but was not provided when a resident was transferred to the hospital. In an interview on 4/29/21 at 2:44 p.m., the Administrator stated the written transfer and discharge form stated the responsibility might fall on the Social Worker but was unsure if it was occurring. In an interview on 4/29/21 at 3:03 p.m., the Social Worker stated the nurses complete the transfer and discharge form when a resident is transferred to the hospital. [10 NYCRR 415.3(h)(1)(iii)(a-c)]

Based on interviews and record review conducted during a Recertification Survey completed on 5/3/21, it was determined that for two of two residents reviewed the facility did not provide written notice of the facility's bed hold policy to the resident or representative at the time of transfer to the hospital. The issue involved Residents #40 and #87 and their representatives who were not provided information regarding the facility's bed hold policy when transferred to the hospital. This was evidenced by the following: 1. Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 2/15/21, revealed the resident had severely impaired cognition. Review of the medical record revealed that on 3/26/21 Resident #40 was transferred and admitted to the hospital. There was no documented evidence the resident or the resident's representative was notified in writing of the facility bed hold policy. 2. Resident #87 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 4/13/21, revealed the resident had moderately impaired cognition. Review of the medical record revealed the resident was transferred and admitted to the hospital on 3/3/21 and again on 3/23/21. There was no documented evidence that Resident #87 or their representative was notified in writing of the facility bed hold policy for either hospital transfer. In an interview on 4/29/21 at 2:38 p.m., the Business Office Manager stated the facility did not provide information related to bed holds at the time of the transfer because it was part of the Admission Agreement. In an interview on 4/29/21 at 2:44 p.m., the Administrator stated the facility did not have a bed hold policy and that residents are returned to the facility as a courtesy. In an interview on 4/29/21 at 2:48 p.m., the Admissions Director stated there were no longer bed holds per Medicaid regulations but that the facility holds the resident's beds as a courtesy. [10 NYCRR 415.3(h)(4)(i)(a)]

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined for one (Resident #31) of three residents reviewed, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, Resident #31 was not assisted with proper nail care. This is evidenced by the following: The facility policy Nail Care, dated March 2020, includes the purpose is to ensure cleanliness and to prevent infection. Routine nail care is to be done following a bath or shower whenever possible. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 2/7/21, revealed Resident #31 had severely impaired cognition, had no behavioral symptoms, and required the extensive assistance of two persons for personal hygiene. Review of the current Comprehensive Care Plan and Kardex (bedside care plan) revealed the resident required the extensive assistance of one person for personal hygiene. When observed on 4/28/21 at 11:27 a.m., Resident #31 was observed with untrimmed, jagged fingernails on both hands and a large amount of dark brown debris underneath the left thumbnail. When observed on 4/29/21 at 1:10 p.m., the resident's fingernails remained untrimmed and jagged. Dark brown debris was noted underneath the left thumb, index finger, and middle finger nailbeds. When observed at 1:12 p.m., Resident #31 was holding and eating a cookie with the left hand. When interviewed on 4/29/21 at 2:20 p.m., the Certified Nursing Assistant (CNA) stated that Resident #31 was a total assist for all of their ADLs, and they did not usually refuse care. She stated that while she did assist the resident with hand hygiene before eating their lunch, she had not performed nail care. The CNA said the resident's nails were dirty and needed to be cleaned. When interviewed on 4/29/21 at 2:22 p.m., Resident #31 stated their nails were dirty and needed to be cleaned. When interviewed on 4/30/21 at 1:47 p.m., the Nurse Manager stated it was her expectation that staff are performing nail care at least on shower days, and that staff should also be assisting residents with washing their hands and ensuring their nails are clean before they eat. [10 NYCRR 415.12(a)(3)]

Based on observations, interviews, and record reviews conducted during the Abbreviated Survey (complaint #NY 780), it was determined that for one of three residents reviewed for advanced directives, the facility did not ensure that there was an organized, effective system in place to ensure that residents' wishes regarding Cardio-pulmonary Resuscitation and Do Not Resuscitate were initiated and implemented according to their wishes. Specifically, Resident #1 had a Medical Order for Life Sustaining Treatment (MOLST) for Do Not Resuscitate and was wearing a blue identification bracelet (full code) with the word RED written on the bracelet. Resident #1 was found unresponsive and Cardio-pulmonary Resuscitation was initiated. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] and [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated [DATE], documented that the resident was cognitively intact. Review of the facility's policy, Cardio-pulmonary Resuscitation (CPR), dated as last revised [DATE], revealed that the policy was to assist the facility in ensuring that all residents suffering a cardiac or respiratory arrest will receive the treatment of [REDACTED]. The procedure included that those residents who wish to be resuscitated shall wear a blue name band on their wrist or if they refuse to wear it on the wrist, the ankle. The resident's DNR status will be identifiable on the resident at all times as feasible to do so. The [DATE] MOLST was signed by the Health Care Proxy, the Social Worker, the Attending Physician, and documented that the resident was a DNR. The Comprehensive Care Plan for Advanced Directives/MOLST, dated [DATE], included that the goal was that the resident's wishes would be honored. The interventions included that a DNR band would be worn on the wrist and the MOLST was in place. The interventions did not include the color of the DNR band. Review of the nursing progress notes and CPR Documentation Log, dated [DATE], revealed that the resident was being returned from Physical Therapy at 11:15 a.m. when the resident became non-responsive, not breathing, and pulseless. The resident was lowered to the floor, CPR was started, and 911 and Code Blue were called. After two to three sets of compressions and breaths the resident became responsive and was transported to the hospital. As of [DATE] the resident remained in the hospital in the intensive care unit. The facility investigation, dated [DATE], revealed that the resident was wearing an identification bracelet that was blue indicating a full code and had the word red (indicating DNR) written on it. The facility completed the investigation and was not able to identify the individual who made or placed the wrong color of ID bracelet. Interviews conducted on [DATE] included the following: a. At 12:45 p.m., the Licensed Practical Nurse (LPN) stated that she was called into Physical Therapy and saw all four of the resident's extremities twitching. She said the resident was conscious but not reacting at their baseline. The LPN said that as she and the Director of Nursing (DON) were wheeling the resident to their room, the resident went limp. She said she looked at the color of the identification band and it was blue, so they lowered the resident to the floor and began CPR while simultaneously calling for help to call 911 and a Code Blue. The LPN said after two cycles of compressions, the resident became responsive and was breathing and had a pulse. She said the Social Worker told the staff at that point that the resident was a DNR. b. At 2:10 p.m., the Social Worker said when he heard the alarm for the Automated External Defibrillator (AED) he went to the computer to look up the resident's advanced directive status and saw the resident was a DNR. He sent staff to the resident's room to report that the resident was a DNR. c. At 2:20 p.m., the DON stated that she was called into Physical Therapy because all four of the resident's extremities were twitching. She said the resident was staring and the resident's hands and legs were twitching. The DON said she called in the LPN and as they moved the resident to their room via the wheelchair, the resident went limp. She said they assessed the resident quickly and the resident was non-responsive, not breathing, and pulseless. The DON said she saw that the resident had a blue identification bracelet, so she and the LPN lowered the resident to the floor while calling out Code Blue and directing staff to call 911. She said that after about three cycles of compressions and rescue breathing the resident was responsive, breathing, and had a pulse. (10 NYCRR 415.3(e)(1)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute and serve food under sanitary conditions. Specifically, food was prepared and served from a kitchen with a sewage back up and food was contaminated by condensate in the walk-in freezer. This is evidenced by the following: 1. Review of the facility Disaster Drill Report revealed that on 10/31/18 (no time on the report), the Maintenance Director received a call from an employee that there was a drain backing up in the kitchen. On 11/1/18 at 7:49 a.m. as breakfast was being made, drainage started to back flow. At 2:15 p.m., the sewer service contractor arrived and at 3:21 p.m., the sewer issue was resolved. Interviews conducted on 12/12/18 included the following: a. At 1:35 p.m., the Food Service Director (FSD) said she received a call at home on the morning of 11/1/18, notifying her that the sewer had backed up and everyone was getting out of the kitchen. She said the sewage was only in one certain spot in the kitchen and right after breakfast, the staff moved the kitchen service to the dining room. Registered Dietician (RD) #2 said she arrived around 8:00 a.m. or so, and there was water on the floor. She said the tray line had started around 7:30 a.m., and food was still being served. RD #1 said RD #2 called her to notify her of the situation and was directed to tell the staff to stop food service operations and to take everything out of the kitchen, to the dining room, and continue operations in the dining room. RD #2 said staff were not told the liquid was sewage, just that it was greasy water. Both the FSD and RD #2 said they did not document any corrective actions. b. At about 2:26 p.m., the Administrator said that on the evening of 10/31/18, the Director of Maintenance made the decision to keep the kitchen open, after cleaning up. She said the following morning on 11/1/18 when sewage was again noted, she directed staff to leave the kitchen. c. At 2:35 p.m., the Kitchen/Evening Supervisor said she had been working days at that time and had come in around 6:00 a.m. on 11/1/18, and she saw a big flood on the floor and she had never seen it like that before. She said water was in front of the prep table and by the freezer and the cooler. She said she called the FSD who did not answer the phone and when RD #2 came in, around 8:00 a.m., she asked her what to do. RD #2 told her to shut the kitchen down. The Kitchen Supervisor said that the Director of Maintenance arrived around 8:00 a.m. and told her to shut the kitchen down. She said staff had started tray delivery at 7:30 a.m. and continued to do so, pushing the food caddies through the dish room so they did not touch the water on the floor. She said after breakfast was served, staff moved everything out to the dining room. She said she thought the water was sewage because it was black. d. At 3:51 p.m., RD #2 said she arrived around 8:00 a.m. on 11/1/18, maybe a bit later. She said the Kitchen Supervisor told her about the back up and water on the floor and she could see it. RD #2 said staff should not have served any food with waste water on the floor. e. At 4:18 p.m., the Administrator said she had just found out that neither the FSD or Director of Housekeeping had provided in-service training with their staff regarding what to do in the event of a sewage back-up. She said she had directed them to provide education now. Interviews conducted on 12/13/18 included the following: a. At 8:50 a.m., RD #2 said if any water of any kind comes out of the kitchen floor and or drains, staff are to stop what they are doing, cover the food, and report the situation to the Administrator or Director of Nursing. b. At 4:36 p.m., RD #1 said RD #2 had called her at 8:20 a.m. on 11/1/18 (she verified this on her cell phone), after the Director of Maintenance had already directed staff to shut down operations at 7:49 a.m. RD #1 said staff should have shut down operations the minute he told them to. 2. Observations and interviews in the Main Kitchen on 12/10/18 with the FSD and Cook included the following: a. At 10:22 a.m., condensation had dripped from the insulated line below the evaporator in the walk-in freezer on and into a full-size pan of packaged food that was set on a cart below the evaporator. The Cook said the bags contained deli meat and should not have been left there. The Cook removed the pan and placed it in another area of the freezer. The FSD said that was a new concern and she would contact maintenance for repair. b. At 3:14 p.m., the FSD and RD #1 said there were about ten bags of deli meats with visible ice on the plastic bags and in the pan. They both said the seals on the bags were not secured so they discarded the meat. (10 NYCRR 415.14(h), 14-1.10(c)(3) Imminent health hazard, 14-1.141, 14-1.140 Plumbing)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for three of three residential units, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, the facility was unable to provide evidence of a complete Infection Control Program that investigates, controls, and prevents infections in the facility. This is evidenced by the following: Review of the Infection Control Program on 12/13/18 at 4:32 p.m. with the Director of Nursing (DON) responsible for Infection Control revealed that the Site Wide Infection Logs from (MONTH) (YEAR) through (MONTH) (YEAR) did not include any data analysis or control measures that were implemented to trend any areas of concern. The Infection Control Site Wide Infections Line List from (MONTH) (YEAR) through (MONTH) (YEAR) revealed that in (MONTH) the facility had 13 residents with respiratory infections and 11 residents had [MEDICAL CONDITION] (eye infection). The (MONTH) list revealed that 11 residents had lower respiratory infections. When interviewed at that time, the DON said she was unable to provide any documentation of data review or follow up. The RN said that she did not look to see what unit the infections were on. She said her program is for the facility not unit specific. The DON was unable to provide any documentation on what control measures were implemented for the respiratory outbreak. She said that she did not investigate the possible cause for the [MEDICAL CONDITION]. She said if she provided education, it was done verbally, and there was no documentation. The DON said that she did not notify the Medical Director directly of any potential outbreaks and was not sure if he knew. She said that she would expect the Nurse Practitioner to notify the Medical Director. When interviewed on 12/14/18 at 12:21 p.m., the Regional Quality Assurance nurse said she spoke to the DON and understands what the program needs to improve. When interviewed on 12/14/18 at 12:30 p.m., the Administrator said that she discussed the (MONTH) respiratory outbreak with the Medical Director. She said he was not aware of the outbreak and asked what was being done. The Administrator said she knows the program needs to be improved. (10 NYCRR 415.19(a)(1-3))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of four residents reviewed for dental services and two of six residents reviewed for unnecessary medications, the facility did not ensure the Minimum Data Set (MDS) Assessment accurately reflected the resident's status. The issues involved inaccurate coding for dental (Residents #94 and #13), inaccurate coding for the use of an antidepressant (Resident #58), and inaccurate coding for the use of an antianxiety medication (Resident #30). This is evidenced by, but not limited to, the following: 1. Resident #94 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 6/5/18, revealed the resident had no dental issues and edentulous was not checked. A dental evaluation, dated 11/23/18, revealed the resident had full upper and lower dentures and was edentulous. During an interview on 12/13/18 at 9:01 a.m., the Registered Nurse (RN) MDS Coordinator stated the MDS assessment dated [DATE] was inaccurate. She said that edentulous should have been checked. She stated she had in her notes the resident had full upper and lower dentures. 2. Resident #58 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/19/18, revealed the resident did not receive antidepressants during the seven day look back period. Review of the current physician orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview on 12/13/18 at 12:50 p.m., the MDS Coordinator stated Duloxetine was an antidepressant. She said the MDS Assessment, dated 10/19/18, was inaccurate and should have documented the use of an antidepressant. 3. Resident #30 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/2/18, revealed the resident received antidepressants in the seven day look back period. Physician orders, dated 9/21/18, included [MEDICATION NAME] (antianxiety medication) 5 mgs three times a day for anxiety. The (MONTH) (YEAR) and (MONTH) (YEAR) MARs revealed the resident had received [MEDICATION NAME] daily from 9/21/18 through 10/2/18. When interviewed on 12/13/18 at 12 :45 p.m., the MDS Coordinator stated the resident received an anti-anxiety medication. She said the MDS Assessment, dated 10/2/18, was inaccurate and should have documented the use of an anti-anxiety medication. (10 NYCRR 415.11(b))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for six (Residents #46, #47, #52, #100, #103, and #170) of eight residents reviewed for Baseline Care Plans, the facility did not develop and implement a thorough Baseline Care Plan within 48 hours and or provide a written summary to the family and or representative. This is evidenced by, but not limited to, the following: The facility policy, Comprehensive and Baseline Care Plan Development and Care Areas Assessments revealed that a baseline care plan was required within 48 hours and was an initial care plan, not all inclusive, or the final product and listed each discipline (nursing, social services, dietary and activities), and included specific items to address including goals and interventions. The resident and designated representative should be notified of the content of the baseline care plan within five days of admission. Notification should be completed by the Social Worker and documented in a progress note. 1. Resident #46 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/22/18, revealed that the resident had moderately impaired cognition and required extensive assistance of staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. There was no documentation in the medical record that a Baseline Care Plan had been completed or that the resident and or representative were provided with a summary. 2. Resident #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 6/28/18, revealed that the resident was cognitively intact and required extensive assistance of staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. There was no documentation in the medical record that a Baseline Care Plan had been completed or that the resident and or representative were provided with a summary. 3. Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 9/18/18, revealed that the resident was cognitively intact and required the extensive assistance of staff for all activities of daily living. There was no documentation in the medical record that a Baseline Care Plan had been completed or that the resident and or representative were provided with a summary. When interviewed on 12/13/18 at 9:43 a.m., Registered Nurse (RN) #1 stated that the facility does not develop baseline care plans. She said that regular care plans are developed and continuously edited. She said that she does not write a specific note about reviewing the care plan with the resident and or representative. The RN said that some disciplines document that their area was reviewed with the resident and or representative. During an interview on 12/13/18 at 11:46 a.m., RN #2 said that Resident #103's care plan was started on 9/16/18. When interviewed on 12/13/18 at 4:20 p.m., the Social Worker said that nursing provides the resident and or representative with a written summary of the Baseline Care Plan. In an interview on 12/14/18 at 12:30 p.m., the Administrator said that the facility would start to develop baseline care plans right away. (10 NYCRR 415.11)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of two residents reviewed for bowel and bladder and one of one resident reviewed for [MEDICAL CONDITION] medication use side effects, it was determined that the facility did not develop and or implement a comprehensive person-centered care plan for each resident that addressed the resident's medical, physical, mental and psychosocial needs. Specifically, the resident did not receive incontinence care per the plan of care (Resident #94), and the care plan did not address the use of an anti-anxiety medication (Resident #30). This is evidenced by the following: 1. Resident #94 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/5/18, revealed that the resident had severely impaired cognition, required the extensive assistance of two staff for toileting and personal hygiene, and was always incontinent of bowel and bladder. The facility policy Perineal Care, dated 8/1/17, revealed the resident's care plan was to be reviewed for any special needs, assemble the equipment, document the date and time perineal care was provided in the resident's medical record, and notify the supervisor if the resident refused perineal care. The Comprehensive Care Plan (CCP), initiated 10/20/16, and the current Kardex revealed that the resident was incontinent of bladder. Interventions included to check the resident every two to three hours and as required for incontinence, offer toileting and incontinence care every two to three hours, and clean peri area with each incontinence episode. A review of the documentation for urinary incontinence and toilet use revealed the resident was incontinent and care was documented as provided on 12/10/18 at 1:59 p.m. and 6:58 p.m., on 12/11/18 at 12:22 p.m. and 9:50 p.m., and on 12 /12/18 at 1:20 a.m., 12:31 p.m. and 9:59 p.m. During an observation on 12/10/18 at 1:53 p.m., the resident was receiving incontinence care and had been incontinent of a large amount of urine. The resident stated at that time that she asked for a bedpan but was told staff could not find one. Intermittent observations on 12/12/18 at 8:52 a.m. and 9:30 a.m., revealed the resident was in the dining room eating breakfast with the assistance of staff. At 9:30 a.m., 10:48 a.m. and 12:06 p.m., the resident was sitting in a recliner chair in her room with the overbed table in front of her across her lap and was covered with a blanket from her toes to her shoulders. At 1:50 p.m., two Certified Nursing Assistants (CNA) were observed to provide incontinence care. The resident had been incontinent of a large amount of strong dark urine which soaked through the disposable brief and the resident's pants. At that time, a CNA stated the urine was strong smelling and dark in color. The CNA stated the resident had last been changed earlier that morning. She stated the resident was supposed to be changed every two hours, but it was a crazy morning and she was not provided care until that time. The CNA stated the resident's Kardex directs how often they are to be checked and changed. During an interview on 12/14/18 at 11:18 a.m., the Registered Nurse Manager (RNM) stated she was responsible to ensure that the CNAs provided care as directed in the care plan. The RNM stated she expected that if a resident was incontinent of urine they would be checked and changed every two to three hours. She stated residents should be up and out of bed between 6:00 a.m. and 7:00 a.m., changed at that time, and then again after breakfast. 2. Resident #30 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/2/18, revealed that the resident's cognitive skills for daily decision making were severely impaired and the resident received antidepressants in the seven day look back period. Review of the facility policy, Comprehensive care Plans and Baseline Care Plan Development revealed the resident shall have a CCP developed and implemented that will contain objective, measurable resident specific goals to improve, maintain, or prevent decline for each resident's medical, physical, mental and psychosocial needs. Physician orders, dated 9/21/18, included [MEDICATION NAME] (anti-anxiety medication) 5 milligrams (mg) three times a day for anxiety. A Nurse Practitioner (NP) note, dated 9/21/18, documented the resident was observed slapping herself repeatedly with her right hand, denied pain and stated she did not feel right. The resident stated slapping herself made her feel better and she felt anxious and nervous. The resident had a history of [REDACTED]. The resident's anxiety had worsened following a gradual dose reduction of [MEDICATION NAME] (antidepressant) a month ago. The plan included to start [MEDICATION NAME] 5 mg three times a day and monitor the resident for altered mental status and sedation. A Registered Nurse note, dated 9/21/18, documented the resident was noted to have mild jerky movements. The resident stated that it made her feel better as she was nervous inside, and new laboratory tests were ordered. The current CCP revealed the resident had communication difficulties, to monitor and document physical and nonverbal indicators of discomfort or distress, and follow up as needed. The CCP identified the use of an antidepressant ([MEDICATION NAME]) for depression. Interventions included to monitor and document side effects and effectiveness. During an observation on 12/11/18 at 12:43 p.m., the resident had tremors of the right hand while at rest. On 12/12/18 at 11:17 a.m., the resident was in the hallway and had her eyes closed. The resident's left pointer finger was tapping and the right pointer finger and thumb were tapping together. When interviewed on 12/13/18 at 11:42 a.m., the NP stated she had observed the resident slapping herself on the leg and face. She stated there should be documentation from nursing supporting that behavior as nursing had reported the behavior as well as her own observations. The NP stated she felt the [MEDICATION NAME] had helped tremendously. During an interview on 12/13/18 at 4:02 p.m., the Director of Nursing (DON) stated the interdisciplinary team developed the CCP. She stated Social Work would address the use of [MEDICAL CONDITION] medications on the CCP and revise as needed. After review of the resident's CCP, the DON stated it should have been updated no later than 9/22/18 ([MEDICATION NAME] ordered 9/21/18). The DON stated there should be nursing progress notes documenting any episodes of the resident slapping herself if it occurred. (10 NYCRR 415.11(c)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 4 of 27 residents reviewed for care planning revisions, the facility did not ensure that the resident's care plan was reviewed or revised to reflect the resident's current condition. The issues involved the lack of care plan revisions following a fall with fracture, newly diagnosed cancer, and pain (Resident #103), the lack of individualized non-pharmacological interventions and targeted symptoms (Resident #52), the lack of revision for poor appetite and weight loss (Resident #46), and the lack of revision of speech therapy recommendations regarding the use of straws (Resident #63). This is evidenced by the following: 1. Resident #103 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/6/18, revealed that the resident had severely impaired cognition, required the extensive physical assistance of two persons for all activities of daily living, and was assessed as having pain almost constantly. The Comprehensive Care Plan (CCP) for pain initiated on 9/12/18 was not updated to include the pelvic fracture or the peritoneal [MEDICAL CONDITION] and did not include any individualized interventions to manage the resident's pain level. The CCP for falls did not include the resident's fall on 11/26/18. When interviewed on 12/12/18 at 11:20 a.m., the Licensed Practical Nurse (LPN) said that the resident complained of severe pain when she touched her leg even though the resident was barely touched. The LPN stated that the resident was now receiving hospice services, has a [MEDICATION NAME] (pain medication) patch, and can receive Roxonol (pain medication) as needed. When interviewed together on 12/13/18 at 11:46 a.m., the Registered Nurse Manager (RNM) and the MDS Coordinator reviewed the CCP and stated that the pelvic fracture was not included on the CCP. They both said that the potential for pain was included in the CCP, but the resident's current pain level and medication needs were not included. 2. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/13/18, revealed the resident had moderately impaired cognition and had no concerns with mood or behavior. Review of the progress notes from 9/4/18 through 9/7/18 revealed that the resident was making statements and seeing things such as her roommate was possessed by the devil and trying to kill her, and the resident was reaching for things in front of her that were not there. The resident was becoming more and more agitated and upset. The interdisciplinary team met on 9/7/18 to review the resident's recent behaviors and possible delusions. It was determined that the resident's behaviors started after the family told the resident that her house had to be sold and that she would be staying at the facility. A family member was notified and agreed with the tele-psych consult and had stated that the resident hallucinated in the past while at home. A progress note, dated 9/26/18, revealed that the resident had been reviewed in the Behavior Management Committee with the recommendations for the resident to begin [MEDICATION NAME] (an antipsychotic) 25 milligrams at night for [MEDICAL CONDITION]. The CCP initiated on 9/27/18 and the current Care Card did not include the target behaviors or symptoms treated using the antipsychotic medication and does not include any individualized non-pharmacological interventions. When interviewed on 12/13/18 at 1:20 p.m., the RNM stated that the nurse managers are responsible for writing care plans. She said that the resident's current care plan was not individualized to include non-pharmacological interventions related to [MEDICAL CONDITION] and does not reflect the resident's targeted symptoms. During an interview on 12/14/18 at 10:32 a.m., the Nurse Practitioner stated that the CCP does not reflect the resident's symptoms, treatment or interventions. 3. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].>diverticulitis of the intestines, [MEDICAL CONDITIONS], and dysphagia. The MDS Assessment, dated 11/25/18, revealed the resident had moderately impaired cognition and required extensive staff assistance for all activities of daily living. The current CCP revealed that the resident required limited assistance for eating and hygiene. The resident had a nutritional problem with a significant weight loss that was resolved on 12/6/18. The goal included to maintain the resident's weight within one to four pounds of 144 pounds, and consuming 75 percent of all meals and nourishment daily. Review of the weight record revealed that the resident's admission weight was 163 pounds on 3/15/18, and 126 pounds on 12/10/18. In an observation on 12/10/18 at 12:22 p.m., the resident was being fed by a family member and was refusing to eat despite much encouragement. When interviewed on 12/14/18 at 10:46 a.m., the CNA said the resident does not eat well. She said the resident drinks and receives supplements at each meal. When interviewed on 12/14/18 at 2:31 p.m., the RNM reviewed the current care plan, and then stated that the resident's care plan does not reflect her continued weight loss and loss of appetite. 4. Resident #63 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/23/18, revealed that the resident was cognitively intact. The CCP and Care Card revealed no straws and to provide a sippy cup with hot beverages. The Speech Therapy Evaluation, dated 2/22/18, revealed the reason for the referral was that the resident was refusing to drink hot beverages through a sippy cup, and the previous Speech Therapist recommended avoiding using straws although the resident uses a straw in her water thermos daily. It was documented due to her physical impairments and associated functional deficits, the resident was at risk for aspiration and pneumonia if drinking by straw, and was educated to avoid the use of straws. The resident explained that she only uses straws with her water. The Speech Therapist educated the resident to take small sips and avoid tilting her head back when eating and or drinking. The Summary of Skill section of the form documented that the resident no longer needs a sip lid or sippy cup and that dietary services were notified in writing of the recommendations. When observed on 12/13/18, at 8:46 a.m., the resident was alone, in her room, and had a glass of water with a straw on the overbed table and said that she was drinking water and glad to have it. When interviewed on 12/13/18 at 9:12 a.m., the Registered Dietician reviewed the CNA Care Card and stated that the resident is not supposed to have straws and hot beverages are to be in a sippy cup. During an interview on 12/13/18 at 9:31 a.m., the Speech Language Therapist (SLP) stated that when she evaluated the resident in (MONTH) (YEAR), it was determined that the resident could use a straw for drinking water only and may drink hot liquids from a standard plastic coffee cup. The SLP said she notified dietary but nursing had not been notified so the CNA Kardex and Care Plan had not been revised. (10 NYCRR 415.11(c)(2)(iii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 766), it was determined that for one (Resident #13) of three residents reviewed for Activities of Daily Living, the facility did not provide each resident with adequate assistance to maintain personal grooming. The issue involved the lack of shaving and nail care. This is evidenced by the following: Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/13/18, revealed that the resident was cognitively intact and required the extensive assistance of one staff person for personal hygiene including shaving. The current Care Card and Comprehensive Care Plan revealed that the resident required the extensive assistance of one staff person for personal hygiene. During an observation and interview on 12/11/18 at 8:37 a.m., the resident had brown colored debris under all five fingernails on his right hand and facial hair. When interviewed at that time, the resident said that the staff shave him once a week unless they are too busy. The resident said that he was trying to get rid of his mustache. In an observation and interview on 12/13/18 at 3:34 p.m., the resident had brown colored debris underneath three fingernails on the right hand and two fingernails on the left hand and facial hair. The resident said that he was still waiting to get his mustache shaved. When interviewed on 12/14/18 at 10:57 a.m., the Certified Nursing Assistant (CNA) said that she just shaved the resident. The CNA said that residents are usually shaved on shower days. She said the resident's shower was Monday evening (12/10/18) so he should have been shaved. The CNA said the resident had a few weeks of facial hair growth. The CNA observed the resident's nails and stated yes, the resident's nails need to be cleaned. The resident requested that this CNA shave him all the time. During an interview on 12/14/18 at 11:10 a.m., the Registered Nurse Manager said that she and the Licensed Practical Nurse should be ensuring that the residents are receiving care including nails and shaving. (10 NYCRR 415.12(a)(3))

Based on observation, interviews and record reviews, it was determined that for two (Residents #65 and #179) of four residents reviewed for pressure sores, the facility did not ensure, based on the comprehensive assessment, that a resident who enters the facility without pressure sores does not develop pressure sores. Specifically, Resident #65 developed a pressure sore from lying on the tubing from an indwelling urinary catheter (Foley), and Resident #179 developed blisters on both heels from prolonged wear and staff non-attendance of ankle and foot orthotics (AFOs). This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: 1. Resident #65 has [DIAGNOSES REDACTED]. The resident was admitted to the facility from thehospital on [DATE] for wound care and rehabilitation. The admission to the hospital was from another skilled nrusing facility. Record review revealed the following: a) The admission physician orders, dated 11/13/13, and subsequent orders included the use of a urinary catheter for wound healing. b) The Minimum Data Set (MDS) Assessment, dated 11/26/13, included the resident's risk for pressure ulcers. Interventions included a pressure relief mattress, chair pad, and a turning/positioning program. The MDS Assessment, dated 2/13/14, documented that the resident is cognitively intact, requires the extensive assistance of two staff for bed mobility, is totally dependent on two staff for transfers, and did not have pressure sores upon admission. c) Documentation for turning and positioning, dated from 2/16/14 through 2/28/14, was initialed as completed on all three shifts. d) On the wound evaluation sheet, dated 2/19/14, a Registered Nurse (RN) documented the presence of a deep tissue injury, 9 centimeters (cm) x 1 cm on the right calf, dark purple in color. The Foley tubing was under the resident's leg, where there was a red line consistent in size with the Foley tubing. The area appeared to be bruised. The RN noted that new orders were obtained, and the plan included to monitor for pressure relief. Skin prep applied. e) There was no order for skin prep to this area until 2/26/14, when the Nurse Practitioner (NP) wrote an order. f) In a progress note dated 2/26/14, the NP included the resident was seen for a wound on the right calf that was discovered five days before. The wound bed was covered with black intact, dry necrotic tissue, with no drainage. The wound was described as unstageable. The plan included to apply skin prep daily and to reduce pressure to the area. Orders were written for skin prep application at that time. g) In a progress note, dated 3/4/14, the NP documented that the wound on the back of the resident's right lower extremity was covered with intact dry black necrotic tissue, an unstageable wound. No new treatment plans were noted. h) The wound evaluation sheet, dated 3/5/14, included that the area was assessed by the Nurse Manager (NM), the Director of Nursing (DON), and the NP and had measured 7 cm x 7 cm, was open, with black eschar in the wound bed at the proximal end of the wound and a purple intact blister at the distal end. New orders were received to apply skin prep and cover with nonstick dressing. Gel pad was to be applied under the leg to relieve pressure. i) The wound clinic, dated 3/10/14, described the right lateral lower leg wound as unstageable and recommended treating this wound with a medi honey wound dressing. j) The Exceptional Care Plan, dated 3/12/14, included an unstageable pressure sore to the posterior calf with approaches that included treatment per standards of care for pain, nutrition, hydration and physician orders. k) The wound clinic note, dated 3/24/14, revealed the right leg was debrided and included recommendations to apply medi honey and an absorbent dressing, with dressing changes daily. The care plan identified the resident at risk for pressure sores including approaches per standard of care for skin breakdown. l) The wound clinic note, dated 4/21/14, indicated to continue current treatment. m) The Care Guide, dated 5/5/14, reveals equipment for the wheelchair to include foot pedal, a leg/calf board and a wheelchair Roho cushion. The guide indicates the resident to be turned and positioned every two to three hours, has a Foley, and has an airflow mattress on the bed. During an observation of the right calf on 5/7/14 at 7:20 a.m., the Licensed Practical Nurse (LPN) measured the area to be approximately 10 cm x 7 cm, and oval in shape. There was a dark strip in the center of the wound, approximately 1 cm x 3 cm in size, dark areas on the edges at 5 o'clock and 10 o'clock, and the wound base was a beefy red color. A Foley catheter leg strap was in place on the right thigh. During an interview on 5/5/14 at 11:21 a.m., the resident stated she had a hole in her leg from laying on the catheter. Interviews on 5/8/14 included the following: a. At 9:32 a.m., the NM, a RN, stated the wound was caused by the Foley catheter tubing. She stated the area started out as a deep tissue injury and now is a Stage III. The NM said when she first saw the area, she knew how it happened; the area was a perfect indent to where the Foley tubing was. She stated she did not talk to staff to determine how it happened because the resident is to be repositioned every two to four hours and staff would tell you they did it. The NM stated the resident is repositioned every two to four hours, as she allows and per her request. She said if a resident refused, they would document. The NM stated she does weekly skin assessments on all pressure ulcers. c) On 5/8/14 at 3:59 p.m., the NP stated the first time she saw the area was on 2/26/14, and she wrote orders. She stated the staff told her the area was from lying on the Foley catheter tubing. The NP stated the pressure sore was preventable. d) On 5/8/14 at 4:48 p.m., the DON stated that when she first was told, staff were not sure if the area was a deep tissue injury or a bruise. She stated she saw the area, and it looked like the Foley tubing. The DON stated the NM investigated and found the resident did not have a Foley leg strap in place. She stated the staff are responsible for positioning of the tubing. In an interview on 5/9/14 at 9:53 a.m., the physician stated they discussed the wound, which was caused by the Foley, that Tuesday. He stated the wound could have been avoided. Review of the facility's policy, "Urinary Catheters," undated, revealed that a urinary catheter is to be secured to the resident's thigh with a leg strap. 2. Resident #179 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In the Admission Nursing Assessment, dated and signed on 4/16/14, a RN documented that there was a Stage II pressure sore on the resident's sacrum and that an air mattress was in place on the bed. There were no other pressure sores identified. The Exceptional Care Plan, dated 4/16/14, documented pressure sores as a problem and directed staff to follow the standard of care for preventing skin breakdown. A Physical Therapy (PT) evaluation, dated 4/18/14, includes the use of bilateral ankle foot orthosis (AFO) and weight bearing as tolerated for transfers only. There was no corresponding medical order for AFOs. The Certified Nursing Assistant (CNA) care guide, dated 4/18/14, included the use of bilateral AFOs and indicated bed mobility as extensive assistance of two staff. The shower schedule currently in place included that this resident has a shower on Thursday evenings. The Physician History and Physical, dated 4/19/14, does not mention the use of AFOs. The MDS Assessment, dated 4/23/14, revealed that the resident is cognitively intact, needs the extensive assistance of two staff for bed mobility and transfers, and is non ambulatory. Also, the resident is at risk for developing pressure sores, had a Stage II pressure sore on admission, and has functional limitations of both sides of the lower extremities. During the weekly skin check, dated Friday 4/25/14, the LPN documented that there was no new skin breakdown. In a progress note, dated 4/29/14 at 8:00 p.m., a RN documented that the resident had a large blister on each heel. The blisters were fluid filled, and the areas surrounding both blisters were red but blanchable. The NP was notified, the Ace wraps were to be discontinued, skin prep was to be applied to the blisters three times a day, and a gel pad was to be implemented for the heels. In a progress note, dated 4/30/14 at 10:50 a.m., the Physical Therapist documented that the resident was wearing AFOs and recommended to discontinue the AFOs and use multipodus boots (pressure relieving devices) at all times. The Physical Therapist documented that PT would monitor the current pressure relieving interventions. On the weekly skin check form, dated 4/30/14, a LPN documented that no new issues were identified. A nursing progress note, dated 5/1/14 at 11:00 a.m., documented multipodus boots were removed and skin prep applied and that the blisters were intact. The note revealed orders from the NP to discontinue the Ace wraps, remove multipodus boots periodically to check skin integrity, and to refer to the wound clinic per family request. The Care Guide, dated 5/5/14, indicated weight bearing as tolerated with bilateral multipodus boots at all times, a gel cushion on the foot of the bed, an overlay mattress, and to turn and position every two to three hours. The care guide included instructions to remove the boots every two to three hours, monitor the skin, and report findings to the nurse. During interviews on 5/5/14 at 1:43 p.m., the resident stated she had blisters on each foot and would be going to the wound doctor the following day. The resident removed her sock and revealed a fluid-filled blister on her left heel approximately 2.5 cm x by 2 cm in size. The report of consultation from the wound clinic, dated 5/6/14, documented the right heel had a Stage II intact bulla (blister), and the left heel had a non-stable intact bull. [DIAGNOSES REDACTED]. Interviews on 5/7/14 included the following: a) At 8:55 a.m., CNA #1 stated the resident was wearing braces when she was admitted that were plastic and molded like her foot that went into her shoes. CNA #1 stated the resident wore the braces when she wore her shoes, and she had her shoes on getting in and out of bed. CNA #1 stated she was shown how to put the braces on by the resident, by the resident's family member, and therapy. CNA #1 said that she looks at the resident's feet with cares, when applying lotion, and when putting the resident's shoes and socks on. b) At 12:30 p.m., the Director of Rehabilitation (a Physical Therapist) stated he had done the PT evaluation on admission. He stated the resident had bilateral AFOs for foot drop. The Physical Therapist stated that for a resident newly wearing AFOs, they would don and doff (take on and off) every couple of hours to check the skin. He stated because this resident's AFOs were established (wearing them prior to admission) and the resident was weight bearing as tolerated for transfers, he recommended wearing the AFOs for transfers only. The Physical Therapist stated that he added these instructions to the handwritten care guide (which is used until the printed copy is available), and he entered the information into the computer for the printed copy. He stated that he checks for the fit of the braces on admission and trains the staff on application. c) At 3:15 p.m., CNA #2 stated she has worked at the facility for approximately a month and cared for the resident when she was first admitted . She stated the resident wore splints on her legs during the day and liked them off at bedtime. Interviews on 5/8/14 included the following: a) At 9:27 a.m., the NM stated the resident did not have AFOs on when she did the admission nursing assessment, and she was not aware the resident wore AFOs until the resident developed blisters on her heels. She stated PT assesses AFOs and places information on the care guide. The NM stated she would obtain a physician order [REDACTED]. b) At 3:45 p.m., the NP stated she examined the resident on 4/29/14 at the family's request, when the resident presented with [MEDICAL CONDITION] in the lower extremities. She stated the resident could not have had the AFOs on at that time, as the AFOs would have impeded her assessment. The NP stated that with the [MEDICAL CONDITION] the resident had in her lower extremities, the AFOs could have caused the blisters. The NP said that these blisters were avoidable. When interviewed on 5/9/14 at 9:53 a.m., the resident's physician and facility Medical Director, stated that when he completed the Physician History and Physical, he was not sure he was aware the resident wore AFOs. He stated that he would want to know if a resident was wearing AFOs so that he would write an order including specific instructions to ensure that staff knows what to do. The physician stated the blisters were avoidable. Review of the facility's "Standard of Care for Prevention of Skin Breakdown," dated July 2012, indicated to protect high risk areas, such as heels, to eliminate pressure on heels by raising the heels off the bed, using heel booties or a gel cushion. Review of the facility's policy, "Splints/Prostheses/Orthoses," dated January 1999, revealed that therapists and nursing will assess the restorative device, and physician approval will be obtained. The policy included to apply the device per physician orders, therapists recommendations, and/or nursing instructions. (10 NYCRR 415.12)