Every finding on record at Bethany Gardens Skilled Living Center

Based on observations and interviews, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness in one of one main kitchen. Specifically, the kitchen had numerous unclean areas and improperly used sinks. The facility policy Kitchen Sanitation Policy, reviewed 05/2026, documented the facility was to ensure the safe preparation, storage, and serving of food in compliance with local, state, and federal regulations. Staff were expected to inspect refrigerators, freezers, dishwashers and cooking equipment daily. Dietary staff were to follow daily, weekly and monthly cleaning checklists. They were to follow a schedule of deep cleaning for ovens, hoods and vents per the maintenance plan. They were also supposed to ensure kitchen equipment was operational and met sanitation standards. During an observation on 07/21/2026 at 10:17 AM of the main kitchen, the dish room walls were heavily soiled behind and under machines and had black grease and grime on walls and ceiling. During an observation on 07/21/2026 at 10:19 AM in the main kitchen, [NAME] #8 drained ground beef in a hand sink, and drained pasta in the same hand sink a few minutes later. During observations in the main kitchen on 07/22/2026 from 11:48 AM to 12:06 PM: -the ice machine had a soiled edge with white residue and food debris. -the dish machine, the wall behind it and the floor below it, were heavily soiled. -the floor was soiled in areas with a dark liquid and black grime, and some floor tiles were missing. -a two-bay sink had a leak under one basin. There was a cooking pan on the floor below to catch the leaks; and -on the floor, there was food debris, dried spills, and a buildup of grime beneath the cooking equipment. During an interview on 07/23/2026 at 2:36 PM, Dietary Director #10 stated staff were expected to clean after the tray line including cleaning the carts and sweeping and mopping everything. The restocking staff were expected to do weekly cleaning, including under equipment, and try to run the floor cleaning machine through every other week. They stated the dish machine area was stained. The ice machine was cleaned routinely and there should not be food debris and grime on the floor and ice machine. The two-bay sink was for food preparation but had a leak and needed to be fixed. The sink to the right of the cookline was for handwashing and should not be used for food preparation or disposal due to staff not being able to wash their hands if needed. 10 New York Codes Regulations Rules 483.60(i)(1)-(2)

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

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

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

Based on observation, interview, and record review during the recertification survey conducted 9/5/2024-9/11/2024, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service in the facility's main kitchen. Specifically, in the main kitchen, food was not stored at safe temperatures in the walk-in cooler, there were uncleanable floor surfaces, the toaster was not clean, and the dishwasher instructions were not clean and legible. Findings included: The facility policy, Cleaning and Sanitation of Food Service Areas, revised 10/2022 documented staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The facility policy, Food Receiving and Storage, revised 5/2024 documented foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerated foods must be stored below 41 degrees Fahrenheit unless otherwise specified by law and refrigerated food will be stored in such a way that promotes air circulation around food storage containers. Improper Cooling: During an observation and interview on 9/5/2024 at 4:03 PM, a large hotel pan (6 inch deep) of cooked pasta covered in plastic wrap, located on the lower shelf just inside to the right of the walk-in cooler, measured at 65 degrees Fahrenheit. The Food Service Director stated the pasta was cooked about two hours ago. They cooked the pasta, drained it, rinsed it with cool water, added ice, and let the pasta set out for an hour. [NAME] the pasta was below 70 degrees Fahrenheit, it was placed into the walk-in cooler. They stated they were familiar with the cooling requirements and the cook who made that pasta was new and should not have put the pasta in that deep of a pan and should have used a shallow pan to help the pasta cool quicker. Cooling was supposed to be documented and checked in the logbook. The cooling logbook was reviewed, the logbook was blank, and there was no entry for pasta cooling. Uncleanable surfaces and equipment in disrepair: During an observation on 9/5/2024 at 9:48 AM, the kitchen floor by the main oven had unclean areas on the left side below the oven. The toaster had food debris on it and was not clean. The floor tiles in the main dish washing area were missing and there were stains on the walls above the main dish washing area. During an observation on 9/6/2024 at 3:56 PM, there were broken floor tiles in front of the 3 bay sink area. The wall above the sinks had missing tiles and the wall was unclean. During an observation and Interview on 9/6/2024 at 1:25 PM, Dietary Aide #11 stated they knew how to power on the dish washer and the minimum temperatures for the wash and rinse cycle were posted on the wall outside of the dish machine area. They were not aware there were instructions on the machine. and that the instructions should be easily read. They received training on how to use the dish machine. They stated it was important to know the required washing temperature to ensure the dishes were sanitized properly and prevent germs on the dishes. During an interview on 9/9/2024 at 3:36 PM, the Food Service Director stated the kitchen had a cleaning schedule that included the dirtiest use areas. The floors should be cleaned every night with mop and broom. The dish person was responsible to clean the dishwashing area floor and walls. They stated the broken floor tiles should be replaced, they cannot clean them properly, and dirt could get trapped in the area where the tile was missing. They stated they would put in a work order to get the tiles replaced. The toaster should be cleaned every day. The parts that were able to be removed should be run through the dishwasher to remove any food debris to ensure food does not build up and cause a fire within the toaster. They were not aware that the specifications and instructions for the dish machine were in an area that staff were unable to read it. The director stated the instructions were not easily seen, as the area was worn and dirty. 10NYCRR 415.14(h) 43754 Based on observation, interview, and record review during the recertification survey conducted 9/5/2024-9/11/2024, the facility did not ensure food was prepared, distributed, and served in accordance with professional standards for food service in the facility's main kitchen. Specifically, in the main kitchen, food was not stored at safe temperatures in the walk-in cooler, there were uncleanable floor surfaces, the toaster was not clean, and the dishwasher instructions were not clean and legible. Findings included: The facility policy, Cleaning and Sanitation of Food Service Areas, revised 10/2022 documented staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. The facility policy, Food Receiving and Storage, revised 5/2024 documented foods shall be received and stored in a manner that complies with safe food handling practices. Refrigerated foods must be stored below 41 degrees Fahrenheit unless otherwise specified by law and refrigerated food will be stored in such a way that promotes air circulation around food storage containers. Improper Cooling: During an observation and interview on 9/5/2024 at 4:03 PM, the lower shelf, just inside the walk-in cooler, had a large hotel pan (6 inches deep) of plastic wrap covered, cooked pasta. The pasta's temperature was measured at 65 degrees Fahrenheit. The Food Service Director stated a cook made the pasta about three hours ago. They cooked the pasta, drained it, rinsed it with cool water, added ice, let it sit out for an hour until it was below 70 degrees Fahrenheit, and placed it into the walk-in cooler. It had been there for about two hours. They stated they were familiar with the cooling requirements and the cook who made that pasta was new and should not have put the pasta in that deep of a pan. They should have used a shallow pan to help the pasta cool quicker. They stated cooling was supposed to be documented in the logbook, however, the logbook was blank, and there was no entry for cooling the pasta. They stated the covered pan of pasta was not meeting with cooling requirements because it had only dropped about 5 degrees in the last two hours. Uncleanable surfaces and equipment in disrepair: During an observation on 9/5/2024 at 9:48 AM, the kitchen floor by the main oven had unclean areas on the left side below the oven. The toaster had food debris on it and was not clean. The floor tiles in the main dish washing area were missing and there were stains on the walls above the main dish washing area. During an observation on 9/6/2024 at 3:56 PM, there was some food, debris, and grime under the cooking equipment. The toaster had cooked on food debris inside the unit, and some burn marks on the housing (not smooth and easily cleanable surfaces). The dish machine specifications could not be read because of the grease and grime on the specification plate. The exterior of the machine was coated with a dusty greasy build up of grime. During an observation on 9/6/2024 at 3:56 PM, there were broken floor tiles in front of the 3 bay sink area. The wall above the sinks had missing tiles and the wall was unclean. During an observation and Interview on 9/6/2024 at 1:25 PM, Dietary Aide #11 stated they knew how to power on the dish washer and the minimum temperatures for the wash and rinse cycle were posted on the wall outside of the dish machine area. They were not aware there were instructions on the machine. The instructions should be easily read. They received training on how to use the dish machine and it was important to know the required washing temperature to ensure the dishes were sanitized properly and to prevent germs on the dishes. During an interview on 9/9/2024 at 3:36 PM, the Food Service Director stated the kitchen had a cleaning schedule that included the dirtiest use areas. The floors should have been cleaned every night with a mop and broom. The dish person was responsible to clean the dishwashing area floor and walls. The broken floor tiles should have been replaced, they could not be cleaned properly, and dirt could get trapped in the area where the tile was missing. The toaster should be cleaned every day. The parts that were able to be removed should be run through the dishwasher to remove any food debris to ensure food did not build up and cause a fire within the toaster. They were not aware that the specifications and instructions for the dish machine were in an area that staff were unable to read them, and the instructions were not easily seen, because the area was worn and dirty. 10NYCRR 415.14(h)

Based on observation, interview, and record review during the abbreviated survey (NY00310174) the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service in the facility's main kitchen. Specifically, the kitchen had multiple unclean surfaces and equipment soiled by debris and dried on fire suppression chemicals. Additionally, improper dishwashing technique was observed in two separate locations. Findings included: The Material Safety Data Sheet titled (MSDS) Ansulex Low pH Liquid Fire Suppressant dated 7/31/2010 documented the product was yellowish green liquid. The health injuries were not known, or expected under normal use, and the toxicity had not been tested . The product was considered not hazardous under 29 CFR 1920.1200. Ingestion was not a likely route of entry, but it may cause minor irritation on eye contact. For clean- up, the area should be flushed with water, then surfaces cleaned thoroughly to remove residual contamination. 1) Unclean surfaces: The fire department incident report dated 2/3/23 documented that staff had pulled the kitchen's fire suppression system at the facility. During an observation on 2/8/23 at 1:00 PM, white debris was present on back of the flat top and burners of the stove, also present on the side of the commercial box steamer and into the vents of the steamer. The floor beneath the service line was encrusted with food debris. The inside of two drawers that contained utensils were soiled with dust, dried spills, and debris. The inside edge of the ice machine (located under the exhaust hood beside the oven) lid was soiled with a white residue. The top of the oven and the ice machine were soiled with dust and debris. The floor under the cookline was soiled with dried food spills and debris, it also felt greasy. A cart with spices located by the hand sink at the end of the cookline was soiled with white debris. Covered light fixtures on the edge of the exhaust hood had dried white droplets hanging off the covers. Dietary aide #3 was wiping off the back of the stove and flat top to clean the white debris off. During an interview on 2/8/23 at 2:06 PM, the Dietary Director stated dietary aide #9 accidentally pulled the kitchen's fire suppression system on 2/3/23 at approximately 5:45 PM. They stated there was a green chemical on the stove and on the floor at that time. The Dietary Director stated they voluntarily discarded everything from the tray line and the pans that were on the stove, everything else was washed in the three bay sink. They stated the stove, steamer, and plate warmers were then cleaned and sanitized by the cook and the maintenance staff, but the ice machine was not cleaned because from the fire suppression system got on it. During an interview on 2/8/23 at 2:45 PM, maintenance technician #2 stated they arrived at the facility around 6:00 PM on Friday 2/3/23. They stated the stove was cleaned by the Maintenance Director, and they waited for the vendor to come and reset the fire suppression system. They stated that someone, they could not remember who, had mopped up the floor around the cookline. During an interview on 2/8/23 at 3:23 PM, dietary aide #3 stated that the white substance they had wiped off the stove and steamer earlier today was left over from then the fire suppression system which had gone off on 2/3/23. The kitchen had been cleaned, but not very well. They stated they were not informed about the fire suppression system and arrived at work on Saturday 2/4/23. They stated the kitchen looked perfectly fine, but then they noticed speckles around the kitchen, on the steamer, the back of the stove, and the ice machine. The device that heated the plates was covered in the fire suppression chemical, and they had to wipe that down. Dietary aide #3 stated that it felt like a coating of grease. They realized that the fire suppression system had gone off and that was what was all over everything. During an interview on 2/8/23 at 3:36 PM, the Facilities Director stated they were not at the facility during the incident on 2/3/23 and arrived at the facility later in the night on 2/4/23 to look around and made sure everything was alright. They stated they assumed the kitchen was fully cleaned on Friday night, 2/3/23. They stated the chemical that was discharged from the fire suppression system was non-toxic. During an interview on 2/8/23 at 3:50 PM, the Dietary Director stated the kitchen was fully cleaned on Friday 2/3/23. During an interview on 2/8/23 at 3:58 PM, the Maintenance Director stated they arrived at the facility around 6:00 PM on Friday 2/3/23. They stated that the stove needed to be cleaned, so they cleaned that with soap and water, as well as the top and side of the steamer. They stated dietary staff were mopping the floor and had discarded food that was on the stove. During an interview and observation on 2/8/23 at 4:10 PM with the Facilities Director and the Maintenance Director they were shown the white residue on the lights under the kitchen hood, the white residue on the ice machine, and the dusty debris and spills under and around the cookline and tray line. The Facilities Director stated they did not think the residue was from the fire suppression system because a greenish liquid would be released. The Maintenance Director stated that the floor was not clean, and the dusty dry debris appeared to be older than today's meal service. The Facilities Director stated that the ice machine was not used for consumable ice. During an interview on 2/10/23 at 4:34 PM, the Facilities Director stated that they did not know what color the fire suppression chemical would be after it dried, they had only seen it in the past as a wet liquid when discharged from the fire suppression system. 2) Improper Dishwashing During an interview on 2/8/23 at 1:32 PM, the Dietary Director stated that the mechanical dishwasher was taken out of service on 2/3/23 and the facility was using paper products, except for trays, adaptive equipment, small side bowls, and lids to plates, which were washed in the three bay sink. They stated the procedure for the three bay sink was to wash with soapy water in the first bay, rinse with clean water in the second bay, and sanitize in the third bay. The person assigned as the dish washer was responsible for checking and ensuring the level of sanitizer was correct. During an observation on 2/8/23 at 1:40 PM, dietary aide #6 was washing dishes in the three bay sink. The three bay sink had soapy water and dishes in the first bay, water, and dishes in the second bay, and a large wire rack was in the dry third bay. During an interview on 2/8/23 at 1:40 PM dietary aide #6 stated they were washing the trays and the plate lids, and another staff (dietary aide #7) was washing everything else in the back. They stated they had soapy water in the first bay for washing, clean water in the second bay for the rinse, and then they set the dishes out to dry. They stated they normally had sanitizer in the third bay, but the wire rack was in the way, and they were not using that sink. They stated they normally checked the sanitizer twice a day, and it was required to be at 200 parts per million (ppm). During an observation on 2/8/23 at 1:49 PM, dietary aide #7 was washing dessert cups, lids, and other dishware in the two bay sink (dedicated food preparation sink) at the back of the kitchen. There was water spraying in the one bay, soapy water, and dishes in the second bay. During an interview on 2/8/23 at 1:50 PM, dietary aide #7 stated they were soaking the dishes to clean them. They stated they were washing them in the one bay, then they had to fill a bucket with sanitizer and put the dishes through that, then put them away. During an interview on 2/8/23 at 3:50 PM, the Dietary Director stated the manual procedure for washing dishes was to wash with soapy water, rinse with clean water, sanitize, allow the dishes to air dry, and put them away. They stated they were not aware that staff were improperly using the three bay sink, or that they were washing dishes at the two bay food prep sink. They added, all dishware was supposed to be washed through the three bay sink, and no one was to be washing dishes in the prep sink because it was dedicated to food preparation and only had two bays. 10NYCRR 415.14(h)

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

Based on observation, record review, and interview during the recertification survey conducted [DATE]-[DATE], the facility failed to provide a safe, clean, comfortable, and homelike environment on 5 of 5 resident units (Units 2, 3, 4, 5, and 6) reviewed. Specifically, there were stained ceiling tiles, non-working overhead lights, faucets that did not shut off, an exhaust fan that did not work, stained window blinds, a leaking sink, a stained chair, damaged and soiled walls, an unclean window, a broken window screen, a clogged sink, a damaged cabinet, and uncomfortable/incorrect sized mattresses. Findings include: The facility's undated Inservice for Daily/Weekly Cleaning documented the objective of daily cleaning was to ensure cleanliness and safety. Resident rooms should be cleaned in a clockwise manner, the housekeeper should clean and dust all windowsills, tables, chairs etc.; and clean all spot, spills, or scuff marks on vertical surfaces such as walls, doors, and over bed table stands. In the hallways all high touch areas, including handrails, elevator buttons, doorknobs were to be wiped with disinfectant daily. The resident lounge was to be cleaned after each meal. The facility's undated daily housekeeping checklist included the room numbers and bathrooms, walls, window curtains, and did not include the resident lounge. UNIT 2: The following environmental issues were observed on Unit 2 on [DATE]: - at 9:55 AM, resident room 204 had a stained ceiling tile and resident room 208 had a light over the resident bed that was not working. - at 10:15 AM, resident room 218 had a stained ceiling tile. - at 10:38 AM, resident room 201 bathroom had a stained ceiling tile. - at 10:43 AM, resident bathrooms 203 and 209 had faucets that would not shut off. - at 12:25 PM, the Unit 2 dirty utility room exhaust fan was not working. - at 12:36 PM, resident room 200 had two stained ceiling tiles. - at 12:40 PM, the hall outside resident room 204 had a stained ceiling tile. During additional observations on Unit 2 on [DATE] at 2:59 PM and [DATE] at 11:44 AM the same environmental issues observed on [DATE] remained the same. During an interview on [DATE] at 3:55 PM, both the Facility Director and Maintenance Director stated that they were not aware that the exhaust fan was not working in the Unit 2 dirty utility room and this fan was required to provide negative pressure air flow to prevent odors from entering the hallway. UNIT 3: On [DATE] The following environmental issues were observed on Unit 3: - at 10:22 AM, resident room 314 window ledge had a section of wall Formica (laminated composite countertop material) that was missing. - at 10:39 AM, resident room 300 window blinds were stained/unclean. - at 12:05 PM, resident room 319 had two stained ceiling tiles. - at 12:10 PM, the resident lounge had water leaking under the sink into a puddle on the floor below the sink, and there were 5 fruit flies near this sink. - at 12:11 PM, the resident lounge had a stained/dirty chair. - at 12:11 PM the resident lounge window ledge had a section of wall Formica that was peeling. There were multiple dead bugs in between the window screens and the windows, and two of the window screens had small holes. - at 12:22 PM, resident bathroom 314 had a clogged sink. During an interview on [DATE] at 12:10 PM the Facility Director stated they were not aware of the leaking sink in the Unit 3 resident lounge or the clogged sink in resident room 314 bathroom. During an observation on [DATE] at 8:25 AM, resident room 314 had a window ledge with a section of wall Formica that was missing. During an interview on [DATE] at 9:40 AM, housekeeper #12 stated they were assigned to Unit 3 and would cover other units as directed. They were responsible for cleaning everything on the unit, including the floors, walls, bathrooms, emptying trash, and dusting the dining room when residents were not there. Deep cleaning of the rooms was not on a routine schedule. Deep cleaning would take place when a resident expired or went out on pass for the day. Deep cleaning included cleaning and sterilizing the bed and wiping down all items in the room including the window blinds. Housekeeper #12 stated when furniture was dirty it was to be taken out of the resident area and brought downstairs for a deep clean. They stated they did not complete any task sheets or daily cleaning worksheets, but their supervisor would check in with them routinely to monitor the unit's cleanliness. They were aware of the dirty areas in the dining room but were unable to clean them because there were always residents in the area. During observations on [DATE] at 3:14 PM and 3:20 PM resident room 300 blinds remained unclean. The resident lounge window ledge had a section of wall Formica that was peeling and the multiple dead bugs in between the window screens and the windows remained, and two of the window screens had small holes in them. The resident room 314 window ledge had a section of wall Formica that was missing. During an interview on [DATE] at 3:31 PM, the Facility Director stated they were not aware the 3rd floor resident lounge/ kitchenette sink had a water leak. They stated that they were not aware that the sink in resident room 314 bathroom was blocked by a small cap and stated once the cap was removed the sink was working. Previously there had been other clogged resident room sinks, and they had always been fixed via word of mouth without a work order being completed. UNIT 4: During observations on Unit 4 on [DATE] at 10:45 AM, and on [DATE] at 3:06 PM, the resident lounge cabinet was soiled with a brown substance, and there were crumbs and miscellaneous debris on the cabinet shelf. Additionally, on [DATE] at 3:06 PM there were 2 fruit flies observed in the cabinet. UNIT 5: On [DATE] the following environmental issues were observed on Unit 5: - at 10:52 AM, resident room 510 had a stained ceiling tile. - at 10:58 AM, resident room 512 had a stained ceiling tile. - at 11:04 AM, resident room 514 had a wall near the resident bed with a 2-foot x 1-foot unpainted patch. - at 11:45 AM, resident room 504 had two square patches of wall with spackle and were unpainted. - at 11:50 AM, resident room 517 had 6 stained ceiling tiles. - at 11:56 AM, the resident lounge had four stained ceiling tiles. During an observation on [DATE] from 2:49 PM-2:59 PM, the stained ceiling tiles and unpainted walls remained. During an interview on [DATE] at 3:31 PM, both the Facility Director and the Maintenance Director stated they were not aware of any of the stained ceiling tiles observed in the facility. Stained ceiling tiles should be replaced immediately after being reported. There was no written documentation that maintenance would have completed this task. They stated the facility used paper format for work orders and after work orders were corrected it would be initialed, dated and filed. The Facility Director stated that the facility had a dedicated [NAME] who would patch and paint the walls. During an interview on [DATE] at 9:20 AM, the Maintenance Director stated that the daily housekeeping checklist had only been completed by some of the housekeeping staff, and that all staff were aware of their responsibilities. Resident rooms would be deep cleaned after a resident passed away or left the facility. Deep cleaning would include wiping down beds, mattresses, nightstands, windows, and anything else that was needed. The Maintenance Director stated that if something was found broken during the deep cleaning process it should be immediately repaired by maintenance. After a deep clean was completed, social services would be notified the room was ready for a new resident. They stated that the housekeeping department was responsible for keeping resident rooms clean. Most resident rooms on Unit 6 were rehabilitation short term rooms, and that there was no set frequency schedule for the deep cleaning of resident rooms. Housekeeping staff could not clean in dining rooms when residents were in the room. Dining rooms should be cleaned monthly, and this was not consistently documented. The Maintenance Director stated that each housekeeper had their own scheduled floor, except for their day off in which the other 4 housekeepers would clean 5 rooms each and then work on their floor. During an interview on [DATE] at 12:46 PM, the Facility Director stated they were not aware of the findings on Units 2, 3, 4 and 5 and there were no current work orders for the environmental issues. They stated the facility was the home of these residents and they should have a comfortable, homelike environment. UNIT 6 During an interview on [DATE] at 11:54 AM, Resident #13 stated they were uncomfortable in their bed and was unable to extend their feet and legs due to the curving of the mattress against the footboard. They stated that they had notified staff several times about this problem. During observations on [DATE] at 9:48 AM, [DATE] at 9:26 AM, and [DATE] at 10:57 AM Resident #13 had an oversized mattress on the bed frame and the mattress did not fit. The mattress was too long and rolled up at the footboard. The tag on the mattress documented it was a standard 80-inch x 36-inch mattress, which was used throughout the facility. When measured by the Facility Director it measured 84 inches long. The Facility Director stated they could not find any work orders requesting a change in mattress. During an interview on [DATE] at 10:54 AM, CNA #9 stated that ensuring a proper mattress for a resident was a team effort, and that if staff saw something wrong, they should tell maintenance. They stated a mattress should not be too big or too small, and that a proper sized mattress could prevent resident falls. CNA #9 stated that the mattress in Resident #13's room was too long for the bed and could make the resident's feet curl up or their head bend forward. During an interview on [DATE] at 11:10 AM, LPN #10 stated that a maintenance request work order should be completed for any bed issues, and that any staff that entered a resident room was responsible for observing bed safety. They stated that the mattress fitting properly on the bed was important. The mattress in Resident #13's room was too long for the bed. LPN #10 stated that oversized beds could prevent proper positioning of residents' feet and was not sure how long the oversized mattress had been on that bed. They stated that no staff had made them aware of the oversized mattress in Resident #13's room and they had not noticed the mattress. During an interview on [DATE] at 11:17 AM, the Facility Director stated that the oversized mattress in Resident #13's room could create pressure sores as the resident may not be able to stretch out and this could make the resident uncomfortable. They stated that they were not aware of the large mattress, could not think of any reason why this mattress would have been placed on this bed frame, and that prior to survey the facility had already stopped buying mattresses from this company. During an interview on [DATE] at 12:05 PM, registered nurse (RN) Unit Manager #11 stated resident bed safety was the responsibility of all staff. If a CNA observed a problem, they should let a supervisor know, and then a work order should be created to replace a mattress in a resident room. They stated that a proper fitting mattress could help prevent injury and enhance comfort for the resident. A mattress that was too long for the bed could be a safety issue and could cause the resident discomfort and effect skin integrity. 10 NYCRR 415.29(j)(1)

Based on observation, interview and record review during the recertification survey conducted 9/8/22-9/13/22, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents # 7) reviewed. Specifically, Resident #7 was not assisted with shaving and was observed with long facial hair on multiple days. Findings include: The facility policy, Activities of Daily Living (ADL) dated 7/2017 documented all residents would receive assistance as needed for their activities of daily living (ADL's), an accurate care plan would be developed, and if a resident's preference was contrary to the plan of care, e.g., shaving, the facility would develop a non-compliant plan of care for the resident and staff would reapproach them within a reasonable amount of time. Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/20/22 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and was totally dependent for ADLs. The comprehensive care plan, (CCP) initiated 5/20/20 documented the resident had ADL deficits. Interventions included assistance of 1 with bathing, toileting, grooming and dressing. The 9/8/22 revised care instructions documented the resident required extensive assistance of 1 with bathing, dressing, and grooming. Shower days with weekly skin checks were scheduled on Mondays during the 7:00 AM-3:00 PM shift. The certified nurse aide (CNA) ADL record did not include documentation ADLs were completed on 9/8/22 for all shifts. The resident was observed: - on 9/8/22 at 10:53 AM, sitting in a wheelchair in their room. The resident had facial hair on their chin approximately 1 inch long and on their upper lip approximately 1/2 inch long. - on 9/9/22 at 8:24 AM, sitting in their wheelchair with facial hair approximately 1 inch long on their chin and facial hair approximately 1/2 inch long on their upper lip. - on 9/9/22 at 1:53 PM, sitting in the dining room with facial hair approximately 1/2 inch long on their upper lip. The chin hair appeared shorter than 1 inch. - on 9/12/22 at 11:26 AM, sitting in their room in a wheelchair with facial hair approximately 1/2 inch long on their upper lip. During an interview on 9/8/22 at 10:53 AM, Resident #7 stated they preferred to have their facial hair shaved. During an interview on 9/9/22 at 2:50 PM, CNA #3 stated that Resident #7 needed assistance with their ADL's which consisted of washing, dressing, grooming, and shaving if needed. CNA # 3 stated that facial hair on a resident should be shaved if it was visible and they would assist with shaving. During an interview on 9/13/22 at 9:19 AM, CNA # 4 stated Resident #7 required assistance with their ADLs including shaving. CNA #4 stated they cared for Resident #7 on 9/8/22, gave them a bed bath and did not shave them. CNA # 4 stated that facial hair should be removed if it was visible and 1/2 inch in length or longer. CNA # 4 stated that they shaved residents when time allowed. They were the only CNA on the unit that morning and was not able to shave the resident. During an interview on 9/13/22, registered nurse (RN) # 5 stated they were responsible to ensure direct care staff completed their assignments regarding Resident #7's ADL care. Resident #7 needed assistance with shaving and their AM care involved washing, personal grooming, and shaving. RN #5 stated rounds were not performed to ensure care was completed unless they observed a resident with care not completed. A female resident should not have facial hair. It was unacceptable and a dignity issue unless that resident preferred to have facial hair. RN #5 stated they were aware, at the time of this interview, that Resident #7 currently had facial hair. During an interview with the Director of Nursing (DON) on 9/13/22 at 11:44 AM, they stated that female residents should not have facial hair unless it was their preference and were care planned to have it. They expected direct care staff to remove facial hair and ask for assistance if needed. 10NYCRR 415.12 (a)(3)

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

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

Based on record review and interview during the abbreviated survey (NY 275), the facility did not ensure residents were free of significant medication errors for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was not provided with her anticoagulation (prevents blood from clotting) medication for an extended period and subsequently developed a blood clot. This resulted in actual harm to Resident #1 that was not immediate jeopardy. Findings include: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 7/26/2018 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, she required extensive assistance for most activities of daily living and received an anticoagulation medication daily. The comprehensive care plan (CCP) updated on 8/8/2018 documented the resident was at risk for abnormal bleeding related to anticoagulant use. Interventions included to administer medications as ordered. Physician orders [REDACTED]. The 9/2018 Medication Administration Record [REDACTED] -From 9/2/2018 at 8:00 PM until 9/4/2018 at 8:00 PM [MEDICATION NAME] 150 mg was not administered as the drug/item unavailable. -On 9/5/2018 at 8:00 PM the medication was documented as not administered, drug/item unavailable. -From 9/7/2018 at 8:00 AM until 9/12/2018 [MEDICATION NAME] was not administered as drug/item unavailable and pharmacy still hasn't sent yet. A nursing progress noted completed by registered nurse (RN) #1 on 9/11/2018 at 10:30 PM documented she was made aware the resident's left foot was discolored. The left foot was mottled, cooler to touch, the calf was tender to touch and the there was a faint pedal pulse. The physician and family were notified. The family did not want the resident sent to the hospital and medical would address in the morning. A physician assistant (PA) progress note dated 9/12/2018 documented the resident was evaluated for complaints of left leg pain and tenderness. There were some questions if the resident had received her ordered [MEDICATION NAME] and nursing was investigating. On 9/13/2018 the PA documented the resident had an arterial ultrasound that showed an occlusion of the left femoral artery. The resident had missed multiple doses of her [MEDICATION NAME]. During an interview with RN #1 on 12/4/2018 at 12:52 PM she stated on the evening of 9/11/2018 she was the nursing supervisor and was notified the resident's foot was blue. She had not been notified prior to that evening the resident's [MEDICATION NAME] had not been available and had not been administered. She assessed the resident's leg and it was blue and cold. She notified the physician, who wanted her to go the hospital. When she talked to the family they did not want the resident to go to the hospital. During an interview with licensed practical nurse (LPN) #5 on 12/4/2018 at 1:15 PM she stated if a medication was running low she would pull the sticker on the blister pack and fax it to pharmacy. If a medication was not available she would notify the supervisor and call the pharmacy to reorder the medication. On 9/4/2018 the resident's [MEDICATION NAME] had not been available. She did not notify a supervisor, as she had been busy, but she did call the pharmacy who told her the medication was being sent out. She did not recall documenting in a progress note or on the 24-hour report the resident's [MEDICATION NAME] was not available. During an interview with LPN #4 on 12/4/2018 at 2:03 PM she stated she worked the evening shift, full time, as the Assistant Unit Manager and her responsibilities included passing medications. If a medication was not available she would notify the supervisor and follow up with them later in the shift to see what the plan was. She would also document in a nursing progress note and on 24-hour report the medication was not available. She did not do that for Resident #1 when her [MEDICATION NAME] was not available. She had discussed the medication not being available with the day nurse (LPN #6) 2-3 times and each time LPN #6 told her the medication was on its way but had not shown up with the pharmacy runs. She had called the pharmacy once and was told the [MEDICATION NAME] was on its way. She had notified the supervisor when the medication was not available but could not remember who the supervisor was. On the evening of 9/11/2018 she was informed the resident's leg was blue and she notified RN #1. During an interview with LPN #6 on 12/18/2018 at 12:06 PM she stated she had worked fulltime on the day shift and while passing medications she had noticed Resident #1's [MEDICATION NAME] had not been available for several days. She had called the pharmacy and they told her it was on the way. On 2 separate occasions when the medication was not available she had notified the Unit Manager. She had not documented in the medical record or on 24-hour report the medication was not available or that she had reported it. During an interview with RN #7 on 12/6/2018 at 2:00 PM she stated on 9/9/2018 (Sunday) she worked in the morning and had passed medications. Resident #1's [MEDICATION NAME] was not available and she was not aware the resident had gone several days without it. On 9/9/2018 when the medication was not available she did not assess the resident, call the physician or the pharmacy. She did report to the oncoming supervisor the medication was not available. On the morning of 9/10/2018 she ran a report on the resident's medications which showed the resident had gone several days without the [MEDICATION NAME]. She did not assess the resident or call the physician. She called the pharmacy and they told her the medication had been sent on 9/4/2018. If she could not find it, they would need authorization to send more. She did not authorize the pharmacy to send more but notified the Assistant Director of Nursing (ADON) who she thought would follow up. During an interview with LPN #8, ADON, on 12/18/2018 at 11:13 AM she stated she was notified on 9/10/2018 the resident's [MEDICATION NAME] was not available that day. The pharmacy had been called and they reported they had already sent the medication and would need authorization to send more. The ADON instructed RN #7 to authorize it and she did not know if RN #7 had. She was notified at home on the evening of 9/11/2018 Resident #1 probably had a clot and she had not received her [MEDICATION NAME] for several days. Prior to that notification she was under the impression the resident had only missed one dose of the [MEDICATION NAME] on 9/10/2018 when the Unit Manager reported to her that it was not available. During an interview with the Director of Nursing (DON) on 12/18/2018 at 12:58 PM she stated she had not been notified until 9/12/2018 the resident had missed several doses of [MEDICATION NAME] and her leg was ischemic (lack of blood flow). When she reviewed the pharmacy delivery sheets it was documented 28 tablets of [MEDICATION NAME] was delivered to the facility on [DATE] for Resident #1. It apparently was lost, and they had looked everywhere for it on 9/12/2018. The investigation of the incident included reviewing progress notes and the 24-hour report. There was nothing documented regarding the resident's medication not being available. The resident had not been monitored and the physician had not been notified. At the time there was no policy or procedure on reordering medication or instructions if a medication was unavailable. During an interview with the facility's Medical Director on 12/19/2018 at 12:14 PM he stated the resident had not received her [MEDICATION NAME] for several days and she developed an [MEDICAL CONDITION] (clot). The leg became ischemic and necrotic (dead) as a result. The issue was the medication was not given, there was no communication the medication was unavailable, and the medication omission was not identified until the resident developed symptoms and had a complication. The facility should not have waited until the resident developed a complication to identify the medication was not available. The resident was taking the [MEDICATION NAME] for a history of [MEDICAL CONDITION] and she was at an increased risk for developing blood clots. 10NYCRR 415.12(m)(2)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY 753), the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #29) reviewed for falls. Specifically, Resident #29 had a lap buddy (a lap cushion used in a wheelchair to aid in fall prevention) and was left unsupervised with the lap buddy released and the resident sustained [REDACTED]. Findings include: The facility's Restraint Use policy dated 5/2018 included the definition of a physical restraint is a device or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to the body. Types of restraints included seatbelts, trays, and tables that the resident cannot easily remove and which prevent the resident from rising. The policy did not include parameters for release of the restraint and supervision when not in use. Resident #29 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 5/25/2018 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment with disorganized thinking and inattention. The resident exhibited behaviors of wandering one to three days during the assessment period and required extensive assistance for most activities of daily living (ADLs). The resident had one fall without injury and two or more falls with injury since admission or since the prior assessment. The fall risk assessment dated [DATE] documented the resident had 3 or more falls in the last 3 months, had impaired mobility, balance problems while standing and walking, and was at risk for falls. The restraint assessment dated [DATE] documented the resident had a chair alarm 05/14/18 to 05/18/18. Instructions included to remove every 2 hours and at meal time. Reasons for the use of the seatbelt were poor impulse control and no safety awareness. Physician orders [REDACTED]. The comprehensive care plan (CCP) dated 5/23/2018 documented the resident had a lap buddy due to unsafe attempts to self-ambulate and not asking for help. The lap buddy was to be released every 2 hours and as needed for toileting, meals and ambulation. The resident was not to be left unattended in his wheelchair without the lap buddy in place. The resident care profile (care instructions) dated 5/23/2018 documented the resident had a lap buddy, to release it every 2 hours, as needed, for toileting, meals, and ambulation. The incident and accident report dated 6/16/2018 documented the resident was found on the floor at 09:50 AM in front of the elevator and had a [MEDICAL CONDITION] and hematoma (a collection of blood under the skin). The resident was sent to the emergency department and admitted with a subdural hematoma (a collection of blood on the brain's surface). Follow up interventions noted a possible change to an alarming seatbelt and to educate staff to replace the lap buddy if the resident was unattended. Staff statements included: - Licensed practical nurse (LPN) #17 noted she was on break and returned when she heard the page for a Supervisor to the unit; - CNA #16 noted she was told the resident fell and she assisted CNA #15 in taking the resident to the bathroom before the incident; - Occupational therapy aide #20 noted another resident notified her in the hall of the resident's fall and she went to get help. The undated investigation summary prepared by the Director of Nursing (DON) documented on 06/16/2018, the resident was brought to the dining room and placed at the table; his lap buddy had been removed; staff assisted other residents, and the resident got up, walked down the hall, and fell near the elevator door frame. The DON and Assistant Director of Nursing (ADON) reviewed camera footage and noted staff did not replace the lap buddy after returning the resident to the dining room and left the resident unsupervised. CNA #15 was disciplined and stated she was unaware the lap buddy was to be put back on as the resident was at the table. The hospital discharge summary dated 6/19/2018 documented the resident was admitted to the hospital on [DATE] with left temporal subarachnoid hemorrhage (bleeding in the space that surrounds the brain). The resident had left parietal scalp swelling and surgical staples. A physician's orders [REDACTED]. The resident was observed: - On 10/09/18 at 12:02 PM, eating lunch in the dining room, his seatbelt on in the wheelchair; and - On 10/10/18 at 08:59 AM, in the dining room eating breakfast with his seatbelt on in the wheelchair; The resident's family member was interviewed on 10/09/18 at 01:31 PM and stated the primary reason the resident was admitted to the facility was due to his ongoing falls at home. He had no safety awareness and was not steady on his feet. She stated he would impulsively stand without assistance at any given time and this was the reason he was now utilizing the alarming seat belt. He used to have a lap buddy, but he would remove it and did not care for it. During an interview on 10/12/18 at 10:30 AM, CNA #16 stated when the resident fell on [DATE], she was assisting another resident and CNA #15 had gone on break, she was unaware of the LPN's location at the time. She stated any resident with a restraint (lap buddy) needed to be supervised when the restraint was released. She stated CNAs were not always able to directly supervise residents and nurses and activities staff also helped. Resident #29 was to be checked often, and if his lap buddy was not in place, he needed to have direct supervision. CNA #15 stated during an interview on 10/12/18 at 10:40 AM, she took the resident to the bathroom after breakfast, did not replace his lap buddy, and placed him at the table in the main dining room. She stated she thought the resident could not have his lap buddy while at the table and she knew he required supervision when the lap buddy was off. She stated LPN #17 was just outside the dining room talking with LPN #18 and she (CNA #15) went on break. She stated she should have told LPN #17 she was leaving the floor and the resident was in the dining room without his lap buddy. She was one of 2 CNAs on the day shift that day and she knew the resident required supervision. When interviewed on 10/12/18 at 12:30 PM, the DON stated she reviewed the video footage after the resident's fall. She observed the resident was brought back into the dining room by CNA #15 after breakfast. LPN #17 was just outside the dining room and LPN #18 joined her, and they left down the stairwell to go on a break. CNA #15 had left just before the LPNs and did not communicate with them she was leaving or the resident was at the table without the lap buddy. CNA #16 was on the other side of the unit caring for residents. Resident #29 was observed to push back his wheelchair from the table, stand, and walk out of the dining room, toward the elevator and appeared to stumble over his feet. The DON stated the resident walked at a quick pace and only minutes had elapsed from being seated to walking down the hall. CNA #16 was still in a resident's room and the resident fell forward and hit his head. The expectation was for staff to supervise residents anytime a restraint was released and CNA #15 should have told someone she left resident unattended without his lap buddy and was leaving the unit. The DON stated even if the resident profile did not specify to provide constant supervision while the lap buddy was off, the standard for CNA practice would be to provide supervision anytime a restraint was released. 10NYCRR 415.12(h)(2)

Based on observations, record review, and staff interviews during the recertification survey, the facility did not ensure for 1 of 5 residents (Resident #58), reviewed for activities of daily living (ADL), that each resident was provided the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless unavoidable. Specifically, Resident #58 was discharged from physical therapy (PT) and occupational therapy (OT) with a plan to maintain his current level of function by receiving services in the restorative nursing program (RNP); the resident did not receive the planned services. Findings include: Resident #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident's cognition was moderately impaired; he required extensive assistance with all ADLs except eating which required supervision and set up, and he did not ambulate. The resident profile (care instructions) dated 8/8/2018, documented the resident ate by himself after set up, had a wheelchair propelled by staff for mobility, was non-ambulatory, required a mechanical lift for transfers and toilet use, and was incontinent at times. He required extensive assistance for bathing, bed mobility, dressing and grooming. The PT discharge summary dated 9/7/2018, documented the resident had reached maximum potential. Discharge recommendations included encouraging the resident to participate in activities of interest to promote socialization and active lifestyle; and the resident was also to participate in the RNP. The RNP was to facilitate the resident to maintain his current level of performance and to prevent decline. The summary documented that development and instruction was completed with the interdisciplinary team for AROM (active range of motion). The OT discharge summary dated 9/7/2018, documented the resident had achieved his highest practical level. Discharge recommendations included a reacher, low bed, and restorative nursing for PROM (passive range of motion) and AROM. The RNP was to facilitate the resident to maintain his current level of performance and to prevent decline. The summary documented that development of and instruction was completed with the interdisciplinary team for AROM and PROM. The comprehensive care plan (CCP) updated 9/21/2018, documented the resident was discharged from skilled services on 9/7/2018 and to see the discharge summary for full details. The resident's ADL plan was not updated to include AROM/PROM; the ADL status was unchanged from the resident profile dated 8/8/2018. When observed and interviewed on 10/09/18 at 1:49 PM, the resident was sitting in his wheelchair with a Hoyer (mechanical lift) pad under him. He stated was not getting PT or OT services anymore and was unsure why. When interview on 10/11/2018 at 11:43 PM, certified nurse aide (CNA) #8 stated she took care of resident, he no longer went to PT, and she was not sure if he was seen by the restorative aide. On 10/11/18 at 12:25 PM, the Director of Therapy #9 stated they did not have a RNP policy. She stated the program was for residents to be seen by a therapy/rehab aide after discharge from skilled services to maintain their level of function. She said when the resident was discharged from therapy, if the therapist wanted the resident to have some type of continuing program such as ROM, bed mobility, or ambulation, the rehab aide was trained by the therapist on the resident's needs. The rehab aide would then schedule to see the resident 3-5 times a week and complete the recommendations. She stated if there was a decline or problem the aide reported it to nurse manager or therapist and the resident would be re-evaluated. She stated the rehab aide documented their activities on the kiosk (electronic medical record). When interviewed on 10/11/18 at 1:00 PM, rehab aide #12 stated she saw the residents for the RNP and documented the number of minutes she worked with each resident in the kiosk. She stated she took over this responsibility 9/24/18 and had not seen Resident #58. She stated she got a notebook that the previous rehab aide used and that was how she knew who to see. She stated she was not given information on the resident and did not know Resident #58 was on the program until the Director of Therapy and physical therapist (PT) #10 told her a few minutes ago. When interviewed on 10/11/18 at 1:06 PM, PT #10 stated the discharge plan was to provide AROM in the RNP. He said he wrote a plan for the aide (no longer at the facility) to administer and she documented in a book. He said the plan was verbalized to the aide and a written plan was given to her. He stated he was unable to find a copy of the plan he wrote. He said the resident was not highly motivated and needed a lot of encouragement to perform ROM. He stated the resident preferred not to be bothered and required maximum encouragement to perform exercises. The resident was put in the program to maintain his current level of function. When interviewed on 10/11/2018 at 2:15 PM, occupational therapist (OT) #11 stated when a resident was discharged from OT she consulted the rest of the interdisciplinary team to see if continuing a restorative nursing program was necessary. She stated then she would communicate with the RNP aide verbally and in writing as to the resident's needs. She stated the previous rehab aide had been in and out a bit and she was not sure what happened. She stated she put the resident on the program and he should have received the RNP services. When interviewed on 10/12/18 at 11:23 PM, registered nurse (RN) Manager #13 stated the therapy department was responsible for updating the ADL care plan and the RNP. She stated she did not know if the rehab aide had seen the resident for ROM. She stated the resident would benefit from the program. 10NYCRR 415.12(a)(1)

Based on record review and interview during the recertification survey, the facility did not ensure the services provided were consistent with professional standards of quality for 1 of 3 residents reviewed for accidents. Specifically, Resident #142 sustained a fall and neurological checks were not done accurately and according to policy, the physician was not notified timely, and falls were not communicated so that interventions could be implemented. The resident subsequently had a change in condition and altered mental status and was hospitalized . Findings include: The facility's neurological assessment policy dated 10/2010, documented a resident was to have neurological assessments following an unwitnessed fall or after a fall with a suspected head injury. The neurological assessment flow sheet documented assessments were to be done every 15 minutes x 4, then every 30 minutes x 4, then every 1 hour x 4, then every 4 hours x 2, and then every 8 hours x 2. The facility's fall policy dated 7/2017 documented the attending physician was to be immediately notified, the resident's comprehensive care plan (CCP) was to be updated with interventions to reflect the event, and the event was to be documented on the 24-hour report. Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired. The resident required extensive assistance of 2 for bed mobility, transfers, dressing, toilet use, hygiene, and bathing. He required limited assistance of 1 for walking and supervision with set-up for eating. The MDS documented the resident had no falls in the past 6 months. A hospital discharge summary dated 5/30/2018 documented the resident was admitted to the hospital on [DATE] for a fractured pelvis. A hospital discharge summary dated 8/17/2018 documented the resident was admitted to the hospital on [DATE] for generalized weakness and leukocytosis (high white blood cell count, infection) without fever. The summary also documented the resident had a recent [MEDICAL CONDITION] ramus and acetabulum (pelvic bone where the head of the femur meets). The admission fall risk assessment dated [DATE] documented the resident had no falls in the past 3 months and determined he was not at risk for falls. (He was previously at the facility for rehabilitation after the fractured pelvis.) The resident's care plan dated 8/17/2018 documented the resident used a wheelchair and ambulated in therapy only. He required extensive assistance of 1 for bed mobility and extensive assistance of 2 with a rolling walker for transfers. The care plan did not document the resident was at risk for falls. The physician's history and physical dated 8/20/2018 documented the resident was admitted for physical therapy (PT) and occupational therapy (OT) after an episode of profound weakness. The resident was doing well and was discharged from the facility previously after having rehab for a fractured pelvis. He went home and 2 days later was admitted to the hospital with [REDACTED]. The plan was to return home after rehabilitation. The nursing progress note dated 8/25/2018 at 5:02 PM, documented the resident was found on the floor in his room. The resident stated he did not know how he got there and stated he hit his head on the nightstand. No injuries were noted and the resident was assessed and assisted back to bed. He was reminded to use the call bell and neurological checks were initiated. The incident report dated 8/25/2018 documented at 4:50 PM, the resident was found on the floor in his room. It was not documented if the physician was notified. The neurological assessment flow sheet documented the resident was given Tylenol for pain at 6:15 PM. The neurological assessments were done from 8/25/2018 at 5 PM until 7:45 AM on 8/26/2018, the last 2 assessments to be done every 8 hours were not documented. There were no updates made to the care plan to protect the resident from further falls. The incident report dated 8/28/2018 documented at 2:00 AM, the resident was found on the floor in his room. It documented a note was left in the physician's book for minor injuries. The report documented 2 bumps on the resident's head measuring 1/2 x 1/2 inch and 1-1/4 inch circle. He also had 2 skin tears measuring 1/2 x 1/2 inch and 2-1/4 x 1-1/4 inches. The neurological assessment flow sheet documented neurological checks were done every 15 minutes from 2:00 AM to 2:45 AM. There were no checks done from 2:45 AM to 4:45 AM and it was documented the resident was sleeping. A nursing progress note dated 8/28/2018 at 8:27 AM, documented the resident was found on the floor at 2:00 AM by the certified nurse aide (CNA) who heard a loud noise. The resident was face down next to the bed and said he rolled out of it. The neurological assessment was benign, his grips were equal and strong, range of motion was good, his pupils were equal and reactive to light, there was no pain and no change in mental status. He had 2 skin tears, and on the upper right aspect of his head had a 1-1/4 inch circle/bump slightly raised and tender to touch. Above his right eye was a 1/2 inch circle/bump raised and tender to touch. He was transferred safely back to bed, rechecked numerous times, and had no change in mental status. The resident was not on the 24-hour report (shift to shift nursing communication) for falling on 8/28/2018 at 2:00 AM. The incident report dated 8/28/2018 at 8:45 AM, documented the resident was found kneeling on the floor with his elbows on the bed. It was not documented when the provider was notified. Neurological checks were documented per protocol from 8:45 AM to 3:30 PM and noted the resident's level of consciousness as alert at every check. A nursing progress note dated 8/28/2018 at 2:39 PM, documented the resident was lethargic throughout shift and fell at 8:45 AM. The neurological assessment flow sheet dated 8/28/2018 for the fall at 8:45 AM was discontinued at 7:30 PM and did not document the last 3 checks to be done. The resident was not on the 24-hour report (shift to shift nursing communication) for falling on 8/28/2018 at 8:45 AM. There was no further documentation in the resident's record regarding the head injuries (bumps) he sustained when he fell on [DATE] at 2:00 AM. The physician assistant (PA) progress note dated 8/29/2018 documented the resident was seen for follow-up of the emergency room visit on 8/27/2018 for abdominal pain with tenderness, and diaphoresis (profuse sweating). He was diagnosed in the emergency room with a UTI and started on an antibiotic. The note did not document the resident's falls. A hospital discharge summary dated 9/13/2018 documented the resident was admitted to the hospital on [DATE]. His discharge [DIAGNOSES REDACTED]. When interviewed on 10/12/2018 at 9:49 AM, RN #22 stated he assessed the resident on 8/28/2018 at 2:00 AM when he fell out of bed. He stated he was the floor nurse and the RN Supervisor that night. He stated he did not call the physician that night as there was no change in the resident's mental status. He said he wrote a note in the physician book and gave a verbal report to the next shift. He completed the incident report and put it in the box in the nursing office. He said all incidents should be put on the 24-hour report and he did not remember if he put the resident on the report. He stated if the resident was sleeping, he would not wake for neurological checks. If there was a major injury such as bleeding, a change in physical or mental status, pain, or a behavioral change he would wake the resident for neuro checks. He said the resident had no change in condition and the bumps on his head did not worsen. When interviewed on 10/12/2018 at 11:25 AM, RN Manager #13 stated she was unaware of the resident's fall on 8/25/2018 and he should have had floor mats put into place after the fall. She stated she was unaware of the resident's falls on 8/28/2018 until a day or 2 later. She stated the resident should have been woken for neurological checks during the night and the nurse's documentation on 8/28/2018 was conflicting. She stated the resident could not be both alert and lethargic. She stated the medical provider saw the resident on 8/29/2018 and was aware of his falls. She stated the physician should be notified of any falls with injury. When interviewed on 10/12/2018 at 12:30 PM, the physician stated he was usually notified immediately of falls. He stated it depended upon the fall if they needed to call during the night. If there was an injury, the physician expected to be notified. He stated he was aware the resident had falls and did not know how often. He was not sure if he knew the resident hit his head. He stated it was difficult to assess the resident as some days he presented better than others and progressively got weaker. The resident ended up with a subdural hematoma and it could not be determined when it started. He stated the resident was at high risk for falls on admission as he was at the facility before for a fractured pelvis and had a history of [REDACTED]. When interviewed on 10/12/2018 at 1:20 PM, the DON stated the physician should be notified immediately of any fall with injury. She stated during the night they could wait until morning if there was no injury. She said for major injuries the resident would be sent to the hospital and with other injuries the physician was notified. She stated the resident should be woken for neurological checks if he hit his head. She could not tell from the incident report if the provider was notified on 8/25/2018 as the box was checked for the physician and there was no time or date documented. For the incident on 8/28/2018 at 2:00 AM, the physician should have been notified and the resident should have been put on the 24-hour report, and the resident should have been woken for neuro checks. She stated the nurse taking care of the resident on 8/28/2018 on the 7:00 AM to 3:00 PM shift had conflicting information on the neuro check sheet and her progress note as the resident could not be both lethargic and alert at the same time. 10NYCRR 415.11(c)(3)(i)

Based on record review and interviews during the recertification survey, for 1 of 22 residents (Resident #142) reviewed for comprehensive care plans (CCP), the facility did not develop a comprehensive person-centered CCP to meet the resident's needs. Specifically, for Resident #142 the Minimum Data Set (MDS) and admission fall risk assessments were not completed accurately and the resident was not care planned for falls; the CCP was not revised to include recommended fall interventions after the resident fell ; the resident fell again and sustained injuries. Findings include: The facility's fall policy dated 7/2017, documented the resident's CCP was to be updated with interventions to reflect the event, and the event was to be documented on the 24-hour report. Resident #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired. The resident required extensive assistance of 2 for bed mobility, transfers, dressing, toilet use, hygiene, and bathing. He required limited assistance of 1 for walking and supervision with set-up for eating. The MDS documented the resident had no falls in the past 6 months and received physical and occupational therapies (PT/OT). The admission fall risk assessment dated [DATE] documented the resident had: - intermittent confusion, poor recall, judgement, safety awareness; - no falls in the past 3 months; - impaired mobility and required assistance with toilet use; and - required use of an assistive device for walking. It was determined he was not at risk for falls. The resident's care plan dated 8/17/2018 documented the resident used a wheelchair and ambulated in therapy only. He required extensive assistance of 1 for bed mobility and extensive assistance of 2 with a rolling walker for transfers. He was not care planned for risk of falling. The physician's history and physical dated 8/20/2018 documented the resident was admitted for physical therapy (PT) and occupational therapy (OT) after an episode of profound weakness. The resident was doing well and was discharged from the facility after having rehab for a fractured pelvis secondary to a fall. He went home and 2 days later was admitted to the hospital with [REDACTED]. The plan was to return home after rehabilitation. The nursing progress note dated 8/25/2018 at 5:02 PM, documented the resident was found on the floor in his room. The resident stated he did not know how he got there and stated he hit his head on the nightstand. No injuries were noted and the resident was assessed and assisted back to bed. He was reminded to use the call bell and neurological checks were initiated. An incident report dated 8/25/2018 documented at 4:50 PM, the resident was found on the floor in his room. The incident report was signed off as reviewed on 8/27/2018 by the interdisciplinary team and the Director of Nursing (DON). The review documented the resident was found on the floor, the call bell was not on, and the plan of care was followed. New interventions included encouraging the use of the call bell for assistance and to offer floor mats. The CCP did not contain any documentation or interventions for fall risk following the 08/25/18 fall. The incident report dated 8/28/2018 at 2:00 AM documented the resident was found on the floor next to his bed with skin tears on the right wrist and left elbow, and bumps on the head and right eye. The incident was reviewed by the interdisciplinary team on 8/28/2018 and determined the care plan was followed and new interventions included floor mats, a low bed, and medical to follow. A nursing progress note dated 8/28/2018 at 8:27 AM, documented the resident was found on the floor at 2:00 AM by a certified nurse aide (CNA) who heard a loud noise. He was face down next to the bed and said he rolled out of it. The incident report dated 8/28/2018 at 8:45 AM, documented the resident was found kneeling on the floor with his elbows on the bed. The incident was reviewed by the interdisciplinary team on 8/29/2018 and determined the care plan was followed and interventions included medical to see due to increased confusion and ? floor mats. The RN progress note dated 8/28/2018 at 6:05 PM, documented the resident was found kneeling to the left side of his bed with elbows on the bed at 8:45 AM. The resident stated he did not know what happened and he fell . He was assessed and returned to bed. A fall assessment completed 8/30/2018 at 11:45 AM, documented the resident was at risk for falls. The resident's care plan was updated 8/30/2018 and documented the resident was at risk for falls due to recent falls and the goal was to have no further falls. Interventions included a low bed, call bell within reach, and bilateral floor mats. When interviewed on 10/12/2018 at 9:49 AM, RN #22 stated he assessed the resident on 8/28/2018 at 2:00 AM when he fell out of bed. He stated the resident's bed was in the low position and he did not remember the resident having floor mats. When interviewed on 10/12/2018 at 11:25 AM, RN Manager #13 stated the resident did not trigger as a fall risk when she assessed him on admission and he was not care planned for falls. She stated he was at the facility before after fracturing his pelvis and she thought it was more than 3 months before his admission on 8/17/2018. She stated she was unaware of the fall on 8/25/2018 and he did not have floor mats. She stated she did not update the care plan to include fall interventions until 8/30/2018 and it should have been updated after the first fall on 8/25/2018. When interviewed on 10/12/2018 at 12:30 PM, the physician stated the resident was at high risk for fall and he would have expected a care plan to include falls. When interviewed on 10/12/2018 at 1:20 PM, the DON stated to determine the care plan was followed, they looked at the care plan and the interventions that were in place. She stated on the statement forms completed by the LPN and CNAs the last question asked about interventions in place. She reviewed the incident forms from the falls on 8/25 and 8/28/2018 and stated they did not fill them in correctly. She stated fall interventions were added to the care plan after he had falls and should have been updated 8/25/2018. She stated on the 8/28/2018 incident report for the fall at 8:45 AM she wrote ? floor mats as she was not sure if he had them. 10NYCRR 415.11(c)(2)(iii)

Based on observation, record review and interview during the recertification survey, the facility did not ensure each resident's drug regimen must be free from unnecessary drugs for 2 of 7 residents (Resident #69 and 193) reviewed for unnecessary medications. Specifically, Resident #69 had orders for as needed [MEDICAL CONDITION] medications and those medications were not reviewed timely to determine if the medications could be discontinued. Resident #193 had orders for as needed (PRN) antipsychotic medication ([MEDICATION NAME]) and there was no documentation of non-pharmacological interventions attempted prior to the medication administration and no parameters to specify when the medication was to be given. Findings include: 1) Resident #193 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The nursing admission progress note dated 10/5/2018 at 4:30 PM documented the resident arrived at the facility at 3:30 PM and was alert, able to make needs known, and was cooperative with care. The initial care plan dated 10/5/2018 documented the resident had behavioral symptoms due to a history of dementia with Sundow[DIAGNOSES REDACTED] (change in behavior in the evening hours). The goal was to make the resident calm and comfortable in his new surroundings and he would be cooperative with care. Interventions included: - giving evening medications at 6:00 PM for compliance; - redirecting the resident when he became behavioral; - involving the family in the resident's care; and - attempting to keep the resident on a routine towards the evening when his confusion increased. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. The registered nurse (RN) Supervisor's progress note dated 10/5/2018 at 7:05 PM documented the resident was walking in the hallway attempting to go in other residents' rooms. When staff tried to redirect, the resident became belligerent and combative. He attempted to push past staff into another resident's room and was placed in a wheelchair and taken to his room. He did not want to stay there and was taken to the lounge. The resident thought staff were keeping him at the facility against his will and he wanted to go home. The resident's wife came in and the resident settled after she arrived and stayed for a while. The licensed practical nurse (LPN) progress note dated 10/5/2018 at 10:13 PM documented the resident was alert and confused. He walked out of his room several times and went into other residents' rooms. He was combative with staff and threatened staff on several occasions. The supervisor was notified and the resident was given [MEDICATION NAME] at 6:30 PM as ordered without effect. The resident offered no complaints. The MAR indicated [REDACTED]. The nursing progress note dated 10/6/2018 at 10:09 PM documented the resident was alert, confused, and able to make his needs known. He refused his meal and was given [MEDICATION NAME] at 7:00 PM as ordered, with effect. He did not have any behavior issues noted, denied pain, and had no complaints. The MAR indicated [REDACTED]. The nursing progress note dated 10/7/2018 at 10:12 PM documented the resident was given [MEDICATION NAME] at 8:00 PM for wandering in the hallways unassisted. The physician's progress note for 10/8/2018 documented the resident was placed on [MEDICATION NAME] while at the hospital and needed it for the first few days of his admission. The plan was to continue and monitor the need, try [MEDICATION NAME] at bedtime, and if the resident slept adequately, he would try to discontinue the [MEDICATION NAME]. The resident was interviewed on 10/9/2018 at 11:10 AM, he was alert and cooperative and stated he had pneumonia and was at the facility for strengthening with a plan to go home. The resident was observed on 10/10/18 at 09:07 AM in his room. He stated he felt good and had no complaints. The MAR indicated [REDACTED]. There was no documentation in the nursing progress notes for the shift. On 10/11/2018 at 3:15 PM, certified nurse aides (CNA) #3 and #4 were interviewed and stated they were full-time CNAs on the unit and knew Resident #193. CNA #3 stated she worked on 10/5/2018 when the resident was admitted and he was very calm at the time. She stated around 6 or 7 PM on the evening of admission he became very agitated, then his wife came in and he was fine. CNA #4 stated she worked on 10/6/2018 the day shift and the evening shift until 9 PM. She stated in the morning he was out of it, they found him on his knees and then he laid on the floor. They got him up and put him back to bed. She stated she got report from the overnight shift that he had to be medicated for being combative. She said during the evening he came out of his room with a hat, gloves, jacket, and shoes on and was ready to leave. CNA #4 brought him back to his room and talked him into staying and turned on the television. She said he came out for dinner and was fine. When interviewed by telephone on 10/11/18 at 3:30 PM, LPN #5 stated the resident had dementia with behaviors. He said the resident was fine during the day and in the evening his behaviors increased due to Sundow[DIAGNOSES REDACTED]. He said the family wanted the resident to have the television and lights on until he fell asleep at night to avoid sundowning behaviors. He said the resident wandered out of his room and into other rooms and they had to get him in a wheelchair to take back to his room. He stated the first night (10/5/18) the resident was aggressive and told the CNA they were going to get into a tangle. He went in and out of other rooms and became aggressive when they tried to get him back to his room. The supervisor was called and it took 2 CNAs, himself, and the supervisor to get him into a wheelchair and back to his room. Later, he walked out of his room and went into an empty room and used the bathroom. The staff got him back to his room and the RN Supervisor told LPN#5 the resident had a PRN order for [MEDICATION NAME]. He said he gave the resident the [MEDICATION NAME] and by the time he left the resident was in his room and was not behavioral. LPN #5 stated the next night, 10/6/18, the resident was calmer. He stated the resident was not aggressive and seemed agitated and was wandering. He stated the resident was also not using his call bell to get assistance for the bathroom and was going into the bathroom by himself. He said staff tried to redirect him and reminded him to use his call bell. He stated he gave the resident [MEDICATION NAME] as a measure to calm him down. LPN #5 said on 10/7/18 he gave the resident [MEDICATION NAME] to enable the CNAs to give the resident a shower. He stated the resident's wife was in and wanted to give him a shower. He told the wife she was not allowed to shower the resident and the CNAs would give the shower. He said the resident's behaviors also included being non-compliant with using his call bell, and he was resistive to going back to his room when he was wandering in the hall. When interviewed by telephone on 10/11/2018 at 3:50 PM, LPN #6 stated she was told in report on 10/10/2018 that the resident had a PRN order for [MEDICATION NAME] for behaviors and often needed it in the evening. She stated she was in the dining room and while the residents were waiting for dinner, he kept trying to get out of his wheelchair. She stated she gave the [MEDICATION NAME] before the dinner arrived and when dinner came he refused it and kept pointing to a lady and asking what was wrong with her. She stated he wanted to go back to his room and the CNA took him back. When asked what interventions she tried before giving the [MEDICATION NAME], she stated she repeatedly told the resident to sit down. When interviewed on 10/11/2018 at 4:10 PM, RN Supervisor #7 stated [MEDICATION NAME] as a PRN should only be used if the resident was combative and putting other residents at risk or if the resident was so fearful and the cycle could not be broken. She stated when a resident was combative or acting out, redirection, reassurance, calling the family, or diverting attention by giving food or drink would be interventions to try prior to giving [MEDICATION NAME]. She stated on 10/5/2017 she admitted the resident to the facility and he was calm and appropriate at the time. She stated later in the evening he started wandering, was confused and combative. She stated they were unable to redirect the resident, he was going into other resident's rooms and thought they were holding him prisoner. She stated they gave him [MEDICATION NAME] and called the family. The family came later and stayed with him. She stated she was unaware of the resident needing [MEDICATION NAME] after that night. She stated she worked 10/10/2018 and did not hear anything about the resident's behavior, only that he refused to use Bi-pap (breathing apparatus). When interviewed on 10/12/2018 at 11:10 AM, RN #13 Manager stated the resident had a PRN order for [MEDICATION NAME] that was started in the hospital and she expected other interventions to be tried before giving [MEDICATION NAME]. She stated it was appropriate to give if the resident was going to cause harm to himself or others and all other interventions were tried. She stated wandering, non-compliance with the call bell, and not sitting down were not acceptable reasons to give [MEDICATION NAME]. When interviewed on 10/12/2018 at 12:30 PM, the physician stated he did not like to use antipsychotics and if the resident came from the hospital he did not want to discontinue it abruptly. He stated antipsychotics should be used as a last resort if there was the potential for harming self or others. He stated the resident came with a PRN order for [MEDICATION NAME] and he expected it to be used after other interventions were tried. 2) Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired, she had physical behavioral symptoms directed towards others (hitting, kicking, scratching) and she had other behavioral symptoms not directed towards others (disrobing, disruptive sounds). The 3/16/17 comprehensive care plan (CCP), updated 7/25/18, documented the resident had intermittent [MEDICAL CONDITION], and could be aggressive and combative at times. Interventions included to provide a quiet, non-hurried environment and monitor negative interactions with staff and other residents. On 10/11/2018, the resident's record was reviewed on survey and documented: - A 9/18/2018 physician assistant (PA) note. The resident had increased behaviors. She was being treated for [REDACTED]. - A 9/18/2018 physician order [REDACTED]. - A nursing progress note date 9/26/2018 at 2:27 PM, written by licensed practical nurse (LPN) Manager #14, the resident was seen by medical and [MEDICATION NAME] was added every 6 hours PRN for agitation, anxiety and combativeness. - A 9/26/2018 physician order [REDACTED]. The resident's record did not document a rationale for the extended timeframe (23 days) of both PRN medications and did not document a specific duration the medications would be used. On 10/12/2018 at 11:20 AM, LPN Manager #14 stated in an interview the resident's behavior consisted of being combative, obsessing about using the bathroom, and she stripped and yelled at times. She stated she was aware of the new regulation for PRN [MEDICAL CONDITION], the time limit was 14 days and was not aware the resident had two current orders for [MEDICAL CONDITION] that exceeded 14 days. She stated liquid [MEDICATION NAME] was added on 9/26/2018 because the resident occasionally would not swallow pills. She was not aware the order written for [MEDICATION NAME] tablets on 9/18/2018 was not discontinued and should have been. On 10/12/2018 at 12:15 PM, the Medical Director stated the PA (physician assistant) that prescribed the resident's medication was not available for interview. He stated he was aware that PRN [MEDICAL CONDITION] needed to be reviewed after 14 days, nursing was responsible to alert medical when 14 days were up, and he was not aware the resident's medications had not been re-evaluated. 10NYCRR 415.12(l)(2)

Based on record review, observation, and interview conducted during the abbreviated surveys (NY 347 and NY 661) the facility did not ensure resident comprehensive care plans (CCP) were implemented for 2 of 6 sampled residents (Residents #1 and 4). Specifically, a certified nurse aide (CNA) completed bed mobility for Resident #1 when the resident was care planned for 2 person assistance. A second CNA assisted Resident #4 with transferring alone and the resident was care planned for assistance from 2 people. Findings include: 1) Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident had moderately impaired cognition and required extensive assistance of two people for transfers per the 12/30/2017 Minimum Data Set (MDS) assessment. The comprehensive care plan (CCP), updated 11/2/2016, documented the resident needed assistance from 2 persons with bed mobility and transfers. The certified nurse aide (CNA) care instructions, updated on 2/2/2017, documented the resident needed extensive assistance from 2 people with transferring and bed mobility. The 1/8/2018 Incident Report initiated by registered nurse (RN) #6 at 5:45 PM, documented the resident and CNA #2 were observed on the floor. Statements attached to the incident report included: - CNA #2's statement dated 1/8/2018 at 8:35 PM, documented she was helping the resident to a seated position (from bed), when the CNA's ankle gave out and she fell causing the resident to fall on her. - RN #6's statement (undated) documented she was called to the unit to assess the resident. The resident complained of pain to her right upper arm and an x-ray was ordered. - An unsigned oral interview with CNA #2 at 1:15 PM on 1/9/2018, documented CNA #2 stated she helped the resident sit up on the edge of the bed and noticed the resident was leaning off the bed so she picked her up to move her back and the CNA lost her balance and her ankle gave out causing her to fall and the resident fell with her. The resident fell on top of her and the resident landed on her side. CNA #2 reported she knew the resident was a 2 person assist with transfers and she thought if someone was a 2 person assist for transfers then they were a 2 person assist for everything. She reported she did not review the care plan prior to providing care to the resident as she did not know how to review it. She stated she was shown how to review care plans in the Kiosk (a wall mounted computer for documentation) during facility orientation. The 1/8/2018 at 11 PM, RN #6's progress note documented the resident had an acute humeral fracture and the nurse practitioner (NP) was notified and ordered narcotic pain medication and as needed ice packs. On 7/3/2018 at 2:15 PM, CNA #2 stated in an interview she knew the resident was a 2 assist for transfers and did not know that she was a 2 assist for bed mobility. At the time of the resident's fall, she stated she did not know what bed mobility meant and for the first several months of her employment, she did not know how to check care instructions in the Kiosk. She stated she determined a resident's care needs by looking at what other CNAs were documenting and following their documentation. She was trained on the Kiosks at orientation but did not understand the training, and did not ask for help. On 7/5/2018 at 1:15 PM, the Assistant Director of Nursing (ADON) stated in an interview, it was her understanding that CNA #2 did not check the resident's care instructions prior to providing care. She stated if someone was a 2 assist for bed mobility, there needed to be 2 staff members present and assisting. The ADON provided documentation that CNA #2 was educated on checking care instructions and use of the Kiosks when she was hired by the facility. 2) Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition was moderately impaired per the 1/26/2018 Minimum Data Set (MDS) assessment. The comprehensive care plan (CCP), updated on 11/4/2017, the resident needed extensive assistance from 2 persons with transferring and a bariatric walker. The 2/22/2018 at 8:15 PM, registered nurse (RN) Supervisor #15's progress note documented she heard certified nurse aide (CNA) #16 calling for help from the resident's room. She went into the room and saw the resident lying on the bed with her left leg hanging off the bed and bleeding profusely. There was a large laceration to the left calf involving fascia and muscle. It was 5 centimeters (cm) deep by 7 cm in length with irregular edges. The resident was sent to the emergency room . The 2/22/2018 emergency room report documented the resident was seen for a deep laceration requiring wound repair. The facility's 2/22/2018 incident report included a statement from CNA #16 which documented she was transferring the resident alone and the resident sat down heavily on the bed. After the transfer, the CNA noticed the resident's leg was bleeding and she did not know what the resident hit her leg on. On 7/5/2018 at 1:15 PM, Assistant Director of Nursing (ADON) stated in an interview, after the incident, the facility determined CNA #16 transferred the resident alone when she was a 2 assist and CNA #16 admitted to not checking the resident's care instructions prior to providing care. On 7/12/2018 at 11 AM CNA #16 was interviewed and stated at the time of the incident, she did not really know how to review care instructions in the Kiosk. She stated she learned it in orientation but found it confusing. She stated during the transfer, she had the resident in the wheelchair and planned to transfer her into bed. The resident stood on her own and held onto her nightstand and turned herself and plopped down onto the bed. She stated after the transfer, she saw blood on the floor and realized the resident was injured. 10NYCRR 415.11(c)(1)

Based on record review and interview during the abbreviated survey (NY 661), the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents reviewed for quality of care (Resident #4). Specifically, Resident #4 sustained a laceration to the leg and a treatment ordered by medical was not entered into the medical record as an order and was not implemented as planned. Findings include: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's cognition was moderately impaired per the 1/26/2018 Minimum Data Set (MDS) assessment. The 2/22/2018 at 8:15 PM, registered nurse (RN) Supervisor #15's progress note documented she assessed the resident after an incident and the resident had a large laceration to the left calf involving fascia and muscle that was 5 centimeters (cm) deep by 7 cm in length with irregular edges. The resident was sent to the emergency room (ER). The 2/22/18 at 10:16 PM RN #15's progress note documented she received a telephone call from the ER and the resident would be returning and had received 11 sutures to her left calf. The 2/22/2018 at 11 PM, RN Supervisor #15's progress note documented the resident returned to the facility with 11 sutures. The treatment administration record (TAR) documented on 2/22/2018 to protect wound area, keep dry and clean and elevate on pillow. There was no corresponding physician order. The 2/23/2018 physician assistant's (PA) progress note documented the resident sustained [REDACTED]. The plan was to do dressing changes twice a day with triple antibiotic ointment and monitor for infection. There was no documentation the treatment for [REDACTED]. There was no documented evidence on the treatment administration record (TAR) the resident received a treatment to her left lower leg on 2/23/2018. A physician order [REDACTED]. The 2/24/2018 RN #7's progress note at 3:56 AM, documented the resident complained that her dressing change was scheduled for twice a day and it was never done. RN #7 documented she explained to the resident there is no such order. The 2/24/2018 at 9:52 PM LPN #17's progress note documented the resident was adamant that her dressings were to be changed twice a day and LPN #17 advised her they were ordered for once a day. The 2/25/2018 RN #6's progress note at 7:17 PM documented the left lower leg continued with sutures and the area surrounding it was slightly red. The Supervisor was aware and medical was to evaluate. The 2/2018 TAR documented dry sterile dressing was applied to the left leg wound on 2/24/2018 and 2/25/2018. The 2/26/2018 PA's progress note documented the resident had [MEDICAL CONDITION] to the laceration on the lower leg. Keflex (antibiotic) was ordered and the dressings were changed to [MEDICATION NAME] (an antibiotic) dressings twice a day. A physician order [REDACTED]. The 2/2018 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A nursing progress note dated 2/27/2018 at 5:55 PM documented a call was place to the physician regarding temperature of 102.6 degrees Fahrenheit, severe reddened area generalized to lower left leg, symptoms of [MEDICAL CONDITION]. The plan was to administer [MEDICATION NAME] (an antibiotic), obtain a wound culture and monitor temperatures. If temperatures did not resolve send to the hospital. A physician order [REDACTED]. The 2/28/2018 at 9:37 AM and 10:01 AM, RN #6's progress notes documented the resident was sent to the hospital as the sutures on the leg wound were in place but the skin was fragile and sloughing off around the site. The 2/28/2018 hospital record documented the resident's admission [DIAGNOSES REDACTED]. On 8/22/2018 at 12:20 PM, the PA stated in an interview, he recalled the resident's incident well. He stated she had sutures placed and he wanted twice a day dressing changes to be done and triple antibiotic ointment to be applied. He stated when he wanted something ordered, he wrote a written order and left it in a box in the Nursing Supervisor's office. The Nurse Managers or Supervisors emptied the box and entered his orders into the medical record. He stated in this case, he wanted triple antibiotic ointment initially because it was a dirty wound as they did not know what the resident cut her leg on. On 8/22/2018 at 12:51 PM, RN Manager #6 stated in an interview, herself or one of the other Unit Managers or Supervisors entered the PA's orders for him. She stated she did not recall the specific order for triple antibiotic ointment or twice a day dressing changes for the resident and the copies of the handwritten orders were saved for a short time but would not be available going back to 2/2018. On 8/22/2018 at 1:10 PM, the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were interviewed and stated they did not have a copy of the PA's handwritten order for twice a day dressing change and triple antibiotic ointment from 2/2018. They stated the handwritten orders were saved for a few weeks. 10NYCRR 415.12

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure 2 of 3 sampled residents (Residents #8 and 9), reviewed for weight loss, maintained acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible. Specifically, Resident #8's nutritional needs and interventions for wound healing upon admission and subsequent significant weight loss were not addressed in a timely manner by the nutrition staff. Resident #9 was not provided nourishments as planned and did not receive a meal item as requested. Findings include: 1) Resident #8 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required supervision with eating, and extensive assist to total dependence for most activities of daily living (ADLs). The resident had an unhealed pressure ulcer, was on a mechanically altered diet, and did not have significant weight loss or gain. The comprehensive care plan (CCP) dated 3/7/2017 documented the resident was admitted with a Stage IV pressure ulcer on the sacrum (tailbone area), and did not include nutritional interventions. The weight record documented the resident weighed 253.4 pounds on 3/8/2017. A registered dietitian (RD) assessment dated [DATE] documented the resident was on a low-fat diet, no further weight gain was desired, and she would recommend discontinuing the low fat dietary restriction as it was not warranted. She would recommend starting Prosource (nutritional supplement) 30 cc (cubic centimeters) BID (twice daily) to provide an additional 200 kcals (calories)/30 grams of protein each day. She would provide snacks TID (three times daily) between meals for additional kcals/protein to help meet estimated nutritional needs and to promote wound healing. The CCP was updated on 3/12/2017 and documented the resident was at increased risk for alteration in nutritional status related to potential for weight loss, as the resident was leaving greater than 25% of meals uneaten and had increased nutritional needs secondary to wound healing. The goal was for the resident to maintain current body weight of 258 pounds, plus or minus 3%. Staff were to provide Prosource 30 cc BID, and snacks TID between meals. The resident's weight was to be monitored weekly for 4 weeks, then monthly if stable. The physician was to be updated with significant changes. Staff were to encourage/monitor oral intake at meals, snacks, and medication passes. Staff were to offer alternate foods/beverages if refused, provide specific food preferences, assess intake and weights, and document and report non-compliance. There was no documentation in the CCP regarding the resident's preference for planned weight loss. A diet technician progress note dated 3/28/2017 documented the resident was being treated for [REDACTED]. She would recommend offering the resident Jello for lunch to aid in hydration and yogurt at lunch to support gut flora (normal microorganisms in the intestines). She noted the resident's weight had been stable. The resident's meal intake record documented between 3/7 - 3/29/2017, the resident consumed between 1-25% 8 times, 26-50% 12 times, 51-75% 18 times, 76-100% 23 times, and no refusals. The weight record documented the resident weighed 238.2 pounds (15.2 pounds/6.0% significant loss) on 4/3/2017. The weight record noted 5.0 percent change in weight in 30.0 days. The resident's meal intake record documented a decline in intake between 3/30 - 4/11/2017. The record documented the resident consumed between 1-25% 14 times, 26-50% 12 times, 51-75% 2 times, 76-100% 4 times, and no refusals. An RD progress note dated 4/11/2017 at 1:44 PM documented the resident's nutritional POC (plan of care) was reviewed and appropriate, including needs assessed for wound status. The note did not document on the resident's weight loss. The resident's meal intake record documented a decline in intake between 4/12 - 5/17/2017. The record documented the resident consumed none 6 times, between 1-25% 31 times, 26-50% 19 times, 51-75% 6 times, 76-100% 6 times, and 8 refusals. The record documented the resident declined or did not consume most of her AM and PM snacks during this time. The 2017 weight record documented the resident weighed: - 236 on 4/17 (17.4 pounds weight loss since admission/6.8% significant loss); - 225.8 on 4/24 (27.6 pounds/10.89% significant loss); - 190.8 on 4/27, no re-weight documented, (62.6 pounds/24.7% significant loss); - 229.8 on 5/3 (23.6 pounds/9.31% significant loss); - 212 on 5/8 (41.4 pounds/16.34% significant loss); and - 210 on 5/17 (43.4 pounds/17.13% significant loss). There was no documentation by nutritional or interdisciplinary staff between 4/17 - 5/17/2017 regarding the resident's weight loss. A diet technician progress note dated 5/18/2017 at 1:41 PM documented the resident's weight was down. She had not been eating well and had been making an effort on her own to lose weight. Regaining the weight lost was not indicated; however ongoing rapid weight loss should be avoided. The diet technician would request low fat restrictions be re-evaluated and recommend it to be discontinued. She would refer the resident to the RD for diet counseling and the resident's weight would be monitored weekly. The weight record documented the resident weighed 207.6 on 5/22/2017 (45.8 pounds/18.07% significant loss). A diet technician progress note dated 5/22/2017 at 3:56 PM documented the resident's low fat diet had been discontinued due to weight loss and poor intake. The resident was observed on 5/22/2017 at 12:18 PM, seated in the dining room with her noon meal consisting of a swiss burger, potatoes, and green beans, on a fully rimmed plate. The resident was drinking her liquids out of Kennedy cups (spill-proof cups). At 5:52 PM, during the dinner meal, the resident notified staff she did not want her entree, grilled cheese, carrots, and soup, and wanted an egg salad sandwich in a bowl. At 5:57 PM, the resident was offered a peanut butter and jelly sandwich by another staff member, which the resident declined. During an interview with the resident on 5/23/2017 at 10:50 AM, RD #12 entered the room. The RD notified the resident she recognized the resident had lost a lot of weight at one time, and it would be healthier to lose weight slowly, for example, 2 pounds per week. She asked the resident if she wanted to lose weight, and the resident stated yes. The RD stated she was notified the resident requested supplements at meals. The resident confirmed she wanted to maintain her weight and not continue with rapid loss. The resident stated she was okay with having whole milk added at meals, and she wanted vanilla Mighty Shakes (supplements) in the AM and PM between meals. An RD progress note dated 5/23/2017 at 11:10 AM documented the RD met with the resident to discuss a request for a supplement. Although weight loss was desired, per the resident her appetite was poor and she was requesting a supplement to steady her weight loss and regain her appetite. Low fat milk was changed to whole milk and she would have a Mighty Shake sent BID between meals. During an interview with certified nurse aide (CNA) #13 on 5/24/2017 at 1:42 PM, she stated the resident consumed fluids well and did not consume solids well. CNA #13 stated the resident did not eat good. During a telephone interview with RD #12 on 5/25/2017 at 10:53 AM, she stated she could not recall details about the resident's nutritional status without viewing it in person. She saw the resident recently and could not recall which date. If a resident had a significant weight loss or gain in 1 week, the RD or diet technician should see the resident. They would look to see if the resident had a change in appetite or intake and potentially make changes in a supplement. She would follow up with a resident if there was a concern or change in a resident's status. During an interview with diet technician #11 on 5/25/2017 at 11:15 AM, she stated she had spoken with the resident maybe twice since the resident was admitted to the facility. The RD primarily followed the resident's nutritional status and would see all residents within the first week they were admitted . Another RD had assessed the resident following admission, as RD #12 had not started yet. At that time the RD had recommended Prosource. She was not sure about the resident's acceptance of the Prosource, and they would not check the administration record unless there was a clinical indication to do so. In viewing the record, she felt the resident had accepted the Prosource more than she had declined it and she would continue it as part of the resident's plan of care. She stated stated the facility had weight meetings on Wednesdays that included the diet technician, RD, and nurse Managers. She would print out a report on weights to bring to the meetings. They discussed the resident's weight loss/intake the first or second weekend in 5/2017. When she approached the resident, the resident stated she did not want to feel full and preferred more supplements than regular meal items. The diet technician stated the resident had a history of [REDACTED]. The resident was not eating well and the low fat diet was not helping her, so they discontinued the low fat diet. She had notified the RD to see the resident. They had added Jello and yogurt to the resident's plan of care, specific to the resident's urinary tract infection [MEDICAL CONDITION] and not to address weight loss. She was not aware of other interventions added to the resident's meal plan prior to the 5/2017 weight meeting. During an interview with registered nurse (RN) Supervisor #8 on 5/25/2017 at 12:40 PM, she stated she completes rounds on the 3 PM - 11 PM shift and she did not see the resident out of her room often for dinner time. Since the resident had moved to a new unit, she would often find the resident in her room during the dinner meal. 2) Resident #9 was readmitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required supervision after set-up for eating, and weighed 148 pounds. The MDS dated [DATE] documented the resident's weight was 149 pounds. The comprehensive care plan (CCP) updated 4/27/2017 documented the resident was at increased risk for alteration in nutritional status. Interventions included to provide supplements, monitor intake, and provide adaptive equipment to aid in self-feeding. The resident's weight record (vital report) documented the resident's weight was 140.6 pounds on 5/1 and 5/3/2017, 139.8 pounds on 5/9/2017, and 132.6 pounds on 5/15/2017. A physician progress notes [REDACTED]. A dietary progress note dated 5/15/2017 documented the resident had a significant weight loss, and she refused pureed foods at times. Interventions included pureed consistency diet, provide fortified mashed potatoes and cereal, add shakes twice daily between meals to provide additional calories, and monitor weights weekly. A dietary progress note dated 5/17/2017 documented the resident was being treated for [REDACTED]. Her intakes of foods and fluids had been poor and she was not meeting her minimum fluid needs. A dietary progress note dated 5/22/2017 documented the resident's diet was changed to mechanical soft. Her intakes were sporadic, and pureed food items continued to be provided on her meal trays to allow the resident food consistency choices. The resident was observed on 5/22/2017 at 12:50 PM with her meal in front of her in the unit dining room and she was not eating. The resident's menu slip documented she was on a mechanical soft diet. Attached to the menu slip was a printed slip that documented salt potatoes. The meal observed included the listed mashed potatoes with gravy and did not have the salt potatoes. At 12:55 PM on 5/22/2017, a tray of the PM (afternoon) nourishments was observed on the window sill in the dining room. Licensed practical nurse (LPN) #18 stated she was in the middle of passing them out to the residents in the dining room for lunch. On 5/23/2017 at 9:15 AM, the resident was observed in the unit dining room with her breakfast in front of her, including her AM Mighty Shake. The resident's meal pattern printed on 5/25/2017 documented the resident was to receive nourishments including: a morning (AM) nourishment of Mighty Shake Plus and canned fruit, and an afternoon (PM) snack of a Mighty Shake Plus and a snack, such as ice cream. During a telephone interview with the registered dietitian (RD) on 5/25/2017 at 11:00 AM, she stated the between meal nourishments were to be passed generally at 10 AM, 3 PM, and at bedtime. Fortified mashed potatoes were usually provided with lunch and supper and, depending how the meal pattern was set up, a resident could have a second starch when chosen from the menu. On 5/25/2017, during an interview with the diet technician at 11:15 AM, she stated the resident was to receive fortified mashed potatoes at lunch and supper. The attached slip on the resident's menu was the item the resident ordered for the meal and the resident should have received both the fortified mashed potatoes and the salt potatoes for the meal on 5/22/2017. The checker on the tray line should have seen the menu slips and should have made sure the resident received both items. All the nourishments for the day were sent to the floors at breakfast. Nursing was to pass the nourishments at 10 AM and between 2 to 3 PM. She preferred the nourishments not be passed during meals unless there was a specific reason to do so. She never observed nourishments being passed with meals, as it was important for residents to first eat their planned meal prior to receiving the between meal nourishments. On 5/25/2017 at 12:45 PM, LPN #18 was observed passing the PM nourishments in the dining room while the residents were eating lunch. During an interview at this time, the LPN stated she always passed the AM nourishments with breakfast and the PM nourishments with lunch and was never told to do it differently. 10NYCRR 415.12(i)(1)

Based on observation, record review and interview conducted during the standard survey, it was determined for 1 of 3 residents (Resident #8), reviewed for pressure ulcers, the facility did not ensure the necessary treatment and services were provided to prevent new pressure ulcers from developing. Specifically, for Resident #8, who was assessed as not at risk for pressure ulcer development, the resident developed boggy heels, the facility did not document regular monitoring of the resident's heels, did not properly implement pressure relieving devices, did not update the comprehensive care plan (CCP) in regards to pressure ulcer prevention, and did not communicate the use of planned pressure relieving devices to direct care staff. The resident subsequently developed an unstageable pressure ulcer, found by the surveyor, the facility had not been previously aware of. This resulted in actual harm to Resident #8 that is not immediate jeopardy. Findings include: Resident #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission skin check completed by a registered nurse (RN) dated 9/18/2013 documented the resident's heels were dry. The Braden Scale (for predicting pressure ulcer risk) dated 9/18/2013 documented the resident was not at risk for pressure ulcer development. The resident was to use a standard pressure reducing mattress. The comprehensive care plan (CCP) dated 9/18/2013 documented the resident was at risk for skin breakdown and used a pressure relieving mattress and cushion. The Resident Care Summary (care instructions) dated 9/18/2013 contained no documentation in regards to the use of pressure relieving devices for the resident. The CCP meeting progress note dated 9/24/13 documented the resident was at risk for developing pressure ulcers due to decreased mobility. The CCP recorded the resident was admitted with bruises, old scar tissue on the buttocks, and soft heels. The plan included initiating Heelbos (pressure relieving socks that provided extra padding under the heels). There was no documented evidence the CCP or Resident Care Summary were updated to include the use of Heelbos. The physician's admission history and physical dated 9/25/13 documented the resident's skin was intact. The 9/30/2013 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, was at risk for developing pressure ulcers, and had pressure relieving devices for the bed/chair. The 10/10/2013 physician's orders documented the resident was to receive skin prep (topical application that toughens the skin) to the heels 3 times a day, and was to wear heel protectors when in bed. The licensed practical nurse's (LPN) progress note dated 10/15/2013 documented the resident's heels were "feeling spongy" and she notified the physician who ordered skin prep via a telephone order. There was no documented evidence in the medical record the resident's heels were assessed by a qualified professional (registered nurse, physician). The telephone physician's orders dated 10/15/2013 documented the resident was to receive skin prep to both heels every shift. Review of the medical record from 10/15/2013 through 10/30/2013 revealed no documentation related to the condition of the resident's heels or in regard to the heel protectors as ordered. The Resident Care Summary was signed as reviewed on 10/21/2013 and contained no documentation in regards to pressure relieving devices for the resident. The MDS assessment dated [DATE] documented the resident was cognitively intact, had severely impaired vision, and needed extensive assistance with all activities of daily living (ADL), except eating. The resident did not resist care. The resident's skin was intact, he was at risk for developing pressure ulcers, and had pressure relieving devices for the bed/chair. The CCP meeting progress note dated 10/30/2013 documented the resident "has no skin issues but has scar tissue on coccyx." The note contained no documentation in regards to the condition of the resident's heels or a plan of care to address pressure relief for the heels. The progress note did not document the resident was resistive to care or non-complaint with interventions in place. Review of the medical record from 10/30/2013 - 11/19/2013 revealed no documentation regarding the condition of the resident's heels or the use of heel protectors. The 11/19/2013 physician's progress note documented the resident complained of "quite a bit of [MEDICAL CONDITION]," in his feet and heels. He reported they burned and he felt pins and needles. The physician adjusted the resident's dosage of [MEDICATION NAME] (medication for [MEDICAL CONDITION]). The physician's orders dated 11/19/2013 documented the resident was to receive skin prep to the heels twice a day and was to wear heel protectors when in bed. Review of the medical record from 11/19/2013 - 12/12/2013 revealed no documentation regarding the condition of the resident's heels or the use of heel protectors. The 12/12/2013 Braden Scale documented the resident was assessed not to be at risk for developing pressure ulcers and used a standard pressure reducing mattress. The resident's monthly renewal physician's orders signed by the physician on 12/17/2013 physician's orders did not contain an order for [REDACTED]. There was no corresponding medical/physician or nursing progress note on 12/17/2013 that included documentation regarding discontinuing the resident's skin prep and heel protectors. The 12/2013 Treatment Administration Record (TAR) documented the resident used heel protectors every day on each shift during the month and also received skin prep 3 times daily. There were no refusals documented for the resident for either treatment. The Daily Care Record (CNA care documentation) dated 1/2014 documented the resident's skin condition was "reddened" everyday for 1/1/2014 - 1/15/2014. The care record did not document where the reddened skin was located. The 1/2014 TAR documented the resident received skin prep to the heels every shift, everyday, and used the heel protectors daily, when in bed. The TAR documented a weekly skin check was done on 1/14/2014. The current Resident Care Summary dated 10/21/2013 contained no documentation regarding the use of pressure relieving devices for the resident. The facility's wound tracking book contained no assessments or skin tracking sheets for the resident. On 1/13/2014 between 10:30 AM and 11 AM, the resident was interviewed while he was lying on his back in bed. He was wearing regular socks on both feet, and his heels were resting directly on the mattress. The surveyor observed large pressure relieving booties on a chair in the resident's room. On 1/13/2014 at 11:50 AM, 12:10 PM, and 12:25 PM, the resident was observed sitting in the dining room. He was wearing black canvas shoes on both feet. On 1/13/2014 at 2:05 PM, the resident was observed ambulating on the unit with staff. He was wearing black canvas shoes on both feet. On 1/13/2014 at 2:20 and 3:10 PM, the resident was observed lying in bed, wearing regular socks on both feet. His heels rested directly on the mattress, and the pressure reliving booties were on the chair in the room. On 1/13/2014 at 5:30 PM and 5:50 PM, the resident was sitting in the dining room wearing black canvas shoes on both feet. On 1/14/2014 at 11:10 AM, 11:25 AM, and 11:30 AM, the resident was lying in bed wearing regular white socks on both feet. His heels rested directly on the mattress. At 11:34 AM, the resident was slid down in the bed, the back of his ankles were against the mattress, and his heels were hanging off the bottom of the bed. On 1/15/2014 at 9:15 AM, CNA #6 stated she was the resident's regular CNA. She stated he wore pressure relieving booties at night and not during the day. She stated he wore black canvas sneakers during the day because he needed those for walking. CNA #6 stated he did not need anything else for pressure relief when he was in bed during the day, as he was so tall his heels hung off the bottom of the bed. On 1/15/2014 at 9:30 AM, LPN # 4 stated in an interview, she applied skin prep to the resident's heels that morning. She stated his heels were "clear" with no open areas and "felt like heels, fine with no softness." On 1/15/2014 at 11:30 AM, the resident's heels were observed with LPN #4. LPN #4 removed Heelbos from both of the resident's heels. The resident's left heel was red with a small area of black eschar on the left side bottom of the heel. The right heel was intact and clear. LPN #4 put the Heelbos back on the resident's feet, and when she put the slipper on his left foot, the resident stated "that hurt". LPN #4 stated to the resident she was sorry to hurt his foot and left the room without asking further questions about his complaint of pain. The resident remained with Heelbos on and slippers over the Hellbos. LPN #4 stated to the surveyor immediately following the observation, that she worked per diem, did not know the resident, and the RN Manager (RN #1) could answer questions about the resident's skin. During an interview on 1/15/2014 at 11:45 AM, with RN #1, she said the resident received skin prep to both heels daily. She said she last saw the resident's heels about 2 weeks ago, and they were red. She said the resident's heels were checked weekly by nursing. The Director of Nursing (DON) did skin rounds, and she was not sure if the DON had seen the resident. RN #1 stated the DON had all paperwork regarding residents' skin in her office. On 1/15/14 at 2:05 PM, the DON stated in an interview, she had no skin documentation including assessments or skin tracking sheets for the resident as he was not followed on wound rounds. She stated all resident skin information was kept in her office so it did not get lost on the nursing units. She stated the resident was admitted with scabs on his toes and "never had anything on heels." She stated she saw his skin 2 - 3 weeks ago for a weekly skin check, and his heels were "healthy, pink, and spongy." She stated she had no documentation from 2-3 weeks ago when she saw his heels. She stated in addition to herself, the resident's family member looked at his feet within the last 2 weeks and stated they were fine. The DON stated after the surveyor observed the resident's heels, she assessed him. She stated the resident had an unstageable pressure ulcer on the left heel that was black and dry. She stated the resident had Heelbos, and foam pressure relieving booties, and he refused to wear them. She stated if he refused them, staff should have elevated his heels on pillows. She stated the resident also had a "noncompliance care plan." There was no documented evidence on the resident's current CCP (last reviewed by the interdisciplinary team on 11/7/2013) the resident was non-complaint with care or with planned interventions. Following the interview with the DON on 1/15/2014 at 2:05 PM, a Skin Team Review form dated 1/15/2014 was provided to the surveyor. The form documented the resident had an unstageable pressure ulcer, on the left heel measuring 0.5 centimeters (cm) x 0.3 cm, with eschar (dark, hard, dead tissue) and dry, pink edges. The DON documented the resident had skin prep ordered 3 times daily, with Heelbos and gel cushion socks. She documented the resident refused the Heelbos at times, and only wanted to wear shoes. 10NYCRR 415.26(C)

Based on observation, staff interview and record review, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents and did not have qualified professional staff assessments prior to moving residents off the floor after falls for seven (7) (#6, 8, 22, 62, 88, 92, and 93) of 18 residents reviewed for falls and injuries of unknown origin during the recertification survey. Specifically, the facility did not ensure that residents were assessed by a registered nurse (RN), physician or other authorized health professional prior to being moved after falling for Residents #22, 62, 92 and #93. Resident #92, who has dementia, was found in the bathroom on the floor, and the licensed practical nurse (LPN) #1 moved the resident from the floor in the bathroom to the toilet, without an assessment by an registered nurse (RN) and/or other authorized health professional. Resident #92 complained of left hip pain, the physician was then notified after the resident was moved off the floor and an order was received to send the resident to the emergency room (ER), and the resident was found to have a fractured left hip. In addition, the U.S. National Library of medicine notes do not move a person with an injured hip, pelvis, or upper leg unless absolutely necessary. This resulted in actual harm to Resident #92. In addition, the facility did not ensure the use of gait belts when ambulating residents that required extensive staff assistance for residents #6, #8,# 62 and #88. The facility did not ensure Resident #88 was ambulated as planned, with two (2) staff extensive assist with a gait belt and staff pulled on the resident's arms, and the resident sustained [REDACTED]. This resulted in actual harm for Resident #88. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy for residents #6, 8, 22, 62 and #93. This is evidenced by the following: 1. Resident #92: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as sometimes understood and usually understands and required extensive staff assistance of two (2) staff for activities of daily living. The Comprehensive Care Plan (CCP) for noncompliance dated 10/18/2012, noted the resident attempts self transfers, attempts to climb out of bed, attempts self toilet and attempts self ambulation. The approaches noted to assess resident's understanding, allow resident to verbalize, involve resident in planning compliance, use tamper proof alarm, and perform hourly checks. The CCP for activities of daily living dated 10/18/2012, noted the resident needs assistance with toileting, bathing, mobility, dressing and eating. The approaches noted that the resident was non-ambulatory due to increase weakness and required extensive assistance of two (2) staff for activities of daily living. The Interdisciplinary Progress Notes (IPN) dated 12/17/2012 at 5:45 AM, written by the supervising licensed practical nurse (LPN) #1, documented the staff heard resident's alarm sounding and went into his room and found the resident sitting on the floor in the bathroom, while on the floor the resident did not complain of any pain while doing range of motion (ROM), then while the resident was sitting on the toilet he complained of pain in left hip radiating down left leg. The physician was called and new order received to send resident to emergency room (ER) for evaluation and treatment. The facility's policy and procedure for when a fall occurs dated 08/08/2008 documented falls are the leading cause of injury. Proper assessment and interventions after a fall occurs is needed to treat injuries resulting from the fall and to prevent further injury. Under procedures was noted when a resident falls or is found on the floor, do not move the resident; call for assistance and cover with bath blanket. The nurse will do an initial evaluation checking for life threatening injuries, and give emergency care to stabilize the resident's condition. The nurse will then do a secondary, more thorough evaluation including a complete set of vital signs, neuro signs, if needed, range of joint motion and skin survey. If the resident is turned during this assessment, log roll and support neck to prevent further injury. If there is a question of hip, leg or spinal fracture, do not move the resident. Stabilize only. Call the physician. The U.S. National Library of Medicine-the World's largest medical library - PubMed Health last reviewed on 04/13/2013 documented for bones: broken fracture; and stress fracture that if more pressure is put on a bone than it can stand, it will split or break. It further notes the following under Do Not: move the person unless the broken bone is stable; move a person with an injured hip, pelvis, or upper leg unless it is absolutely necessary. If you must move the person, pull the person to safety by his clothes (such as by the shoulders of a shirt, a belt, or pant-legs); move a person who has a possible spine injury; attempt to straighten a bone or change its position unless blood circulation appears hampered; try to reposition a suspected spine injury; or test a bone's ability to move. There was no documented evidence that an RN or physician was notified in order to assess the resident prior to moving the resident from the floor to the toilet. Also, the NYS Department of Education/Office of the Professions states "Section 6902 of Article 139 of the Education law and section 64.6 of the Regulations of the Commission of Education states that an LPN performs tasks and responsibilities under the direction of a Registered Nurse (RN), physician, or other authorized health care provider. Under the direction of an RN means that an RN must be present on the premises or immediately available by telephone when professional services are give by a LPN. The Hospital Consultation dated 12/17/2012 noted the resident was found to have a fractured hip that required surgical repair. The consultation noted the patient can not give any history and has very advanced dementia. The Accident and Incident (A&I) report, dated 12/17/2012, noted the time of the incident was 5:10 AM. This report noted the certified nursing assistant (CNA) heard an alarm sounding, entered room and found the resident sitting on the bathroom floor. There were no complaints of pain but after sitting on the toilet the resident had a complaint of pain in left hip radiating down left leg. The resident was sent to the ER for evaluation. This A&I report was signed by the supervising LPN #1. The summary of this investigation revealed that there was no cause to believe any alleged resident abuse, mistreatment, or neglect regarding this resident has occurred and was signed by the Director of Nursing (DON). During an interview on 07/17/2013 at 7:00 AM, the supervising LPN #1 stated the resident was able to move his own extremities including lifting arms and legs. He said the resident did not complain of pain. Supervising LPN #1 described the resident's position as sitting on the floor in front of the shower stall facing the toilet. He said he sent a text to the physician to let him know that the resident had no complaints of pain and could move all his extremities. He was unable to provide documentation that the physician was notified prior to moving the resident from floor to toilet. He said the physician usually lets him know if the resident can be moved. He said when the resident was moved and placed on the toilet the resident complained of left hip pain. He said he then called the physician and obtained a new order to send the resident to the hospital. Supervising LPN #1 said that he lets the resident perform the range of motion, then asks the resident if the resident has hit their head, then he will text the physician or DON and sometimes both to find out what to do. He said that because he is an LPN, he can not assess so he checks just for visible injuries. The supervising LPN #1 said he did not have documented evidence of sending a text message to the physician or the DON notifying either of them of the resident's fall. During an interview on 07/17/2013 at 7:05 AM, Unit LPN #3 stated that she was on another floor when the incident occurred. She said that if she finds a resident has fallen she will have a CNA stay with the resident and get the supervisor. She said she does not move a resident as she waits for the supervisor. During an interview with the physician/Medical Director (MD) on 07/17/2013 at 1:30 PM, he stated he did not recall receiving a text message from the supervising LPN #1 for this resident. The physician said he did not have documented evidence of receiving a text from the supervising LPN #1 regarding moving this resident off the floor. He said the supervising LPN #1 can not assess a resident and that includes checking range of motion (ROM). He said the supervising LPN #1 should have called him to find out what to do. He said in this situation he would not have given an order to move the resident and that he believed the resident may have fractured a hip in the past. He said he would have had the resident sent to the ER for evaluation and treatment. The physician did not have documented evidence of receiving a text from the supervising LPN #1 regarding moving this resident off the floor. When the physician/MD was shown there was no documentation in the resident's medical record of the supervising LPN #1 texting him, he said he would expect to be called and that the nurse would document in the nursing notes. During an interview with the DON on 07/18/2013 at 10:30 AM, the DON said they would never get a resident up if the resident complained of pain or had decreased range of motion. When asked how this would be determined without an RN to assess, she stated the LPN would tell the physician and/or DON what she or he saw. When asked how you determine normal limits the DON responded that would be an evaluation. During an interview with the DON on 07/18/2013 at approximately 1:00 PM, she said that she did not receive any information on this resident until she was told the resident was being transferred to the ER. 2. Resident #93: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current Resident Care Plan Summary (used by the caregivers to provide care) documented for restraints/safety/positioning aides to use bed alarm and chair alarm. This plan noted for mobility to ambulate with extensive assist of two (2) staff (ten) 10 feet with roller walker to and from bathroom and wheelchair with pedals. The facility's policy and procedure for when a fall occurs dated 08/08/2008 documented falls are the leading cause of injury. Proper assessment and interventions after a fall occurs is needed to treat injuries resulting from the fall and to prevent further injury. Under procedures was noted when a resident falls or is found on the floor, do not move the resident; call for assistance and cover with bath blanket. The nurse will do an initial evaluation checking for life threatening injuries, and give emergency care to stabilize the resident's condition. The nurse will then do a secondary, more thorough evaluation including a complete set of vital signs, neuro signs, if needed, range of joint motion and skin survey. If the resident is turned during this assessment, log roll and support neck to prevent further injury. If there is a question of hip, leg or spinal fracture, do not move the resident. Stabilize only. Call the physician. The Accident and Incident (A&I) report dated 06/24/2013 documented that at 7:05 PM, the resident was found sitting on the floor. This report noted the resident had the dresser drawer opened with urine on the floor under the dresser. This report noted the resident had no injuries and range of motion was within normal limits (WNL) and was written by the supervising licensed practical nurse (LPN) #2. It was further noted the resident was confused at times. The investigation contained a statement from the certified nursing assistant (CNA) that noted that she was putting another resident to bed and the supervisor came in and got me. The CNA stated that she did not hear the chair alarm as it was low. The Interdisciplinary Progress Note (IPN) written by supervising LPN #2 dated 6/25/2013, untimed, noted this writer sitting at nursing desk and heard a noise went to look and found resident sitting on floor. The resident opened and urinated in the dresser drawer and on the floor. The resident had no injury, range of motion (ROM) within normal limits (WNL) and resident denied pain. This IPN noted the resident was assisted by two (2) staff up to wheelchair and physician aware. During an interview on 7/18/2013 at 10:30 AM with LPN #2, she stated that she works double shifts, evenings through nights. She stated that she heard a noise like a drawer opening and closing and no one should have been in that room. She said that the resident had the drawer opened and was sitting on the floor pushing on the drawer. She said she thinks he may have been trying to pull himself up off the floor with the drawer. She said that the resident's ROM was WNL. She stated that she called for CNAs and one CNA arrived. She said they took resident to his own bathroom. She said that she sent a text to both the physician and the DON to report. She said she believes the resident had a personal alarm and usually removed it. She said she does not recall if the resident's alarm was sounding. During an interview on 07/18/2013 at 10:45 AM with the Director of Nursing (DON), the DON stated that she did not investigate the chair alarm as to why it was not sounding and did not check to see if the batteries needed to be replaced. She said they would never get a resident up if the resident complained of pain or had decreased range of motion. When asked how this would be determined without an RN to access, she stated the LPN would tell the physician and/or DON what she saw. When asked how you determine normal limits, the DON responded that would be an evaluation. 3. Resident #22: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having severely impaired cognition and requires assistance of staff for activities of daily living. The Comprehensive Care Plan (CCP) for history of falls dated 01/2013 documented the resident was non-compliant and attempts unassisted transfers. The approaches noted to keep personal items within reach; provide proper lighting and foot wear; provide routine toileting assist and environment free of clutter; place call light within reach; use chair/bed alarm; place dycem to wheelchair; low bed with floor mats; and anti rollbacks on wheelchair. The Interdisciplinary Progress Note (IPN) written by the supervising Licensed Practical Nurse (LPN) #2 dated 05/21/2013 documented the resident was found in another resident's room on the floor in the closet. The IPN noted, at "7:40 pm resident found sitting in another resident's room closet took pants and brief off. Resident had BM (bowel movement) in closet and alarm was not sounding. No inj (injury) noted, ROM /WNL (range of motion/within normal limits), assist of two (2) staff members to standing position, resident cleaned. The physician, Director of Nursing (DON) and family aware. The facility's policy and procedure for when a fall occurs dated 08/08/2008 documented falls are the leading cause of injury. Proper assessment and interventions after a fall occurs is needed to treat injuries resulting from the fall and to prevent further injury. Under procedures was noted when a resident falls or is found on the floor, do not move the resident; call for assistance and cover with bath blanket. The nurse will do an initial evaluation checking for life threatening injuries, and give emergency care to stabilize the resident's condition. The nurse will then do a secondary, more thorough evaluation including a complete set of vital signs, neuro signs, if needed, range of joint motion and skin survey. If the resident is turned during this assessment, log roll and support neck to prevent further injury. If there is a question of hip, leg or spinal fracture, do not move the resident. Stabilize only. Call the physician. The Accident and Incident (A/I) report dated 05/21/2013 at 7:40 PM. signed by the supervising LPN #2, documented, "Resident was in another resident's room having a BM in closet, lost balance and was sitting on buttocks in closet. No injury noted, ROM/WNL (range of motion/within normal limits)." This incident report had checked that the physician was notified on 05/21/2013 at 7:50 PM and no new orders. The attached investigation summary dated 05/22/2013 written by the DON noted the resident was found sitting in another resident's room closet and was checked " and for recommendations for preventive measures not already in place/additional corrective measures taken was written "alarm". Under Section III for review of the investigation involving this resident has been completed was a check for "the investigation has revealed that there is no cause to believe any alleged resident abuse, mistreatment or neglect regarding this resident has occurred". This A&I report was signed by the DON, Administrator and Medical Director. The section for "follow up needed" was blank. The certified nursing assistant (CNA) statement attached to the investigation dated 05/21/2013 at 7:40 PM noted she was watching the lounge and heard the resident calling for help, went to check on him, seen he was on the floor and called the supervisor. The CNA noted the resident's mode of transfer was two (2) staff member assist and that the resident was not restrained. There was no documented evidence that the resident's plan of care was followed in regard to safety measures including the use of the resident's chair/bed alarms. In addition, there was no documented evidence of a registered nurse (RN) and/or physician assessment done after the resident was found on the floor. During an interview on 7/18/2013 at 10:10 AM with the supervising LPN #2, supervising LPN #2 stated the resident was on the floor with his pants down, pulling clothes off. She said he was trying to get up and was yelling. She said even though he is confused he can state if he is in pain. She said when she arrived the alarm was not sounding. She said to prevent further injury, the resident was picked up by two (2) staff members and brought to his room. She added that before the resident was moved his vital signs were obtained. She said that she either texts or calls the physician and DON. She said that what she writes on the incident report is what she texts to the physician. She said that normally the DON will say go ahead and get the resident up and the physician will say monitor the resident and if imminent injury then would send the resident out. She said she did not check into the alarm to see if it was working and/or was being used at the time of the incident. During an interview on 7/18/13 at 11:15 AM with the DON, she said she does not come in to see the resident. She said she receives a text message. She said that she does not know why the resident's alarm was not sounding and that she did not report this incident to the NYSDOH. The facility's policy and procedure (P&P) for Gait Belt not to provide for resident safety during ambulation and to reduce the risk of back strain to staff through use of the gait belts and proper mechanics. This P&P noted that all residents requiring physical assist of one or more persons will use a gait belt per the plan of care unless there are medical contradictions. 4. Resident #88: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having memory problems and requiring extensive assist of two (2) staff for activities of daily living. The facility's policy and procedure (P&P) for Gait Belt, undated, noted to provide for resident safety during ambulation and to reduce the risk of back strain to staff through use of the gait belts and proper mechanics. This P&P noted that all residents requiring physical assist of one or more persons will use a gait belt per the plan of care unless there are medical contradictions. The Comprehensive Care Plan (CCP) for needs assistance dated 01/03/2013 documented for approaches to ambulate resident with two (2) staff extensive assist with roller walker and gait belt; to use one (1) staff assist to turn in bed; and transfers with two (2) staff extensive assist with roller walker and gait belt. During an observation on 07/17/2013 at approximately 2:15 PM, the resident had her own gait belt in her room. The nursing to rehab referral form dated 01/14/2013 noted that the resident is buckling knees during transfers/ambulation requiring one to two extensive staff assistance. The rehab assessment noted that the resident required minimal assistance of one person to perform sit to stand and extensive assistance of one staff for ambulation and you may use gait belt for safety. The Communication Memo dated 01/18/2013 from Physical Therapy (PT) documented that the resident required minimal assist for transfers and extensive assist of one (1) staff for ambulation about 30 to 40 feet. It noted "you may use gait belt for safety and decrease risk of fall". The Accident and Incident (A&I) report dated 02/13/2013 written by the supervising licensed practical nurse (LPN) #1 documented that while the certified nursing assistant (CNA) was ambulating the resident to her bed the resident started to fall so she grabbed her left arm to keep the resident off the floor. This caused a large skin tear to left forearm, area cleansed with normal saline with three steri-strips applied. It was noted that the skin tear measured 7.4 centimeters (cm). The recommendations noted that staff was educated on using their anticubitals to resident axcillary areas if resident starts to lose balance. The statement from the CNA revealed the resident was transferred with two (2) staff assist with rolling walker short distances. Another CNAs statement revealed that the resident was ambulatory with walker. The resident's statement noted, "she grabbed my arm". The resident was noted to have difficulty with transfers and ambulation and the staff was noted grab the resident's extremities and the resident sustained [REDACTED]. The physician acute visit dated 03/13/2013 documented the resident had quite a bit of bruising on upper and lower extremities, arms and legs. This note documented that occasionally apparently she says that sometimes the staff bump her, which she says she knows they do not mean to, but she does bruise quite easily. We ordered some Geri sleeves for her to help pad her arms. The A&I report dated 04/05/2013 at 4:00 PM documented the resident was assisted by two (2) CNAs into the shower chair when the resident sustained [REDACTED]. The summary of the investigation noted that the resident received a skin tear to her arm when being transferred to shower chair. The investigation revealed that there was no cause to believe any alleged resident abuse, mistreatment or neglect regarding this resident has occurred. There was no documented evidence that the resident was transferred with the gait belt as planned and as noted per facility policy and procedure. The A&I report dated 04/28/2013 at 7:30 AM noted that during morning care staff noted ecchymosis to right upper breast, armpit and down bicep. The summary of the investigation noted that resident has an ecchymotic area noted to upper arm down to chest. The resident is a two (2) staff assist transfer and appeared it was caused during the transfer. This report noted under recommendation noted to use gait belt for transfers. The summary of the investigation noted that the resident has an ecchymotic area noted to upper arm down to chest. The resident is extensive 2 staff assist and appears was caused during transfer. The nursing to rehab referral form dated 06/03/2013 noted that the resident is very weak and unsteady and requires extensive two staff assist - staff used hoyer lift. The rehab recommendation noted to evaluated and treat five times a week for two weeks. During an interview on 07/16/2013 at approximately 3:00 PM, the nurse manager stated she was not aware that staff were ambulating the resident without a gait belt. She said staff needs to use the gait belt when assisting the resident with ambulation. During an interview on 07/17/2013 at approximately 2:00 PM, the Rehabilitation Director (RD) stated a gait belt should be used to transfer and or ambulate the residents that need extensive assistance. The RD and the surveyor completed rounds to all of the nursing units to check for presence of gait belts on the units. When the observation was completed on resident #88's unit, there were no extra gait belts present. The RD spoke to the RNM, who reported that the unit had 2 gait belts that were currently being kept in the rooms of the 2 residents who required them for transfer, resident #88 was stated as being one of the residents. 5. Resident #6: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having no short or long-term memory loss and requiring extensive assistance for activities of daily living, including ambulation. The facility's policy and procedure (P&P) for Gait Belt, undated, noted to provide for resident safety during ambulation and to reduce the risk of back strain to staff through use of the gait belts and proper mechanics. This P&P noted that all residents requiring physical assist of one or more persons will use a gait belt per the plan of care unless there are medical contradictions. On 07/15/2013 at approximately 10:15 AM, the resident was observed ambulating in the main entrance foyer, using a rolling walker with assistance of the Physical Therapist (PT). The resident was not wearing a gait belt and the PT was observed to be holding onto the resident's waist of her shorts as the resident was walking. During an interview on 07/15/2013 at 12:30 PM with the resident, the resident said sometimes the staff uses a gait belt and sometimes they do not. During an observation on 07/17/2013 at approximately 2:00 PM, the resident was observed to be in the physical therapy room as she was using a stationary cycle and she was wearing a gait belt. During an interview with the Physical Therapist (PT), who on 07/15/2013 was observed assisting the resident to ambulate, the PT said she did not use a gait belt to walk the resident secondary to history of back surgery and the fact that she was doing well. When asked why a gait belt was being used today in the therapy room, the PT did not respond. The RD Director stated that the gait belt should be used for those needing assistance. During an interview on 07/17/2013 at approximately 2:00 PM, the Rehabilitation Director (RD) stated a gait belt should be used to transfer and or ambulate the residents that need extensive assistance. The RD and the surveyor completed rounds to all of the nursing units to check for presence of gait belts on the units. When the observation was completed on resident # 6's unit, there were no gait belts present. The RD stated that all of the nursing units should have gait belts available at all times and that she would make sure to have gait belts brought to the unit. 6. Resident #62: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's policy and procedure (P&P) for Gait Belt, undated, noted to provide for resident safety during ambulation and to reduce the risk of back strain to staff through use of the gait belts and proper mechanics. This P&P noted that all residents requiring physical assist of one or mor persons will use a gait belt per the plan of care unless there are medical contradictions. During an observation on 07/17/2013 in the morning, the resident was being assisted for ambulation by two certified nursing assistants (CNAs), one CNA was the rehab CNA, with no gait belt and wheelchair follow. The resident was being supported under his left axilla by the rehab CNA. The resident was observed to be spastic with gait, very unsteady with poor balance, and poor foot control. The Comprehensive Care Plan (CCP) for assistance in activities of daily living dated 01/29/2013 documented to ambulate in hallway with two staff extensive assist with with rolling walker. The CCP did not include the use of a gait belt for ambulation nor did the Resident Care Plan Summary (used by caregivers to provide care). During an interview with the rehab CNA on 5/17/2013, she stated that she did not use a gait belt to ambulate the resident due to his jerking action in the hips during ambulation. During an interview on 5/17/2013 the RN Nurse Manager stated that the use of a gait belt was not included on the CCP or the Resident Care Plan Summary. The Physical Therapy Weekly Summary dated 05/08/2013 documented the resident ambulates 150 feet with contact guard assist. The physician mandatory review dated 6/25/2013 noted the resident says that he usually does well but in the afternoon muscles do tend to start freezing up on him. 10 NYCRR 415.12(h)(1)(2)