Every finding on record at Bethany Nursing Home & Health Related Facility Inc

Based on observations, interviews, and record review conducted during the Recertification Survey from 03/17/2025 to 03/21/2025, the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive (a resident's preferences for medical interventions in the event of a life-threatening episode) that would be honored for one (1) (Residents #89) of 32 residents reviewed for advanced directives. Specifically, the facility did not ensure that Resident #89's advanced directives preferences were consistently identified. This is evidenced by the following: The facility policy Advanced Directives, last reviewed May 2025, included it is the policy of the facility to honor the advance directives of all residents and if no advance directives are available and the resident or family have not stated their wishes to execute an advance directive, the resident will be designated as full code status (attempt cardiopulmonary resuscitation in the event of cardiac or respiratory arrest). 1. Resident #89 had diagnoses that included Parkinson's disease, diabetes, and high blood pressure. The Minimum Data Set (a resident assessment tool), dated 03/11/2025, included the resident was cognitively intact. During an interview on 03/17/2025 at 11:41 AM, Licensed Practical Nurse #1 stated the resident's name tag (outside the residents' rooms) is colored blue which indicated the resident was a full code and a white colored name tag means the resident is a DNR (do not resuscitate meaning cardiopulmonary resuscitation would not be started if the heart or breathing ceases). Licensed Practical Nurse #1 stated they use the name tag indicator in an emergency to know if a resident was a full code or a DNR. During an observation on 03/17/2025 at 3:01 PM, Resident #89's name was printed on a blue name tag (indicating their wishes for full code) on the wall next to the resident's door to their room. Review of Resident #89's electronic health record revealed a Medical Order for Life Sustaining Treatment (also known as a MOLST) signed by Nurse Practitioner #1 on 12/05/2025 that included wishes for DNR or to not be resuscitated in the event of an acute medical episode. Current physician's orders, dated 12/05/2025, included the resident had an advanced directives that included wishes were for DNR and do not intubate (insert a tube into the windpipe to assist with breathing). During an interview on 03/18/2025 at 2:38 PM, Licensed Practical Nurse #2 stated they would use the door tag indicator for code status in an emergency to see if a resident was a full code or not and check the Medical Order for Life Sustaining Treatment. They stated if they found a discrepancy they would treat the resident as a full code and start cardiopulmonary resuscitation. Licensed Practical Nurse #2 stated they had identified discrepancies between name tags, physician's orders, and Medical Order for Life Sustaining treatment forms in the past. During an interview on 03/18/2025 at 3:07 PM with Unit Clerk #1 and Registered Nurse Manager #1, Unit Clerk #1 stated they were responsible for placing and updating the name tags if code status changes. They stated they placed a blue name tag for Resident #89 when they were admitted because they did not have a Medical Order for Life Sustaining Treatment but did not update it when Resident #89 became a DNR. Registered Nurse Manager #1 stated Resident #89 had a blue name tag on their door, but it should have been white. They stated that if the code status indicators (name tag, physician's order, and Medical Order for Life Sustaining Treatment) did not match it would cause confusion and a resident's wishes for life staining treatment may not be followed. During an interview on 3/18/2025 at 3:28 PM, the Director of Nursing stated all code status indicators should match, and nursing staff should confirm residents' code status in the electronic health record and not use the door indicator alone. If there is a discrepancy, nursing staff should go by the Medical Order for Life Sustaining Treatment. 10 NYCRR 415.3(f)(1)(ii)

Based on record review and interviews conducted during the Recertification Survey from 03/17/2025 to 03/21/2025 for seven (Resident #2, #8, #50, #54, #66, #86, and #96) of 32 residents reviewed, the facility did not ensure the Minimum Data Set Resident Assessment (an assessment tool) accurately reflected the residents' status. Specifically, the issues involved inaccurate coding for Section A - Identification Information (Resident #96) and Section N - Medications (Resident #2, #8, #50, #54, #66, and #86). This is evidenced by, but not limited to, the following: The facility policy Resident Assessment Instrument Minimum Data Set, last reviewed September 2016, included the facility must complete an accurate, standardized, reproducible assessment of each resident's care problems on admission and periodically thereafter. 1. Resident #96 had diagnoses that included heart failure, kidney disease, and high blood pressure. The Minimum Data Set Discharge Assessment (a resident assessment tool) dated 02/13/2025, documented Resident #96 was cognitively intact and was discharged from the facility to the hospital. In a progress note, dated 02/13/2025, Registered Nurse #1 documented Resident #96 was discharged home with family and community services. During an interview on 03/20/2025 at 2:31 PM, the Minimum Data Set Coordinator stated Resident #96 was discharged to the community, not the hospital, and the Minimum Data Set was not coded correctly. 2. Resident #2 had diagnoses that included heart failure, diabetes, and chronic obstructive pulmonary disease (a group of lung diseases that cause ongoing breathing problems). The Minimum Data Set, dated dated dated [DATE], documented Resident #2 had moderate impairment of cognitive function and was receiving an anticoagulant (blood thinner to prevent blood clots) medication. Review of physician's orders, effective 01/29/2025 (at the time of the resident assessment), revealed aspirin 81 milligrams once daily initially ordered 04/19/2022. There were no orders for any anticoagulant medications for the time period identified. 3. Resident #50 had diagnoses that included high blood pressure and coronary artery disease (decreased blood flow to the heart caused by blocked or narrowed arteries). The Minimum Data Set, dated dated dated [DATE], documented Resident #50 had severe cognitive impairment and was receiving an anticoagulant medication. Review of the physician's orders at the time of the resident assessment revealed an order for aspirin 81 milligrams once daily, dated 05/18/2021, and no orders for an anticoagulant medication in the time period. During an interview on 03/19/2025 at 1:08 PM, the Minimum Data Set Coordinator stated they were responsible for completing sections A and I and ensuring accuracy of the information documented in the Minimum Data Set Resident Assessments. They stated they had been documenting aspirin as an anticoagulant in the resident assessments and did not know that aspirin should not be documented as an anticoagulant. During an interview on 03/20/2025 at 2:39 PM, the Director of Nursing stated the Minimum Data Set Assessments should be accurate, medications should be documented per the Resident Assessment Instrument manual, and aspirin should not be documented as an anticoagulant. They stated resident assessments should be accurate to ensure residents are receiving the care and services they need. During an interview on 03/21/2025 at 11:00 AM with the Administrator and Director of Nursing, the Administrator stated they had been aware of some discrepancies in the Minimum Data Set Assessments, but had not identified discrepancies specific to medications and discharge information. 10 NYCRR 415.11(b)

Based on observations, interviews, and record reviews conducted during a Recertification Survey from 03/17/2025 to 03/21/2025, the facility did not ensure the daily nurse staffing information was updated on a daily basis. Specifically, the nurse staffing information was not posted daily at the beginning of each shift during the survey, and the information on the form was not updated to reveal current dates and staffing changes. This is evidenced by the following: The undated Daily Nurse Staffing Data Protocol documented: The Scheduling Coordinator is responsible Monday to Friday for ensuring the nurse staffing data is posted in the lobby daily. In the nurse scheduler's absence, Medical Records staff or Skill 2 Unit Manager will post the staffing data. This will be completed as close to 7:00 AM as possible. On weekends and holidays, the Registered Nurse Supervisor will post the nurse staffing data close to 7:00 AM. This responsibility will be reviewed during any new Registered Nurse Supervisor orientation. During observations on 03/17/2025 at 10:03 AM, the nurse staffing information was posted at the main entrance and was dated 03/14/2025. At 4:15 PM on that same day, the nurse staffing information was dated 03/15/2025. During an observation on 03/18/2025 at 8:05 AM, the nurse staffing information remained dated 03/15/2025. During an interview on 03/20/2025 at 11:40 AM, Unit Clerk #1 stated they completed the nurse staffing information in the morning Monday through Friday. On weekends, the supervisor was responsible for updating and posting the nurse staffing information. Unit Clerk #1 stated they usually updated the nurse staffing information between 8:00 AM and 8:30 AM each morning, but they were sometimes behind and did not get it posted until 9:30 AM or 10:00 AM. They stated it had not been brought to their attention that the nurse staffing information was not being updated regularly on the weekends. During an interview on 03/20/2025 at 3:33 PM, the Director of Nursing stated it was Unit Clerk #1 and the weekend supervisor's responsibility to update the nurse staffing information and that the information should be posted daily on the day shift after receiving morning report. Additionally, the Director of Nursing stated there were some newly hired supervisors who had not been trained and that it had not been brought to their attention that the nurse staffing information was not being updated daily. The Director of Nursing stated there was a breakdown in their process, and they needed to train new staff and retrain their current staff. 10 NYCRR 415.13

Based on observations and interview conducted during the Recertification Survey completed on 3/24/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: Observations on 3/24/23 at 11:52 a.m. included two natural gas-powered dryers located in the skilled 3 ground-floor laundry room, and there were no carbon monoxide detectors within or in the vicinity of the laundry area. In an interview at this time the Maintenance Staff Member stated there were carbon monoxide detectors in the generator room, the boiler room, and the kitchen. The Maintenance Staff Member also stated that they test the carbon monoxide detectors and change the batteries but do not keep any logs. No documentation was provided to show that any of the carbon monoxide detectors in the facility were being tested . The 2015 edition of the International Fire Code (IFC), requires 1) carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance 2) carbon monoxide alarms shall be maintained in accordance with NFPA 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer's published instructions at least monthly. 10NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.1, 915.1.4, 915.6, Section 1103.9 2012 NFPA 720: 8.7.1

Based on observations, interviews and record review conducted during a Recertification Survey completed on 3/24/23, it was determined that for one (Resident #46) of three residents reviewed for skin conditions, the facility did not revise the resident's care plan to reflect the resident's current needs. Specifically, Resident #46's Comprehensive Care Plan (CCP) and Certified Nursing Assistant (CNA) Kardex (care plan used by CNA for daily care) was not revised to include the presence of recurring skin issues with related goals, and interventions to prevent such. This is evidenced by the following: Review of facility policy Care Planning Process, dated revised April 2022, revealed that the CCP includes a health assessment beginning on the day a resident is admitted and at least every 90 days after the resident's initial review, and more often if their medical condition changes. CCP changes are communicated to the appropriate staff at the time that the changes are made. The CCP also includes ongoing, regular assessment of a resident's condition to see if their health status had changes, with adjustments to the care plan as needed. Review of facility policy Skin Care, dated reviewed September 2021, revealed that during a resident's admission, skin checks are done weekly for four weeks and then at least quarterly by the Licensed Practical Nurse (LPN) staff, and any changes or new areas of concern are reported. Interventions are placed on the resident's care card (Kardex) and are updated as needed. The resident's care plan would address preventive measures, and if an actual skin issue existed (skin tear, wound, ulcer), it would address appropriate care and services, and would be updated as needed. Communication of any changes to the skin/wound or necessary treatment should be discussed with the Unit Manager and provider. Resident #46 had diagnoses of Parkinson's disease, Alzheimer's disease and frequent falls. The Minimum Data Set assessment dated [DATE], documented that Resident #46 was cognitively intact, had skin tears, and had a skin condition requiring the application of ointments and nonsurgical dressings. Current Physician orders included the following: a. Opti foam (protective wound treatment) to bilateral knee abrasions daily as needed (PRN) for abrasions dated as ordered 4/20/22. b. Alginate (wound treatment often used for draining wounds) with Opti foam to two skin tears on left knee every three days dated as ordered 2/20/23. c. Alginate and Opti foam to the left knee every day for a skin tear dated as ordered 3/20/23. Review of the current CCP and CNA Kardex revealed that Resident #46 was at risk for pressure ulcers, with related interventions including pressure reducing devices, protective and preventive skin care, and weekly skin audits. The CCP also included to make sure the resident had shoes or non-slip socks on at all times when out of bed due to self-transferring and falls and required contact guard (one or two hands on the resident but not weight bearing) with a 4-wheeled walker and a gait belt. The CCP and the CNA Kardex did not include that the resident had any current or recurring skin wounds with related goals or interventions. During an observation on 3/22/23 at 1:34 p.m., the CNA Kardex hanging in Resident #46's room was dated September 2022 and included that the resident required supervision (nearby but not hands on) and a 4-wheeled walker for transfers and for ambulation the resident required supervision with a gait belt and 4-wheeled walker. The room Kardex also included protective and preventive skin care daily and as needed but no interventions for current skin issues related to frequent falls. In a nursing progress note dated 3/18/23 LPN #5 documented that staff had found Resident #46 on the toilet with their left leg bleeding resulting in a skin tear to the left knee measuring approximately four centimeters (cm) by five cm. The resident stated they had gotten up to go to the bathroom without putting their call light on and lost their balance and fell . During an interview on 3/22/23 at 1:27 p.m., LPN #1 stated that the Kardex in a resident's room tells the nursing staff what level of assistance and care each resident's needs. LPN #1 stated that Resident #46 required a contact guard assist with transfers, meaning that a staff member should be near the resident. During an interview on 3/23/23 at 12:51 p.m., CNA #1 stated that the Kardex is based on the therapy recommendations and that things are added to the Kardex along the way as staff learn more about a resident. During an interview on 3/23/23 at 3:09 p.m., the Registered Nurse Manager (RNM) stated that the CCP is reviewed quarterly or more frequently if needed, and that all facility disciplines are involved in revising a resident's CCP. The RNM stated that skin breakdown, preventative interventions and skin treatments should be included on the CCP, and this information is transferred to the Kardex, which is then printed and placed in the resident's room. The RNM stated that Resident #46 has had abrasions on and off for the several weeks, and had bumped their knees, which reopened the scabbed-over areas. The RNM stated that Resident #46's care plan did not include their skin issues (skin tears, lacerations, or abrasions) and related interventions which could have been an oversight. During an interview on 3/24/23 at 10:43 a.m., the Director of Nursing (DON) stated that they would expect the CCP and the Kardex to include all the information that would drive a resident's care, as well as identified concerns or issues and goals and interventions. The DON stated skin issues and treatments should be included on the CCP. 10 NYCRR 415.11(c)(2)(iii)

Based on observation, interview, and record review conducted during the Recertification Survey completed on 3/24/23, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 20 residents reviewed for quality of care. Specifically, Resident #64 was not provided positioning devices for their [NAME] chair (specialized wheelchair), per therapy recommendations and the residents Comprehensive Care Plan (CCP). The finding is: The facility policy Rehabilitative and Functional Maintenance Services, revision dated March 2012, documented the facility will provide rehabilitative and maintenance services such as but not limited to walking, transfer training, bed mobility, Range of Motion (ROM), splint and brace, needs for adaptive equipment, eating and/or swallowing, amputation/prostheses care and communication, when necessary as indicated by the individualized assessment and input of the interdisciplinary team. Resident #64 had diagnoses including dementia, depression, and hypertension. The Minimum Data Set (MDS, a resident assessment tool) dated 2/9/23 documented the resident had severe cognitive impairment, required total assist by two+ staff members for transfers, and extensive assist for one staff member for wheelchair locomotion. The Occupational Therapy Discharge Summary, dated 3/18/22, documented discharge recommendations of bilateral arm troughs (positioning device), and calf/foot support (positioning device) to the residents [NAME] chair. Resident #64's CCP, dated 7/19/21 and the Certified Nursing Assistants (CNA) Kardex (care plan used by CNAs for daily care) included the use of a [NAME] chair with bilateral arm troughs for positioning secondary to poor upright sitting posture and bilateral leg rests and calf support/board. Multiple observations included the following: a. On 3/20/23 at 1:25 PM, Resident #64 was in the [NAME] chair leaning to the left with both feet dangling, making no attempt to self-propel. The bilateral arm troughs and bilateral leg rests with calf support/board were not on the [NAME] chair. b. On 3/21/23 at 11:34 AM, Resident #64 was seated at table, in the [NAME] chair leaning approximately 45 degrees to the left with both feet dangling, making no attempt to self-propel. The bilateral arm troughs and bilateral leg rests with calf support/board were not on the [NAME] chair. c. On 3/22/23 at 8:45 AM, Resident #64 was in a common area in the [NAME] chair leaning to the left with both feet dangling, making no attempt to self-propel. The bilateral arm troughs and bilateral leg rests with calf support/board were not on the [NAME] chair. During an interview on 3/22/23 at 10:01 AM the Director of Rehabilitation stated Resident #64 utilized bilateral arm troughs to assist with proper positioning and comfort secondary to poor trunk strength and the bilateral leg rests with calf support/board to prevent legs from dangling. During an interview on 3/22/23 at 10:10 AM the Registered Nurse (RN) #2/Resident Care Coordinator (RCC) stated they expected the care planned interventions to be implemented. RN #2/RCC stated that Resident #64 should have the bilateral arm troughs and bilateral leg rests with calf support/board in place when in the [NAME] chair. During an interview on 3/24/23 at 8:29 AM the Director of Nursing stated they expected adaptive equipment, including bilateral arm troughs and bilateral leg rest with calf support/board, to be implemented per the plan of care. 10 NYCRR 415.12

Based on interviews and record reviews conducted during a Recertification Survey, completed on 7/23/21, it was determined that the facility did not ensure that prompt efforts were made to resolve resident grievances for six of six (Residents #6, #26, #39, #55, #80 and #81) residents reviewed. Specifically, there was no documented evidence that concerns and issues, identified by residents on a Resident Council Precautionary Isolation Questionnaire provided to residents (in place of resident council meetings during COVID-19), completed April 2021 through June 2021, were addressed. This was evidenced by the following: Review of the facility policy Grievance Procedure, dated May 2006, included that a grievance is brought to the attention of the Social Worker (SW) by the resident, family, or staff member verbally or in writing. The SW will meet with the resident or family and document the grievance in the Grievance Log. Upon resolution of the grievance, the complainant will be notified of the findings within 21 days of receipt. During a resident council meeting on 7/20/21 at 1:30 p.m., with the surveyor, Residents' #6, #26, #39, #55, #80 and #81 shared that they had not been able to meet due to the pandemic, but had been asked if they had any specific concerns or issues. The resident's stated they did not know how to file a grievance, but they filled out questionnaires instead. Resident #6 stated, at this time, that they had missing clothes they reported on previously, and had not received any resolution. Residents #80 and #81 voiced several food issues that had not been resolved. Review of Resident Council Precautionary Isolation Questionnaires for the months of April 2021 through June 2021, revealed 14 questionnaires were completed for April 2021, 14 for May 2021, and 7 for June 2021 with concerns or issues that included, but were not limited to, food quality, short staffing concerns and the attitudes of several staff members. Review of the Complaint/Grievance Logs for May 2021 through July 2021 revealed that none of the concerns or issues raised by the residents on the Resident Council Precautionary Isolation Questionnaires were documented on the Complaint/Grievance Log. There was no documented evidence that any of these concerns or issues were resolved or reviewed with the residents. During an interview 7/21/21 at 10:24 a.m., the Activities Director stated activities staff went around to all residents and asked if they had any concerns or issues. She said the Administrator was the Grievance Officer, but that she forwarded the grievances to the SW. When interviewed on 7/21/21 at 10:24 a.m., the SW stated that they were the Grievance Officer and that the Activities Director provided them with the completed surveys. The SW stated they emailed specific concerns or issues to the appropriate department heads for review and resolution. The SW stated the concerns or issues received were not always grievances, but more about food issues which were reviewed at morning report. On 7/21/21 at 3:28 p.m., the Administrator stated he and the SW were the Grievance Officers. The Administrator stated he received calls from residents with concerns, but did not always formally document them. The Administrator stated the SW conducted surveys during COVID-19 when Resident Council was not meeting and expected the SW to report to him any resident concerns or issues identified and to follow up to resolve the specific concerns. The Administrator stated they did not have any evidence that the concerns or issues identified in the questionnaires had been addressed. 10 NYCRR 415.3 (c)(1)(i)

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 919), it was determined that for one of three residents reviewed, the facility did not ensure that each resident was seen by a physician at least every 30 days for the first 90 days after admission, at least once every 60 days thereafter, and no later than 10 days after the date the visit was required. Specifically, Resident #1 was seen by a Physician's Assistant 101 days after the admission visit. This is evidenced by the following: The facility policy, Provider Services, last reviewed May 2019, includes that the attending physician is to visit the resident at intervals of not less often than every 30 days, for the first 90 days of the resident's stay. After the initial 90 days less frequent intervals may be suitable, i.e. every 60 days. Permitting up to 10 days slippage will not affect the next due date. At each visit the physician must review the resident's total program of care including medications and treatments. If the attending physician is not available every 30 days, he is to designate in writing, an alternated physician, Nurse Practitioner, or Physician's Assistant to make every other required visit to the resident. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/22/18, revealed the resident was cognitively intact. review of the resident's medical record revealed [REDACTED]. There was no documented evidence that the resident had been seen by a provider between those dates; which was a total of 101 days. An Admission History and Physical, dated 11/15/18, revealed that the resident had atypical parkinsonism with concerns for worsening symptoms, primarily with gait (a person's manner of walking) and balance. The plan was to continue [MEDICATION NAME] 25-100 milligrams (mg) four times a day (8:00 a.m., 12:00 p.m., 3:00 p.m., 6:00 p.m.) and [MEDICATION NAME] 50-200 mg CR (Extended Release) at 9:00 p.m. A Provider Encounter, dated 2/24/19, revealed the resident was seen by the Physician Assistant for a monthly follow-up. The assessment and plan included that the resident had [MEDICAL CONDITION] and Autonomic Dysfunction and noted that the resident continues on medications and was stable. The visit note does not include the specific medications prescribed for the resident's [MEDICAL CONDITION]. A Provider Encounter, dated 2/27/19, revealed the resident was seen by the Nurse Practitioner (NP) for discharge preparation. The NP noted that on admission, [MEDICATION NAME] was ordered for 30 days based on hospital orders. The medication was inadvertently discontinued after 30 days and was not resumed. The plan included to resume [MEDICATION NAME] 25-100 mg four times a day and [MEDICATION NAME] 50-200 mg CR at 9:00 p.m. Review of physician orders [REDACTED]. When interviewed on 8/13/20 at 10:11 a.m., the Nurse Practitioner stated that she met with Resident #1 on 2/27/19 in preparation for their discharge and identified a medication variance related to [MEDICATION NAME] at that time. She stated that she did not routinely take care of the resident and had only seen the resident once or twice for acute needs during the resident's stay at the facility. In an interview on 8/20/20 at 10:01 a.m., the Medical Director stated the timeframe for a resident to be seen by a physician after an admission to the facility was at least every other month and on admission. He said Resident #1 should have been seen at 30 days and 60 days. He said medications are reviewed at those visits, and the [MEDICATION NAME] should have been reviewed at that time to determine if it was to be continued or discontinued. He said the physician may have seen the resident during that timeframe, but there was no documentation of any additional visits. He said the physician was no longer employed by the facility. He said the facility had concerns with his documentation and terminated him. When interviewed on 8/20/20 at 10:14 a.m., the Director of Nursing stated the Medical Records Director does the scheduling of physician visits. She said the schedule was printed every week and all new admissions and readmissions were added. She said the providers have up to ten days beyond the scheduled date to complete the visit. She said Resident #1 may have been seen between the admission visit and the visits in February 2019, but it was not documented. After reviewing the record, she could not find any additional provider visits documented. She said there are physician orders [REDACTED]. She said the facility identified that residents were not consistently being seen for their scheduled visits and that was why the physician was no longer with the facility. The physician who signed admission orders [REDACTED]. (10 NYCRR 415.15(b)(2)(ii))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 919), it was determined that for one of three residents reviewed, the facility did not ensure that residents were free of significant medication errors. Specifically, Resident #1 did not receive a medication used to treat [MEDICAL CONDITION] ([MEDICATION NAME]) for 75 days because the physician order [REDACTED]. This is evidenced by the following: The facility policy, Admission to (NAME)any Manor, last reviewed April 2019, included that when a resident is admitted or readmitted to (NAME)any Manor by a physician, nursing personnel will complete the admission process within 24 hours. The Clinical Coordinator or Infection Control Director will ensure that any medications with stop dates will be reviewed by the provider for appropriateness prior to submitting to pharmacy. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/22/18, revealed the resident was cognitively intact. An Admission History and Physical, dated 11/15/18, revealed that the resident had atypical parkinsonism with concerns for worsening symptoms, primarily with gait (a person's manner of walking) and balance. The plan was to continue [MEDICATION NAME] 25-100 milligrams (mg) four times a day (8:00 a.m., 12:00 p.m., 3:00 p.m., and 6:00 p.m.) and [MEDICATION NAME] 50-200 mg CR (extended release) at 9:00 p.m. A Medication Review Report, dated 11/30/18, included orders for [MEDICATION NAME] 25-100 mg give one tablet by mouth four times a day for [MEDICAL CONDITION] for 30 days and [MEDICATION NAME] CR Tablet Extended Release 50-200 mg give one tablet by mouth at bedtime for [MEDICAL CONDITION] for 30 days. Review of the December 2018 Medication Administration Record [REDACTED]. The medications were not included on the January 2019 MAR. On the February 2019 MAR, both medications were included on the MAR indicated [REDACTED]. A Discharge Note, dated 2/27/19, revealed that during discharge preparation the Nurse Practitioner noted that on admission, [MEDICATION NAME] was ordered for 30 days based on hospital orders. The medication was inadvertently discontinued after 30 days and was not resumed. The resident was not aware that they were no longer taking the medication and the plan was to resume [MEDICATION NAME] 25-100 mg four times a day (8:00 a.m., 12:00 p.m., 3:00 p.m., and 6:00 p.m.) and [MEDICATION NAME] 50-200 mg CR at 9:00 p.m. A physician's telephone order, dated 2/28/19, included to restart [MEDICATION NAME] and [MEDICATION NAME] CR at the above doses and times. A Medication Related Incident Report, dated 2/28/19, revealed that the resident's hospital orders had stop dates of 30 days for [MEDICATION NAME]. The orders fell off of the resident's active orders resulting in missed doses of [MEDICATION NAME] from December 15, 2018 to February 28, 2019. It was determined that there was no harm to the resident. When interviewed on 8/12/20 at 3:21 p.m., the Director of Nursing and the Infection Prevention Director stated that Resident #1's admission orders [REDACTED]. They said they were told by the case manager that the orders stand as they were written. The Investigative Summary, dated 2/27/29, included the following plan of correction: All admission orders [REDACTED]. All admission orders [REDACTED]. Providers will evaluate all orders with stop dates prior to the end date of the medication. Education was provided to the medical provider and the medication variance form was reviewed. The Registered Nurses received education regarding admission order entry. When interviewed on 8/13/20 at 10:11 a.m., the Nurse Practitioner (NP) stated that she met with Resident #1 on 2/27/19 in preparation for their discharge. She said the resident was cognitively intact, and when asked when and why the [MEDICATION NAME] was stopped, the resident was not aware that the medication had been stopped. After meeting with the resident, the NP further investigated when and why the medication had been stopped and discovered the variance. She notified the resident, the resident's daughter, and the resident's physician of the variance and reordered the medication. The NP stated that she did not know if not receiving the [MEDICATION NAME] for that length of time would cause a decline in the resident's functional mobility, but in theory that was possible. She said the resident had [MEDICAL CONDITION] which is a progressive disease, and sometimes even on medications a person with a progressive disease could have a decline in their functional mobility. When interviewed on 8/13/20 at 1:41 p.m., the Licensed Practical Nurse (LPN) stated that the LPN was not responsible for entering admission orders [REDACTED]. She said if a medication was ordered for a specific timeframe, when that time period expires the medication goes away and can no longer be seen on the electronic MAR. Based on observations, interviews, and record reviews on 8/10/20 to 8/13/20, the surveyor verified that the facility actions had been implemented. (10 NYCRR 415.12(m)(2))

Based on observations and an interview conducted during the Recertification Survey, it was determined that for one (Skilled One) of three resident units, the facility did not ensure that the resident environment was as free of accident hazards as possible. Specifically, the surface of an electric fireplace exceeded 125 degrees Fahrenheit in a resident occupied space. This is evidenced by the following: Observations in the presence of the Director of Facilities on 1/14/19 at 1:10 p.m. revealed an electric fireplace below a large television on the lower wall of the first floor Skilled One Unit dining room. The unit was blowing out hot air, and the metal surface was very hot to the touch. When measured by the surveyor using a digital(NAME)thermometer, the surface temperature of the heater was 158 degrees Fahrenheit. One resident was sitting in a chair approximately 2 feet from the hot surface and four other residents were seated in the dining room at that time. The Director of Facilities then turned the dial on the heater to lower the temperature and said that they would look for a barrier to put in front of the heater or take the control knob off. An interview with the Director of Facilities on 1/16/19 at 9:50 a.m. revealed they could not find any paperwork on the heater and that it was an older unit so they decided to unplug it. The 2010 edition of the Facilities Guidelines Institute (FGI) states: heating units shall have a maximum surface temperature of 125 degrees Fahrenheit (52 degrees Celsius) or shall be protected from occupant contact. (10 NYCRR 415.29(a)(1); 2010 FGI: 4.1-8.2.6.3(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 741), it was determined that for one (Resident #67) of three residents reviewed for pressure ulcers, the facility did not ensure that a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The issues involved the lack of consistent monitoring of the wound, the lack of timely medical notification of a change in the wound, and the lack of care planning for an actual pressure ulcer. This is evidenced by the following: Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/11/18, revealed the resident had severely impaired cognition, had an unhealed Stage II (partial thickness skin loss) pressure ulcer, moisture associated skin damage, and was receiving pressure ulcer care. Review of the facility policy, Pressure Ulcer Assessment, revealed that any open area would be documented on the resident care plan and care card, the care plan and care card would be updated with any new changes, the licensed nurse performs treatments and documents completion, the licensed nurse communicates information regarding the current status or changes with pressure ulcer immediately to the Registered Nurse (RN), and worsening wounds must be assessed by a RN and seen by medical staff. Review of the facility policy, Pressure Ulcers, revealed the care plan would address preventative measures, and if an actual ulcer exists, the care plan would address appropriate care and services and would be updated as needed. Review of the progress notes revealed on 11/24/18, a Licensed Practical Nurse (LPN) documented that the resident had a dime-sized, red possible decubitus ulcer on the buttocks, and it was documented in the medical doctor's book. On 11/25/18, a RN Supervisor documented that staff reported the resident had open areas in the sacral area and documented a treatment was applied to two small open areas measuring 0.5 centimeter (cm) x 0.25 cm. Review of a medical office visit, dated 11/26/18, revealed the resident was seen by the Nurse Practitioner (NP) and wound nurse for a new Stage II ulcer on the coccyx (area between the crease of the buttocks near the tailbone) measuring approximately 0.5 cm. The plan for treatment included [MEDICATION NAME] (a skin paste used to treat and prevent diaper rash, wet, or cracked skin) to ulcer every shift and as needed with incontinence, weekly checks by the wound nurse, and reposition in bed every two hours. Review of the Comprehensive Care Plan (CCP), dated 11/18/18, revealed the resident was at risk for developing skin breakdown or pressure ulcers secondary to decreased physical mobility with interventions including protective and preventive skin care daily and as needed. The hard copy of the CCP, dated 1/18/18 filed in the resident's chart, did not include any handwritten notes to reflect the new pressure ulcer or interventions. The current Visual/Bedside Kardex revealed pressure reducing devices as recommended to include geo mattress and wheelchair cushion. The Kardex did not include information about the Stage II pressure ulcer, prescribed treatment, turning and positioning every two hours, or the use of a positioning aide while in bed. Review of the resident's active orders, dated 11/27/18, revealed to apply [MEDICATION NAME] to coccyx ulcer every shift and as needed for incontinence. Review of the Treatment Administration Records (TARs) for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) 2019 revealed documentation that the [MEDICATION NAME] had been applied every shift except for 12/2/18 (evening shift) and 1/2/19 (evening shift). There were no documented as needed applications of the [MEDICATION NAME] for the three months. Review of Wound Care Flow Sheets revealed the start date for the Stage II wound was 12/2/18. The first documented assessment on the Wound Care Flow Sheets was on 12/18/18 at which time the wound care nurse documented that the resident had a small open area on her sacrum measuring 2 cm x 3 cm x 0.1 cm. The resident was also seen on 12/28/18, 1/3/19, and 1/13/19 at which time the wound care nurse documented that the wound remained unchanged and to continue with [MEDICATION NAME] as ordered. During an observation of care on 1/18/19 from 10:01 a.m. to 10:43 a.m., the resident was initially lying flat in bed, with no pillow or wedge propped under the resident. The resident requested to use the bed pan at which time her brief was removed and appeared to be dry. The resident had an open area on her coccyx. There was no dressing or ointment visible on the wound at that time. The area measured approximately 3 cm x 2 cm x 0.5 cm with pink granulation tissue (new connective tissue and blood vessels that form on the surface of a wound during the healing process) covering approximately 90 percent of the wound bed and approximately 10 percent of the wound bed covered with yellow slough (dead tissue on the wound bed that can delay or prevent healing). The tissue surrounding the wound was macerated (softened skin resulting from prolonged exposure to moisture) and white in color. There was dark, pink tissue surrounding the maceration that was non-blanchable (skin redness that does not disappear when pressed). After care was completed, the resident was propped slightly to her right side with a pillow. After surveyor intervention, the RNM documented on 1/18/19 that the resident's coccyx wound measured 1.5 cm x 3.5 cm and was 1 millimeter deep and warranted a dressing change. Physician orders, dated 1/18/19, included to apply an alginate dressing (a wound care product used to treat open ulcers which absorbs fluids and promotes healing) to coccyx daily prior to [MEDICATION NAME] application. When interviewed on 1/17/19 at 2:19 p.m., Licensed Practical Nurse (LPN) #1 said the resident did not currently have a pressure ulcer and that she was not getting any treatments that she had to do. Interviews conducted on 1/18/19 included the following: a. At 9:56 a.m., Certified Nursing Assistant (CNA) #1 reviewed the Kardex and then stated that turning and positioning was not on the care card, but everyone required turning and positioning and it should be done every two hours. CNA #1 said when turning and positioning the resident she will put a pillow under her to prop her up but sometimes she wants to lay flat. At 10:30 a.m., CNA #1 said that she saw the wound and would check with the nurse to see if there was anything that needed to be put on the wound. She said that sometimes the nurse directs her to apply cream and other times the nurse applies the cream. CNA #1 exited the resident's room at that time to get the nurse. b. At 10:33 a.m., CNA #2 stated that it is not usually documented on the care card if a resident needs cream applied. CNA #2 found [MEDICATION NAME] Skin Protectant Paste in a drawer in the resident's room and said that was the standard cream. CNA #2 said the nurse would tell us to put it on if there was an open area. She said that she has seen the wound before and it looks about the same. c. At 10:39 a.m., the Registered Nurse Manager (RNM) entered the resident's room with a tape measure and [MEDICATION NAME]. At that time, she stated the wound measured 3.5 cm x 1.5 cm and applied the skin paste. The RNM said that she would get the NP to look at the wound because it looked worse to her and probably warranted a dressing change. d. At 11:55 a.m., after reviewing the resident's medical record, the RNM stated there was a new order for [MEDICATION NAME] written on 11/26/18. After further review, there were no order changes for the wound until 1/18/19. She said that the resident should be turned and positioned each time incontinence care is provided. The RNM stated that the facility does not have a turning and positioning schedule per say but her standard is every two hours, and usually a wedge cushion is used for a repositioning device. The RNM said that CNAs can apply the barrier cream with supervision by the LPN to ensure it was put on. She stated she will revise the CCP to reflect the pressure ulcer, document her assessment of the wound that day, and refer the resident to the skin care team so they can lay eyes on it again. She said the skin team was aware of the Stage II ulcer and have been following it. The CCP was updated at that time. She said that the Kardex was used for the CNAs/LPNs to direct the necessary care for residents. e. At 12:24 p.m, the RN Wound Care Nurse stated that Quick Rounds was used for wound monitoring, and the first day the resident was identified as having the pressure ulcer was 12/2/18. She said that date would be the first day that she would have been notified about the wound. She stated that she had just seen the wound on Tuesday and thought it was stable. The RN Wound Care Nurse said she would expect that the Stage II wound would be on the CCP, it could have been handwritten on the paper copy of the CCP until the next review date, and then updated in Point Click Care (the facility's electronic medical record). She said the unit manager, or whoever was covering the unit at that time, would be responsible for updating the CCP. f. At 2:17 p.m., LPN #1 stated that she did not know the wound was open. She thought when the cream was first ordered, the resident just had some redness. She stated that the CNAs can apply the [MEDICATION NAME], but they should let the nurse know if the wound is open. LPN #1 said that no one notified her that the resident's wound was open. g. At 2:20 p.m., the Director of Nursing (DON) stated that a pressure wound should have assessments weekly and as needed. She said with a new wound, we are looking at it more frequently but not necessarily documenting it. She said that weekly wound rounds are currently documented in Quick Rounds, and there should have been something documented in the record between 11/26/18 and 12/18/18. The DON said if the wound was not improving, it would be reassessed. She said if the wound was stagnant or declining, the NP who is wound certified, would reevaluate it and order a treatment change. CNAs or LPNs can apply the [MEDICATION NAME] to an open wound. The nurses would need to check to make sure that the cream was applied correctly. The DON said that the wound and interventions should be added to the CCP and Kardex so that staff know what is needed for the resident, such as the positioning wedge or preventative skin care. (10 NYCRR 415.12(c)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #45) of two residents reviewed for hydration, the facility did not ensure sufficient fluid intake to maintain proper hydration. The issues involved inconsistent monitoring of supplements and insufficient offering of fluids during meals. This is evidenced by the following: Resident #45 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/27/18, revealed that the resident had severely impaired cognition, had no dental issues, and required assist of staff for eating. The current Comprehensive Care Plan included that the resident had potential for nutritional problems and a decline in eating related to dementia. Approaches included that the resident required assist to set up meals, encouragement and supervision at all meals, aspiration precautions, nectar thick fluids, finger foods as able, no straws, monitor intake and record every meal, and to offer nutritional supplements after meals. Comfort care was initiated on 3/14/16 which included no weights or labs to be done. In the most recent dietary note, dated 11/28/18, the Dietary Technician (DT) documented that the resident feeds herself finger foods and requires assistance as needed. The resident has a variable appetite with a three day average intake of 38 percent of her meals and an average fluid intake of 1,500 cubic centimeters (cc) per day. Fluids are encouraged throughout the day. Review of the Point of Care meal intake (electronic health record) for the past two weeks revealed that the resident averaged 0 to 25 percent of her meal and all fluids recorded were from 240 cc per day to 1,000 cc per day. Review of the Medication Administration Records (MARs), from 11/1/18 through 1/16/19, revealed that Ensure (nutritional supplement) was ordered three times a day but the amounts received were only documented on 30 of 66 opportunities for the past 22 days and not documented at all before that time. Observations included the following: a. On 1/14/19 at 12:05 p.m., the resident was seated in the hallway eating a ground meat sandwich. The rest of her tray, including fluids, was behind her on a shelf out of sight. After 15 minutes, the resident was offered a sip of a drink and was then left alone again without fluids in reach. b. On 1/16/19 from 12:30 p.m. through 1:05 p.m., the resident was eating an egg salad sandwich independently. The lunch tray was again placed behind her on a shelf out of reach. A Licensed Practical Nurse offered her one sip of chocolate Ensure via a straw, and the resident was again left with no fluids in her reach. At no time was the resident offered anything else to eat or drink from her tray. c. On 1/17/19 from 7:55 a.m. through 9:08 a.m., the resident was eating toast. No fluids were in reach, and no fluids were offered to her for the entire observation. The tray was sitting behind her with yogurt, two cartons of milk, and a glass of Ensure on it, none of which was offered throughout the observation. Interviews conducted on 1/17/19 included the following: a. At 10:01 a.m., the primary Certified Nursing Assistant (CNA) stated that she did not pick up the resident's tray that morning, so she was not sure what the resident got. She said the resident was only offered one thing at a time because she will play with it and dump the fluids. The CNA said everyone was assigned to help with dining and offer the resident fluids throughout. The CNA said she did not offer the resident any fluids and that she should have. She said that when staff document the fluids in the computer, it is all the fluids together including the Ensure. b. At 2:56 p.m., the DT stated that the resident eats more when she does not have all the beverages in front of her and that she should get the Ensure after she eats. The DT said that the Ensure is an order, so it should be documented three times a day on the MARs along with the amount which should be 240 cc. She said she realized no amounts were being recorded on the MARs on 12/26/18, and she spoke with the Nurse Manager and staff about it but it appeared they were still not documenting the amounts consistently. She said she would have to do more education. The DT said the resident has juice or milk on her tray which should be offered while she is eating to help keep the food moist but not ruin her appetite. The DT said that the resident was careplaned for no straws. In an interview on 1/18/19 at 10:00 a.m., the Registered Nurse/Resident Care Coordinator stated that absolutely everything on the resident's tray should be offered throughout the meal with drinks in between. She said the resident was on aspiration precautions and needs fluids to help swallow, that is why she is in the common area during meals. (10 NYCRR 415.12(j))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #12) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime was free of unnecessary medications. The issues involved lack of a timely re-evaluation of the resident's continued use of an antipsychotic medication, lack of psychosocial follow up, lack of behavior monitoring, and lack of care planning regarding targeted behaviors and/or non-pharmacological interventions. This is evidenced by the following: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/1/18, revealed the resident was cognitively intact, exhibited no behaviors at the time, and scored 1 out of 27 in the interview for signs of depression due to overeating. admission orders [REDACTED]. The Comprehensive Care Plan (CCP), dated 10/25/18, revealed that the resident was at risk for falls related to weakness and [MEDICAL CONDITION] drug use. Interventions included assistance with all Activities of Daily Living. The CCP does not mention target behaviors, nonpharmacological interventions, or goals related to a taper of [MEDICAL CONDITION] medications. Review of a pharmacy recommendation, dated 10/29/18, revealed a recommendation that the resident was admitted on [MEDICATION NAME] with no clear [DIAGNOSES REDACTED]. The pharmacists wrote that should the workups and nursing behavioral monitoring reveal no significant behaviors or identification of a chronic psychiatric condition, please consider implementing a tapering schedule and/or discontinue the [MEDICATION NAME]. The recommendation was marked 'agree, will do' and signed by the licensed prescriber on 10/30/18. Review of the admitting history and physical, dated 11/2/18 and signed by the physician, revealed that the resident has some [MEDICAL CONDITION]. The resident's periods of [MEDICAL CONDITION] occurred with any type of medical illness including UTIs which caused severe confusion, delusions, and agitation at times. Review of interdisciplinary progress notes from admission on 10/25/18 through 1/16/19 revealed multiple notes that included the resident was alert and oriented. There was no documentation of any negative behaviors or signs of depression. Review of medical visits since admission revealed that the resident was seen by the Nurse Practitioner (NP) on 11/19/18, 11/23/18, 12/17/18m and 1/16/19 for a UTI, eye redness, and hemorrhoids. There was no mention in any note about behaviors, delusions, or complaints of depression. When asked about a psychosocial workup the surveyor was given a preadmission note, dated 9/11/18, that was signed by the attending physician and revealed the resident was seen in memory clinic, diagnosed with [REDACTED]. The goal at that time was to control the risk factors which were being done, and the resident was having no evidence of [MEDICAL CONDITION]. During observations and interviews with the resident on 1/16/18 at 3:54 p.m. and again on 1/18/19 at 11:30 a.m., the resident was alert and oriented, pleasantly conversing with the surveyor, and denied any complaints. The resident stated she knew she was on the [MEDICATION NAME] but she was not sure what kind of medicine it was and believed it was started a few years ago for her memory. The resident said they tried to take her off it once, and she did not do very well but that was awhile ago and she felt she was doing much better now. Interviews conducted on 1/17/19 included the following: a. At 8:39 a.m. and again on 1/18/19 at 10:03 a.m., the Registered Nurse (RN)/Resident Care Coordinator stated that they have behavior meetings monthly. She said that the pharmacist reviews everyone on [MEDICATION NAME] and that everyone on [MEDICATION NAME] should have a behavioral tracking sheet to justify a dose reduction or lack of one. The RN said that she was aware that the resident had some delusions with medical issues but she was not aware of any since admission. She said the resident should have behavioral tracking sheets and should be care planned for the use of a [MEDICAL CONDITION] medication. She said it appeared that the resident fell through the cracks. b. At 8:32 a.m., the primary day shift Certified Nursing Assistant (CNA) stated that the resident was very sweet and independent and has not had any behaviors or hallucinations since admission that she is aware of. c. At 8:56 a.m., the Social Worker (SW) stated the resident was discussed in the monthly behavior meeting in November, and they were trying to track down why the resident was on [MEDICATION NAME]. The SW said staff use the behavior tracking sheets but could not remember if the resident had any monitoring sheets. The SW said she was told to add [MEDICAL CONDITION] to the resident's diagnoses. She said the resident had not had any behaviors since admission and they have not discussed it since. d. At 3:30 p.m., the evening shift CNA stated that the resident has never had any behaviors, delusions, or any issues at all since admission. Interviews conducted on 1/18/19 included the following: a. At 10:17 a.m., the NP stated that she signed that pharmacy recommendation because she agreed with the pharmacist and was going to begin a taper, but she was told by the Nurse Manager at that time that the attending physician preferred to manage his residents and would address it. The NP stated the resident has not had any behaviors, and that if any resident was on a [MEDICAL CONDITION] medication staff should track behaviors. b. At 10:33 a.m., the physician stated that he thought the resident had started the [MEDICATION NAME] approximately six months ago because she was having hallucinations when she was living with the family. He said the goal was to discontinue the [MEDICATION NAME] now that she has stabilized. The physician said that there have been no psychiatric consults because it was felt to be more due to acute medical issues as opposed to anything psychological in nature. (10 NYCRR 415.12(l)(2)(i))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (both medication carts on the Skilled One Unit) of six medication carts reviewed for medication storage, the facility did not ensure that all drugs and biologicals were properly labeled and stored in accordance with State and Federal laws. The issues involved medication carts that were unlocked, unattended, contained open and unidentified pills in a cup, an undated opened insulin pen, and narcotics that were not double locked. This is evidenced by the following: The facility policy, Storage of Drugs and Biologicals, dated as last reviewed on (MONTH) (YEAR), included that all medications are to be kept in a locked medication cart prior to and after administration. During an observation on 1/16/19 at 2:46 p.m. on the Skilled One Unit, both medication carts were observed in the hallway by the nurses' station unlocked out of sight of any nurses for approximately five minutes. In the top drawer of one cart there was a medicine cup filled with eight medications and a second medicine cup filled with crushed medications. Both cups were unlabeled. Several residents were seated nearby, a family member and a non-nursing staff member were in the hallway. In addition, there was one Toujeo insulin pen opened and not dated as to when it was removed from the refrigerator. When interviewed on 1/16/19 at 2:53 p.m. and again at 3:10 p.m., the Licensed Practical Nurse (LPN) stated she had to leave to attend to a resident and forgot to lock the carts. The LPN said that the insulin was being used by Resident #20 and should be dated as to when it was opened or removed from the refrigerator. She said the pills belonged to Resident #81 and included [MEDICATION NAME] (heart medication), [MEDICATION NAME], Senna, Tamsulosin (prostate), [MEDICATION NAME] (antibiotic), iron, [MEDICATION NAME], and [MEDICATION NAME] (pain medication) which were all due intermittently throughout the evening shift. The LPN said she leaves the pills at the resident's bedside because the resident has an order to do that. The cup of crushed pills was Tylenol for Resident #153. Multiple narcotics in the locked drawer included, but were not limited to, [MEDICATION NAME] (opioid), [MEDICATION NAME] (pain reliever), [MEDICATION NAME] (anti-anxiety), and [MEDICATION NAME] (opioid). When interviewed on 1/18/19 at 10:11 a.m., the Registered Nurse/Resident Care Coordinator stated the carts should be locked at all times, insulin pens should be dated when opened, medications should not be left prepoured or unlabeled, and narcotics are to be double locked at all times. (10 NYCRR 415.18(e))

Based on observations and interviews conducted during the Recertification Survey, it was determined that the facility did not ensure that they were in compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the (YEAR) edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. This is evidenced by the following: An interview with the Administrator on 1/15/19 at 11:10 a.m. revealed that he did not think that there were any carbon monoxide detectors in the facility but would have to check with the Director of Facilities. Further interview with the Director of Facilities revealed there are no carbon monoxide detectors in the facility, and there are three sources including the natural gas generator for the Skilled One and Two Units, the kitchen gas range, and natural gas hot water heaters in the Skilled One/Two mechanical room. Observations at that time revealed no carbon monoxide detectors were present in the aforementioned areas containing fuel-burning appliances. The (YEAR) edition of the International Fire Code (IFC), requires carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance. (10 NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b); (YEAR) IFC: Section 915, 915.1, 915.1.4, Section 1103.9)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #47) of four residents reviewed for infection control related to urinary catheters, the facility did not maintain an infection prevention and control program to help prevent the development of infections by ensuring that staff members implemented appropriate processes related to the handling of urinary catheters. The issue involved an indwelling urinary catheter drainage bag laying on the floor. This is evidenced by the following: Resident #47 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/28/18, revealed the resident had moderately impaired cognition and had an indwelling catheter. Review of active orders revealed the resident was prescribed a Foley catheter (a flexible tube that enters the bladder to drain urine) for [MEDICAL CONDITION] (a condition when urine cannot flow through the urinary tract due to a blockage). Review of the current Comprehensive Care Plan revealed the resident was at risk for urinary tract infections related to an indwelling catheter with interventions including catheter care every shift and Foley catheter care per protocol. Observations included the following: a. On 1/16/19 at 9:11 a.m. and 10:01 a.m., the resident was in bed. The urinary catheter bag was lying on the floor with a moderate amount of pale, yellow urine in the bag. b. On 1/16/19 at 10:16 a.m., 10:55 a.m., and 11:15 a.m., the resident was in bed, and the urinary catheter bag was lying on the floor. c. On 1/17/19 at 9:21 a.m., the resident was in bed, and the urinary catheter bag was on the floor with pale, yellow urine in the bag. Interviews conducted on 1/16/19 included the following: a. At 12:02 p.m., Certified Nursing Assistant #1 stated that the urinary catheter bag was not on the floor when she entered the resident's room prior to taking her down for a shower. She said that she had to switch the resident to a leg bag to take her down for a shower because the gravity bag was leaking when she tried to empty it. She said the urinary catheter bag should not be on the floor. b. At 12:14 p.m., Licensed Practical Nurse #1 stated that the urinary catheter bag should never be on the floor. Interviews conducted on 1/17/19 included the following: a. At 9:33 a.m., the Registered Nurse Manager accompanied the surveyor to the resident's room at which time the urinary catheter bag was observed on the floor. She stated that the urinary catheter bag should not be on the floor and should be secured to the non-moveable part of the bed. b. At 10:28 a.m., the Infection Control Nurse said that the urinary catheter bag should not be on the floor. She said she would re-educate staff. (10 NYCRR 415.19)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #20) of three residents reviewed for pressure ulcers, the facility did not develop a comprehensive person centered care plan for the resident's pressure ulcer or pain. This is evidenced by the following: Resident #20 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/6/18, revealed the resident was cognitively intact, had an unstageable pressure ulcer of the right ankle, and had frequent pain that affected her sleep. The facility policy, Pressure Ulcers, revised (MONTH) (YEAR), revealed the care plan will address preventative measures. If an actual ulcer exists, it will address appropriate care and services and will be updated as needed. All residents with ulcers will have pain assessed and interventions implemented and evaluated for effect. A Report of Consultation from the wound clinic, dated 1/11/19, revealed the resident had a right ankle fracture with casting causing a pressure injury. Recommendations included Do Not Change the wound dressing and return to the wound clinic in one week. The Comprehensive Care Plan, initiated 3/16/18, revealed the resident's cast was removed but did not include the unstageable pressure ulcer or the resident's pain in the lower extremities. In an observation and interview on 1/14/19 at 2:48 p.m., the resident said that she has electric type pain from her hips down, she uses cannabis cream for the pain, and it helps tremendously. The resident said she was allowed [MEDICATION NAME] and will ask for it when the pain gets bad. The resident said she had a sore on the right ankle that was caused by the cast. When asked if it would be possible to observe wound care, the resident said the dressing is changed at the wound clinic. Throughout the interview the resident would randomly jump and say sorry my leg was jumping or say she was having pain. When interviewed on 1/16/19 at 2:11 p.m., the assigned Certified Nursing Assistant (CNA) said the resident complains all the time about pain and she uses the cannabis cream. The CNA said some days the resident is comfortable and somedays she will cry. The CNA said the resident has an ulcer on the right ankle and she goes to the wound clinic for dressing changes. When interviewed on 1/17/19 at 11:06 a.m., the Director of Nursing said she could not find a care plan for the resident's pressure ulcer or pain and she does not know why. She said there should be one. (10 NYCRR 415.11(c)(1))

Based on observations and interviews conducted during the Recertification Survey, it was determined that for one of one kitchen, the facility did not store, prepare, distribute, and serve food under sanitary conditions. Specifically, a dish machine did not provide adequate sanitizing, food and non-food contact surfaces were not clean, and the floor in the dishroom was missing grout. This is evidenced by the following: 1. Observations in the presence of the Chef Manager (CM) during the intial walk-through of the kitchen conducted on 8/21/17 from 9:50 a.m. to 10:22 a.m. revealed the following: a. There was brown and pink residue on the drip tray inside the ice machine. When interviewed at that time, the CM said the ice machine was last cleaned out in April and it is cleaned every six months. b. There was an approximately 6-inch by 12-inch section inside the left front corner of the walk-in cooler that was covered with brown and black spots that resembled mildew. c. There was a heavy odor of sour milk in the dishwashing room and the floor had multiple sections of tile that was missing grout. Cleaned and dry dishes were stored on shelves in this room. d. When tested three times in a row by the CM, the chlorine sanitizer level in the dish machine showed zero parts per million (ppm). The test was conducted using a test strip that changes color with the presence of chlorine. When interviewed at that time, the CM said that the dish machine operates at a lower temperature (120-130 degrees Fahrenheit) and the sanitizer level should be at least 50 ppm. The dish machine was being used at that time to wash dishes and utensils from breakfast. e. There was a significant amount of brown, yellow, and tan food particles and crumbs on top of the dish machine. f. A stainless steel drawer containing scoops, spatulas, and other food utensils had food debris and crumbs inside the drawer. 2. Observations on 8/22/17 at 2:30 p.m. revealed the sanitizer level in the dish machine was zero ppm when tested by the CM. The CM then pressed a primer switch on the machine and instructed the workers to make sure to always prime the machine every time they run it, and test it more often. The dish machine was being used at the time to wash dishes and utensils from lunch. Further observations revealed a significant build up of crumbs on the top of the dish machine and a heavy odor of sour milk in the dishwashing room. 3. Observations in the presence of the CM on 8/23/17 at 11:35 a.m. revealed a container full of butter knives that had food residue resembling eggs on several of the knives. The container of knives was located at a station adjacent to the tray line in the main kitchen. When interviewed at that time, a dietary staff worker said the knives were clean and ready to use. (10 NYCRR: 415.14(h), Subpart 14.1-110(d), 14.1-112, 14.1-170, 14.1-171, 14.1-175)

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 960), it was determined that for one (Resident #146) of three residents reviewed for abuse, the facility did not thoroughly investigate injuries of unknown origin to rule out abuse, neglect, or mistreatment. Specifically, there was a lack of documented interviews with direct care staff. This is evidenced by the following: Resident #146 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/3/17, revealed that the resident's cognitive skills for daily decision making are severely impaired, requires the extensive assistance of two staff for transfers, toileting, and locomotion on the unit. A Medical Progress Note, dated 12/5/16, documented the resident was seen for an ecchymosis (purplish patch caused by bleeding under the skin) on the left forearm. There was no fall or specific trauma reported. The resident had tenderness of the left ankle and was unable to report how the injuries occurred. The resident's left ankle had [MEDICAL CONDITION], moderate tenderness and decreased range of motion secondary to pain. The provider ordered an x-ray of the left ankle and arm. An Incident/Accident (I/A) Report, dated 12/4/16, documented a plan of correction that revealed the resident moves around in her chair. There were two staff statements attached to the I/A Report. Review of an x-ray report of the left ankle, dated 12/5/16, revealed fracture fragments of indeterminate age of the ankle (medial and lateral malleolus and cortical irregularities involving the medial talus bone) representing a subtle fracture. The I/A Reports, dated 3/21/17, 4/3/17, 4/26/17, 5/8/17, and 5/28/17, revealed that the resident had injuries of unknown origins resulting in bruises. The I/A Reports, dated 3/21/17, 4/3/17, and 4/26/17, included a statement from the person that discovered the bruise. The I/A Reports, dated 5/8/17 and 5/28/17, included two staff statements. Interviews conducted on 8/24/17 included the following: a. At 10:50 a.m., the Director of Nursing (DON) stated that when staff observe a bruise the Nurse Manager, Supervisor and Registered Nurse (RN) are notified. She stated an I/A Report is initiated and a statement is obtained from the person who found it, staff from prior shifts, and the resident and family, if indicated. The DON reviewed the resident's I/A Reports from March 2017 through June 2017 and stated the reports were incomplete. b. At 5:00 p.m., the RN Manager stated that when a bruise is found she looks back to see who cared for the resident and interviews them. She stated she does not document the interviews and does not have staff write a statement. When interviewed on 8/25/17 at 10:07 a.m., the Administrator stated he is made aware of falls with fractures, resident to resident altercations, and injuries of unknown origin. The Administrator said that he expected the investigations to include staff statements. After review of the investigation, dated 12/5/16, he said it was incomplete. He said the facility had some work to do on investigations. Review of the facility policy, Accidents/Incidents, dated September 2016, directed to maintain a system for monitoring occurrences of incidents involving residents that is designed to identify causative factors and reduce the risk of reoccurrence. A review of the facility policy, Abuse, dated September 2016, directed that a thorough investigation included the following documentation: the date and time that the incident was discovered, who discovered the incident, how the incident was discovered, a description of the resident, an interview log that included names of staff interviewed along with signed statements, and list of staff not interviewed and why. The investigation is to include an explanation of the evidence reviewed, documents reviewed and a conclusion reached because of the investigation with a discussion of its basis. (10 NYCRR 415.4(b)(3))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #44) of three residents reviewed for choices, the facility did not allow a resident the right to choose health care consistent with her preferences. Specifically, the resident was not given a tub bath twice a week and was not given a working key to a locked drawer in her room to secure valuables. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident Preferences and Customary Routine Profile, dated 8/3/16, revealed that the resident prefers a tub bath twice a week. The Minimum Data Set (MDS) Assessment, dated 12/20/16, revealed it is very important to the resident to take care of her personal belongings, have a choice of bathing, and have a place to lock things up to keep them safe. The MDS Assessment, dated 8/7/17, revealed that the resident is cognitively intact. One of two Visual/Bedside Kardex Reports, directed a shower or century tub bath every Friday and as needed. The Kardex in the resident's room does not include that information. The current Comprehensive Care Plan directed that the resident requires the assist of one staff for bathing and adaptive devices (wash mitt, shower chair, and grab bars). The Weekly Bathing Schedule, dated 8/21/17, revealed that the resident is bathed once a week on Friday (2:00 p.m. to 10:30 p.m. shift). During an interview on 8/21/17 at 12:21 p.m., the resident said she is bathed once a week and would like to be bathed more often. She said she prefers a tub bath. Interviews conducted on 8/24/17 included the following: a. At 8:59 a.m., the resident said that she gets a whirlpool tub bath. She said the whirlpool bubbling helps her leg pain. The resident said she would like two baths per week. She said when she transferred to that unit, she was only offered one bath per week. The resident said when she asked for another bath the Certified Nursing Assistant (CNA) did not really offer an answer and she never received another bath. b. At 9:13 a.m., CNA #1 said that the CNAs are responsible for asking the residents about their bathing preference and frequency. CNA #1 said there is a form to use and when it is completed, the form goes to the scheduler, who enters the information into the computer (electronic Care Card). c. At 10:01 a.m., CNA #2 said the resident prefers a tub bath and gets one a week. CNA #2 said the resident had not asked her for another bath but if she had, she would have notified the scheduler to add another bath. d. At 10:24 a.m., the scheduler said the resident must not have told staff on that floor that she wanted a bath twice a week. She said she would have added a second bath to the schedule. During an interview on 8/25/17 at 11:30 a.m., the Registered Nurse (RN)/Discharge Planner and surveyor went to the resident's room. The RN told the resident that the current schedule directed to give a shower or tub bath. The RN said that she would modify the shower schedule. Additionally, when interviewed on 8/24/17 at 9:07 a.m., the resident said that she had a key for her locked drawer but it does not fit the lock. She handed the key to the surveyor, and when the key was put into the lock, it did not fit correctly. The resident said that she had asked anyone and everyone for a new key and/or new stand. Interviews conducted on 8/24/17 included the following: a. At 9:51 a.m., Licensed Practical Nurse (LPN) #1 said she did not know the resident needed a new key for her locked drawer. She said she would have called the front desk to report the concern and log a maintenance request. She said the front desk staff would then notify maintenance to correct or fix the problem. b. At 10:09 a.m., CNA #1 said there is a key for each bedside stand/locked drawer so the resident should have one. c. At 11:15 a.m., an Administrative Assistant said that she receives a maintenance request from the staff on the unit to repair or replace bedside stands or keys. She said she would then forward that request to maintenance. She said she would look for any requests. d. At 11:32 a.m., the Director of Social Work and Social Worker said there was nothing formal in place to notify residents about having a locked drawer to secure personal items. e. At 12:13 p.m., the Administrative Assistant said that she notified maintenance about fixing the drawer/key and their reply was that they have replaced the key a lot, as the resident is always losing it. Interviews conducted on 8/25/17 included the following: a. At 11:30 a.m., the RN and surveyor went to the resident's room. Upon entry, the resident said she received a new key, after asking and asking. b. At 11:42 a.m., the Administrative Assistant said she did not find any maintenance request forms. A facility policy, Resident Clothing and Personal Items, dated September 2016, directs that a locked drawer is available to each resident in their bedside stand. The resident and/or designated representative must request the key from the Social Worker. A duplicate key will be maintained by the facility. Keys are maintained in the front office in a locked box. Review of a facility policy, Resident Preferences, dated September 2016, directed that it is the policy of the nursing home to assess the importance of activities and routines to the resident, such as bathing, dressing, eating, and activities such as being outdoors, reading and participating in a planned activity program. The Resident Preference Check List is completed upon admission for each resident. A nurse, CNA or Unit Clerk may complete the form. The information is incorporated into the Care Plan and utilized to improve the resident's quality of life. (10 NYCRR 415.5(b)(1-3))