Every finding on record at Chemung County Health Center - Nursing Facility

Based on observations, interviews and record review conducted during an Abbreviated Survey (NY00346373, NY00361053, NY00369686, and NY00369760) for three (Residents #1, #2, and #5) of five residents reviewed, the facility did not ensure the residents' environment remained free of accident hazards. Specifically, Resident #1's bed was left in an unsafe position creating a fall hazard. Resident #2's bed was left in an unsafe position and fall mats were not placed per their care plan to prevent injuries in the event of a fall. Resident #5 was on aspiration precautions (steps taken to prevent inhalation of food/drink into the lungs) and was not supervised while eating. This is evidenced by the following: 1.Resident #2 had diagnoses including dysphagia (difficulty swallowing) and hemiplegia (paralysis) affecting the right dominant side. The Minimum Data Set Resident Assessment, dated 11/25/2024, documented Resident #2 had severe impairment of cognitive function. Review of Resident #2's Comprehensive Care Plan dated 06/25/2024 and Certified Nursing Assistant Kardex dated 11/19/2024 revealed the resident was at risk for falls and required a low bed height when unattended and fall mats on either side of the bed. The Kardex included the resident was on a pureed/nectar thick liquids diet. Resident #2's medical orders, dated 07/15/2024, included puree texture, and nectar (thick) consistency for fluids. Review of a Resident Incident form, dated 11/18/2024, revealed Resident #2 had received 60 cubic centimeters of thin liquids (water) during medication administration (versus thickened liquids as ordered). Review of the facility investigation revealed that Resident #2 initially tolerated the fluids, then became flush in the face and had a small emesis. During an observation on 01/21/2025 at 12:30 PM Certified Nursing Assistants #1 and #2 elevated Resident #2's bed to highest position (approximately 3 feet from floor and well above the tray table), boosted Resident #2 up in bed, removed the right floor mat, and placed Resident #2's lunch tray on a tray table over the bed. Certified Nursing Assistants #1 and #2 left Resident #2's room with the bed in high position and no floor mat placed on the right side of the bed. During an interview on 01/21/2025 at 1:10 PM Head Nurse #1 stated that the bed had to be high to get the tray table in and the floor mat should be placed by the tray table on the floor. During an interview on 01/21/2025 at 2:20 PM the Director of Nursing stated that unless mats are care planned not to be placed on the floor when the tray table is in place, the floor mats should have been on the floor. The Director of Nursing stated that bed height is specific to each resident and per resident preference. During an interview on 01/21/2025 at 2:25 PM Certified Nursing Assistant #1 stated that both mats should be down when residents are having meals in bed, and they were told the bed could be in high position so they can get the tray table in. During an interview on 01/21/2025 at 2:40 PM Certified Nursing Assistant #2 stated that for at least the past year when Resident #2 was eating (while in bed) their mat had not been placed on the floor (by the table) and their bed had been left in the high position. During an interview on 01/21/2025 at 2:50 PM Certified Nursing Assistant #3 stated that when they were trained, they were instructed to put the bed up a few inches and both mats on the floor. During an interview on 01/22/2025 at 11:40 AM Registered Nurse #1/Staff Development stated Certified Nursing Assistants are taught that beds have to be completely lowered to the ground if the resident is unattended. Registered Nurse #1/Staff Development stated that unless specified in the care plan, the bed has to be in lowered for all residents and both floor mats placed on the floor. 2. Resident #1 had diagnoses including Alzheimer's disease and a history of falls. The Minimum Data Set Resident Assessment, dated 12/10/2024, documented Resident #1 had moderately impaired cognitive function. Resident #1's admission Comprehensive Care Plan dated 06/21/2024 did not include any guidance to the recommended bed height for the resident's safety. Review of Resident #1's Certified Nursing Assistant Kardex dated 07/03/2024 revealed instructions for the bed height to be in the lowest position. Review of a Resident Incident form, dated 06/24/2024, revealed that Resident #1 was observed on the floor between the beds. Resident #1 sustained a left forehead laceration, measuring 4.5 centimeters that required an emergency room evaluation and sutures. The facility's investigation included that Resident #1's bed was not in the low position as documented on the resident's Certified Nursing Assistant's Kardex. The investigation included that the tape used to indicate bed height (a process the facility uses to ensure a resident's recommended or preferred bed height is maintained) was still on the wall from the previous resident that was in Resident #1's room and the reason why the bed was left elevated. During an interview on 01/21/2025 at 10:00 AM the Director of Nursing stated that Resident #1 was a high risk for falls, and the facility could not determine who was responsible for leaving the bed at the wrong (elevated) height. Review of the facility policy Fall Prevention Measure for High-Risk Residents, dated March 2014, revealed to keep the bed in low position and may adjust height of bed to accommodate placing tray table/roll stand under bed for meal periods, and to assess the need for the bed to be in the low position. 3.Resident #5 had diagnoses including dysphagia. The Minimum Data Set Resident Assessment, dated 12/17/2024, documented Resident #5 had severe impairment of cognitive function. Review of Resident #5's Comprehensive Care Plan dated 08/15/2024 and Certified Nursing Assistant Kardex, dated 01/22/2025, included aspiration precautions, pureed/nectar thick liquids and supervision when eating. Review of Resident #5's medical orders dated 12/26/2024 revealed the resident was on puree texture foods and nectar (thick) consistency for fluids. During an observation on 01/22/2025 at 8:15 AM Resident #5 was eating breakfast in bed. There was no staff present in Resident #5's room or directly outside their door in line of sight. During an interview on 01/22/2025 at 8:30 AM Head Nurse #1 stated that supervision means the resident is to be checked periodically. During an interview on 01/22/2025 at 8:35 AM the Director of Nursing stated that supervision means that someone is with the resident at all times when they are eating. Resident #5 requires a one-to-one with staff during meals. In a follow up interview at 11:00 AM the Director of Nursing stated that Resident #5 received thin liquid coffee for breakfast earlier that day and ingested at least half of it. In another follow up interview at 2:45 PM the Director of Nursing stated that when staff call the kitchen for resident requests, the resident's name and room number should be provided. During an interview on 01/22/2025 at 2:20 PM Head Nurse #1 stated that they made the call for Resident #5's coffee but that the kitchen staff should check the resident's consistency order. Head Nurse #1 stated that the Certified Nursing Assistant should have checked the Kardex before providing Resident #5 with the coffee. During an interview on 01/22/2025 at 4:00 PM the Food Service Director stated the kitchen person who took the call for Resident #5 should have cross referenced to check if thicken liquids were required for Resident #5 before sending the coffee. During an interview on 01/22/2025 at 4:00 PM Resident #5 stated they had received coffee that was not thickened and that they drank the thin coffee because it is better without thickener in it. During an interview on 01/23/2025 at 9:50 AM Speech and Language Pathologist #1 stated that Resident #5's recommendation says supervision (in line of sight) during po (by mouth) intake and aspiration precautions. Review of the facility policy Aspiration Precautions, dated 07/13/2023, 2023, revealed that residents who require the need for supervision with po (by mouth) intake will receive the recommendation for Supervision following evaluation by the Speech-Language Pathologist. Procedures and recommendations included no food or drink to be left with the resident unsupervised, and the resident be in direction line of sight of staff during meals. 10 NYCRR 415.12(h)(1)(2)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (ACTS Reference Number: NY00343164), the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Regulations for two of two medication carts reviewed. Specifically, the medication carts on the North and South halls of residential Unit 4 were observed on multiple occasions unsupervised and/or unlocked by multiple nursing staff. Additionally, residents identified by facility documentation as cognitively impaired and wanderers were observed self-propelling their wheelchairs on both halls by the medication carts during the observations. This is evidenced by, but not limited to, the following: The undated facility policy Medication Administration included during medication administration, the medication cart will be kept closed and locked when out of sight of the medication nurse. The cart must be clearly visible to the personnel administering medications and all outward sides must be inaccessible to residents or others passing by. Resident #2 had diagnoses including dementia. The Minimum Data Set Resident Assessment, dated 04/30/2024, documented that Resident #2 had severely impaired cognitive skills. Resident #5 had diagnoses including dementia and psychosis. Resident #5 was identified by the facility as a wanderer. The Minimum Data Set Resident Assessment, dated 06/27/2024, documented that Resident #5 had moderately impaired cognitive skills. Resident #5's current Comprehensive Care Plan included special medication caps on medication bottles and to ensure the medication cart is locked at all times when not in sight. Resident #6 had diagnoses including Alzheimer's disease. Resident #6 was identified by the facility as a wanderer with wander guard placement (wander management system which uses bracelets, sensors, and technology to alert staff when a resident tries to leave a safe area). The Minimum Data Set Resident Assessment, dated 08/20/2024, documented that Resident #6 had moderately impaired cognitive skills. Review of a facility Incident Report, dated 05/23/2024, revealed that at 8:30 AM (that day), a bottle of trazodone (anti-depressive medication belonging to Resident #2) 50 milligrams containing 55 tablets was found in a sock in Resident #2's room. One tablet was found in the hallway and that (per staff calculations) 4 tablets remained missing from the bottle. Suspected cause of the incident included that Resident #2 removed the bottle of trazodone from the medication cart. In a nursing progress note, dated 05/23/2024, Registered Nurse/Head Nurse #1 documented that Resident #2 was noted to have increased lethargy and was easily aroused when touched by opening their eyes, but immediately dozed right back off to sleep. Vital signs included a blood pressure (BP) of 90/55 and the Nurse Practitioner ordered an evaluation at the hospital. Resident #2 returned to the facility around 10:55 PM with slightly altered mental status. Observations and interviews on 09/24/2024 on residential Unit 4 included the following: a. At 9:30 AM, the medication cart on the North Hall was unlocked with no staff member in view of the cart and in an area where residents had access to it. b. At 12:00 PM, the medication cart on the South Hall was unlocked and no staff member in view of the cart and in an area where residents could access it. Licensed Practical Nurse #1 was approximately 100 feet away walking away from the medication cart. Resident #5 was observed self-propelling their wheelchair by the medication cart. During an interview at this time, Licensed Practical Nurse #1 stated they should have locked the medication cart, but had to get a blood pressure cuff for another resident who almost fell . c. At 3:55 PM, the medication cart on the South Hall was unlocked and in front of the doorway of resident room [ROOM NUMBER] and not in sight of the nurse. During an intervier at 4:00 PM, Licensed Practical Nurse #3 stated they should have locked the medication cart before walking away. d. At 4:05 PM on the North Hall, Licensed Practical Nurse #4 moved the unlocked medication cart to the doorway of Resident #2's room and entered the resident's room with their back to the medication cart. e. At 4:12 PM on the North Hall, Licensed Practical Nurse #4 left the unlocked medication cart in front of resident room [ROOM NUMBER] with a large enough opening for a resident to make their way to the front of the medication cart. Licensed Practical Nurse #4 was in the resident's room with their back to the medication cart. During an interview at this time, Licensed Practical Nurse #4 stated they thought the medication cart was tight to the door and a resident could not get to it. f. At 4:16 PM on the North Hall, Licensed Practical Nurse #4 left the unlocked medication cart in front of resident room [ROOM NUMBER] and went to the far side of the room out of direct sight of the medication cart. During an interview upon returning to the medication, cart Licensed Practical Nurse #4 stated they should have locked the cart before they left. During observation of medication pass on 09/24/2024 on Unit 4's North Hall from 3:55 PM to 4:16 PM, Resident #5 and Resident #6 were both self-propelling their wheelchairs up and down the halls and near the unlocked medication cart. During an interview on 09/23/2024 at 1:40 PM, Licensed Practical Nurse #5 stated that they had witnessed Licensed Practical Nurse #1 leaving the medication cart unlocked and that it was common practice on the 4th floor. During an interview on 09/24/2024 at 12:15 PM, Registered Nurse/Head Nurse #1 stated the medication cart should be visible to the medication nurse and locked at all times, including when administering medications. During an interview on 9/24/24 at 12:40 PM, the Director of Nursing stated that facility-wide training was provided to all nursing staff after the incident involving Resident #2. Training included locking the medication cart and that the medication cart must be in the nurse's line of sight at all times when on the units. 10 NYCRR 415.18(e)(1-4)

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY00319989) 9/18/23 to 9/22/23, it was determined that for 1 (Resident #315) of 26 residents reviewed for person centered Comprehensive Care Plans (CCP) the facility did not review and revise the resident's care plans as necessary to meet the resident's current needs. Specifically, the care plan was not revised to reflect the current level of assist the resident required for safe toileting. This is evidenced by the following: Resident #315 had diagnoses including difficulty with walking, muscle weakness, and heart failure requiring a pacemaker. The Minimum Data Set assessment dated [DATE] included that the resident was cognitively intact, required extensive assistance involving two persons for transferring and toileting, and had no behavioral symptoms or rejection of care. The CCP created on 6/13/23, included that Resident #315 was at risk for falls and had a history of falls with fractures. Interventions included, but not limited to, for staff NOT to leave the resident unattended on the toilet or in the bathroom. The Certified Nursing Assistant (CNA) Kardex (care plan used by the CNAs to drive daily care) at the time of the incident included that Resident #315 required the assistance of one person and a walker for ambulation into the bathroom. The Kardex did not include the instructions to staff that Resident #315 was not to be left unattended on the toilet or in the bathroom. Review of the facility Investigation Report, dated 7/9/23, revealed that Resident #315 was assisted to the bathroom by a CNA and instructed to ring their bell when done. The CNA then left Resident #315 alone in the bathroom. Staff reported hearing the resident yelling who was then found on the floor. The resident had stated (at the time) that they lost their balance while reaching for toilet paper. The resident was sent to the hospital and received seven stitches to the forehead. Resident #315 returned to the facility the following day. When interviewed on 9/20/23 at 3:33 PM, the Occupational Therapy Assistant stated that when therapy evaluates a resident, their condition is documented, and a copy of the therapy notes are given to the nurse on the unit (which occurred in this case). Nursing is then responsible for updating the care plans. When interviewed on 9/20/23 at 3:57 PM, the Director of Nursing (DON) stated that nursing has to hit the letter K (input the updates into the computer in a certain way) to ensure that interventions are also added to the Kardex (along with the CCP). The DON said that every CCP and Kardex should mimic each other so that all the information is up to date, consistent, and accurate and staff can safely and appropriately care for the residents. When interviewed on 9/22/23 at 9:25 AM, the Registered Nurse (RN)/Head Nurse #1 stated it is their job to create a care plan for each resident and that in order for information on the care plan to be transferred to the CNA Kardex, the person documenting (in the care plan) must manually enter the individualized instructions and type in the letter K (referencing the Kardex) so that it is transferred to the Kardex. The RN Head Nurse #1 stated they never went into Resident #315's electronic health record to update the CNA Kardex. 10 NYCRR 415.11(c)(2)(iii)

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 9/18/23 to 9/22/23, it was determined that for one (Resident #34) of three residents reviewed, the facility did not ensure that Activities of Daily Living (ADLs) care was provided for dependent residents. Specifically, the resident was observed on multiple occasions in soiled clothing and was not provided care (for urinary incontinence) in a timely manner. This is evidence by the following: Resident #34 was admitted to the facility with diagnoses that included hemiplegia (unable to move one side of the body), dementia and a right-hand contracture (a shortening of muscles or tendons leading to deformity and rigidity of joints). The Minimum Data Set assessment dated [DATE] included that the resident was moderately impaired cognitively, was frequently incontinent of urine (unable to control bladder) and required the extensive assistance of two people for toilet use. Review of the current Comprehensive Care Plan and Kardex (care plan used by the Certified Nursing Aides (CNAs) for daily care) revealed Resident #34's toileting needs included incontinence briefs, two-person assist to the bathroom and for episodes of incontinence, a urinal on request, and to offer scheduled rounds and as needed (assistance) (resident would make bathroom needs known). During an observation on 9/18/23 at 11:32 AM, Resident #34 was sitting in their wheelchair in the doorway of their room. The resident's pants were discolored and appeared wet in the peri-area (genitals, scrotum, and buttocks). During an observation on 9/19/23 at 9:51 AM, Resident #34 was sitting in their wheelchair in their room and again their pants appeared wet across the peri-area. During an observation on 9/21/23 at 1:08 PM, Resident #34 reported to a staff member delivering clothing outside their room that they needed to go to the bathroom which was also heard by CNA #1 who was in the hallway passing by the resident's doorway at the time. CNA #1 responded that two other CNAs were assigned to the resident and that they were removing residents from the dining room. At 1:14 PM, Resident #34 reported to a staff member that they wanted to go back to bed. CNA #1 stated that they had to remove all residents from the dining room before they can assist residents back to bed. In an observation at 1:42 PM, CNA #1, and CNA #3 assisted Resident #34 back to bed and upon standing from their wheelchair the resident's pants were visibly soaked through their clothing and wheelchair. Resident #34 stated, my pants are wet. The resident was transferred back to bed and requested they go to the bathroom to which CNA #1 responded You did. While incontinence care was provided the resident's briefs were observed saturated with urine. During an interview on 9/21/23 at 2:25 PM, CNA #2 stated that Resident #34 required a two-person assist for toileting, is sometimes incontinent, and will yell that they need the commode, urinal, or bathroom. CNA #2 stated that staff are supposed to check and provide incontinence care (if needed) every two hours, which is not realistic due to staffing. CNA #2 stated that they had gotten Resident #34 out of bed between 7:15-7:20 AM that morning and had not toileted or given incontinence care since then. CNA #2 stated the resident had not told them that they needed to go to the bathroom. During an interview on 9/22/23 at 10:47 AM, Licensed Practical Nurse (LPN) #1 stated Resident #34 was incontinent of bladder and should be on every two-hour toileting schedule in the bathroom with assistance. During an interview on 9/22/23 at 10:58 AM, Registered Nurse Manager (RNM) #1 stated staff should be checking on residents at least every two hours if they are incontinent of bladder. RNM #1 stated Resident #34 could communicate their need to use the bathroom but was also incontinent at times. 10 NYCRR 415.12 (a)(3)

Based on observations, interviews and record reviews conducted during the Recertification Survey, completed on 5/28/21, it was determined for one (Resident #103) of one resident reviewed, the facility did not provide appropriate treatment and services to prevent complications for a resident who receives nutrition via a feeding tube (a tube inserted directly into the stomach via the abdomen). Specifically, the facility did not provide staff with thorough education and training on correct use of the feeding tube pump and did not provide timely preventive maintenance of a feeding pump to ensure the resident was receiving accurate amounts in order to prevent complications. This is evidenced by the following: Resident #103 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 4/13/21, revealed that Resident #103 was severely impaired cognitively, received majority of daily calories and fluids via a feeding tube and had no significant weight loss or weight gain. The current Comprehensive Care Plan revealed an unfavorable weight loss. The plan was to increase the calories in the tube feeding by providing 330 milliliters (mls) per shift versus 280 mls with a goal to maintain the resident's weight within five % of current body weight. In a Quarterly Nutrition Assessment, dated 4/15/21, the Registered Dietician (RD) documented that Resident #103 received 100% tube feeding (TF) as ordered yet an insidious weight loss trend continued. The RD wrote weight losses noted for one month, three months, six months and over the course of a year the resident lost 10.6 % body weight. A continued weight loss would not be desirable so will recommend increasing the TF from 280 mls per shift (1008 calories per day) to 330 mls per shift (1188 calories per day). Current medical orders direct [MEDICATION(S)] 1.2 (a high-protein liquid nutrition TF) at 60 mls per hour for 5.5 hours or until a total of 330 mls each shift. In an observation on 5/24/21 at 2:20 p.m., the tube feeding pump (a Covidien ePump) was turned off (indicating the total amount for that shift had been completed). The pump display read TF delivered at 60 mls per hour with 650 mls fed. A one-liter (1000 mls) bottle of [MEDICATION(S)] 1.2 was dated as hung on 5/24/21 at 2:00 a.m. There were 550 mls remaining in the bottle (versus the 350 mls that should have remained if 650 mls had been fed). In an observation on 5/25/21 at 2:32 p.m., the pump was turned off (indicating the day shift had completed their 330 mls as ordered). A one-liter bottle of [MEDICATION(S)] 1.2 was dated as hung on 5/25/21 at 2:00 a.m. There were 580 mls of TF remaining in the bottle versus 490 mls which should have been remaining. In an interview on 5/26/21 at 9:41 a.m. and again at 11:30 a.m., and at 11:55 a.m., Licensed Practical Nurse (LPN) #1 said they forgot to zero out the pump this morning but knows the pump was turned on at 6:40 a.m. to end at approximately 12 noon. LPN#1 said they had reviewed progress notes by the night nurse who wrote that 150 mls of TF had been given and at 2:00 a.m., a new bottle had to be hung to provide the remaining 180 mls for the night shift and therefore the bottle should have had 490 mls remaining. She said that the pump display read that 656 mls had been administered but 600 mls remained in the bottle, making it difficult to ensure the correct amount is being infused. When asked to run the memory function of the pump, LPN#1 said they had not been taught how to use it. LPN#1 added that there was no current preventative maintenance process in place for feeding pumps that she was aware of, but Central Supply would replace a pump if nursing identified an issue and asked them to. In an interview on 5/26/21 at 12:30 p.m., LPN#2 said they had not been taught how to use the memory function of the pump. During interviews on 5/26/21 at 3:41 p.m., and again on 5/27/21 at 1:18 p.m., the Central Supply Clerk said they had placed a call to the manufacturer who said the pumps are to be calibrated at least once a year but that this had not been done since November 2019. He said they have provided some training for nursing on pump use, but none related to memory function. He said he performed a pump calibration (after surveyor intervention) using sterile water and the pump appeared to be functioning correctly. During an interview on 5/27/21 at 1:27 p.m., the Registered Nurse Supervisor stated that they did not have a yearly training for the LPNs on use of the TF pumps but staff did get an initial competency for using TF pumps at the time of the hire which was 1999 and 2007 for some of the LPN's currently using the TF pumps for Resident #103. In an interview on 5/27/21 at 11:22 a.m., the Certified Dietary Manager said dietitians have not received any training on pump function. She said Resident #103's TF amounts had to be increased recently due to a gradual weight loss. [10 NYCRR 483.90(d)(2)]

Based on observations and interviews conducted during the Recertification Survey, it was determined that for five of five residential units that the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable and homelike environment. Specifically, rigid plastic door coverings were damaged and jagged. This is evidenced by the following: 1. Observations during the initial tour of the facility on 10/29/18 from approximately 1:00 p.m. to 1:20 p.m. revealed the lower edges of the doors and frames to the third-floor day room and Resident room [ROOM NUMBER] were covered with a pink rigid plastic material that was broken and jagged. 2. Observations on 10/30/18 at 8:30 a.m. revealed the rigid plastic covering the lower edges of doors and doorframes in Resident Rooms #200, #202, #206, #210, #214, and #225 were broken, jagged and damaged. 3. Observations on 10/31/18 from 8:22 a.m. to 8:56 a.m. revealed the rigid plastic covering the lower edges of doors and doorframes in Resident Rooms #613, #609, #522, #508, #405, #402, #401, #324, #305, #301, #225, #214, #210, #206 and the fourth floor day room and dining/activities room were broken, jagged, and damaged. 4. On 11/2/18 at 11:18 a.m. the second-floor Registered Nurse Manager (RNM) was shown the jagged damaged edges of the doors on the second floor. When interviewed at that time, the RNM said, yes she could see that the door edges are jagged, and could be a potential accident for residents especially those who self-propel. She said there are some residents in the rooms identified that can self-propel. (10 NYCRR 415.29(j)(1))

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for 5 of 35 residents reviewed for care planning, the facility did not develop and/or implement a plan of care for each resident that included measureable objectives and interventions to address the residents' medical, physical, mental and psychosocial needs. The issues involved the lack of a care plan with person centered approaches for behaviors (Residents #98 and #42), the lack of a care plan for impaired vision (Resident #183), the lack of a plan of care for Tubi-grips (Resident #117), and the lack of following the plan of care for feeding strategies (Resident #56). This evidenced by, but not limited to, the following. Review of the facility policy, Comprehensive Care Plan (CCP), dated 7/31/17, revealed that an individualized CCP included measurable goals, objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident and will always be reflective of the resident's status. 1. Resident #98 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 8/31/18, revealed the resident had severely impaired cognition and exhibited rejection of care daily during the look back period. Review of the CCP, dated 9/12/18, revealed that the resident had the potential for behaviors, and the family reported that the resident had sundowner's symptoms which occurred between 2:00 p.m. and 5:00 p.m., and had a history of [REDACTED]. The current bedside Kardex documented in the behaviors and mood section to analyze circumstances and triggers and alter if able, if resident becomes angry or agitated intervene before escalation by engaging in calm conversation, guide away from the source of distress, and leave and reapproach if the resident is upset or resistive. When interviewed on 11/1/18 at 4:04 p.m., Certified Nursing Assistant (CNA) #1 stated she would check the resident's Kardex for behaviors. She stated if a resident had behaviors and was aggressive, she would reapproach the resident and report the behavior to the nurse. CNA #1 stated the facility had a book that included interventions that were general approaches but not resident specific. Duning an interview on 11/1/18 at 4:15 p.m., Licensed Practical Nurse (LPN) #1 stated the resident was typically very anxious at the start of the shift. She stated the resident would pace, fidget with his clothes, bend over trying to pick up things from the floor that were not there, and sometimes make and remake his bed. LPN #1 stated on occasion the resident would go into another resident's room and would be redirected. LPN #1 stated diversional activities would include giving the resident a magazine or trying standard things. She stated that walking with the resident was an effective intervention. LPN #1 stated that therapeutic communication means trying to comfort the resident. She stated the resident becomes anxious over money and needs reassurance that expenses are taken care of. LPN #1 stated these interventions should be on the CCP and the Kardex. LPN #1 reviewed the resident's Kardex and then stated the interventions were not specific to the resident. She stated the diversional activities contained in the diversional activity book were not resident specific. When interviewed on 11/2/18 at 10:48 a.m., the Registered Nurse Manager stated she developed the care plan addressing the resident's behaviors. After review of the resident's CCP, she stated the interventions were approaches utilized for all residents. She stated the CCP should include interventions specific to the resident. 2. Resident #183 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The comprehensive MDS Assessment, dated 1/22/18, documented in the Care Area Assessment section that visual function was addressed in the CCP. The MDS Assessment, dated 10/2/18, revealed the resident had moderately impaired cognition, impaired vision, and glasses were used. The optometry consult, dated 12/11/17, revealed the resident was seen as requested and a new prescription for glasses was filled. The CCP, dated 7/18/18, revealed the resident's risk for falls included poor vision, and the current Kardex revealed the resident's preference was watching television. During an observation and interview on 10/29/18 at 10:45 a.m., the resident was not wearing glasses. A family member applied the glasses and stated the staff do not put the resident's glasses on. During an observation on 11/1/18 at 9:02 a.m., the resident was sitting up in bed, the television was on, and a pair of glasses were lying folded on the overbed table out of the resident's reach. A CNA entered the room and offered to put the resident's head down. When interviewed on 10/31/18 at 3:28 p.m., CNA #2 stated the resident wore glasses, and it should be on the Kardex. During an interview on 11/1/18 at 11:15 a.m., Unit Manager #2 stated if a resident wears glasses it should be on the CCP and Kardex. She stated the family had expressed concern about the glasses not being applied. 3. Resident #117 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assesment, dated 9/7/18, revealed that the resident was cognitively intact and required extensive assistance with dressing. The current physician orders (with a start date of 7/3/18) included Tubi-grip stockings for legs, apply a double layer on in the morning and a single layer on at bedtime. Review of the (MONTH) (YEAR) through (MONTH) (YEAR) Treatment Administration Records (TAR) revealed entries for the Tubi-grip stocking as ordered and was signed as completed The current CCP revealed that the resident had bliateral leg [MEDICAL CONDITION] with complaints of discomfort. Interventions included a double layer of Tubi-grip stockings during the day and a single layer of Tubi-grip stockings at bedtime. The resident was non-compliant with transfer and toileting assistance. Review of the Integrated Progress Notes, from 7/3/18 through 11/1/18, revealed no documentation that the resident had refused to wear a double layer of Tubi-grips. During an observation and interview on 10/30/18 at 3:00 p.m., the resident was wearing one layer of Tubi-grips and one pair of stockings. The resident said that she was supposed to wear a double layer of Tubi-grips but prefers one pair of Tubi-grips and a pair of stockings. On 10/31/18 at 3:50 p.m. and on 11/1/18 at 10:01 a.m., the resident was sitting in her chair and was wearing one layer of Tubi-grips and stockings. When interviewed on 11/1/18 at 1:00 p.m., the LPN said that the CNA was responsible to put on the resident's Tubi-grips, and the nurses sign off on the TARs that she is wearing them. The LPN stated she wrote a note that the resident refused to wear a double layer of Tubi-grips. She said the resident will only wear one layer and everybody knows, including the Nurse Manager. The LPN said she assumed the Nurse Manager would discuss with the physician the resident's refusal to wear the two layers of Tubi-grips. When interviewed on 11/1/18 at 4:29 p.m., the RN Manager said it was an oversite and it should have been done. 4. Resident #56 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/13/18, revealed the resident had severely impaired cognition, required supervision after set-up for eating, and had a mechanically altered and therapeutic diet. The current physician orders for diet are no added salt and pureed texture with regular consistency. Recommend all meal items in separate bowls. To ensure safety and a low rate of intake, recommend staff and/or family provide one meal item at a time. The CCP for nutrition includes to follow Speech Therapist recommended feeding strategies per the 9/7/17 swallow evaluation which includes to recommend all meal items in separate bowls to ensure safety and slow rate of intake. Also, recommend staff and/or family provide one meal item and one drink at a time and provide distant supervision. During an observation of the lunch meal on 10/29/18 at 12:41 p.m., the resident was served his entire lunch tray with pureed items in separate bowls. The resident quickly emptied each bowl either by drinking the contents from the bowl and/or with a spoon. On 10/31/18 at 12:44 p.m., the resident was served his entire tray that included five bowls with pureed solids and regular liquids including apple juice and milk from a carton. All items were left on the tray for the resident to eat himself. The resident was alternating bites and sips on his own. The resident ate his meal and then got up to leave the dining room. A staff member said to the resident are you done and then documented what the resident ate as he left the dining room. When interviewed on 11/1/18 at 1:19 p.m., the resident's assigned CNA said that the resident required set up for meals. She said that she removes covers and opens everything and then the resident eats on his own. The CNA said that the resident required supervision due to eating so fast. After reviewing the resident's care Kardex, the CNA said that the resident does not like to be given one bowl at a time and will get up and leave the dining room if the tray is served that way. The CNA said that the resident gets his meal tray first because he will get mad and leave if he has to wait. When asked if nursing had been made aware of the resident's refusal to accept one meal item at a time, the CNA responded that all of the nurses are aware that the resident is supposed to receive one meal item at a time and that the resident will leave the dining room if served one item at a time. During an interview on 11/2/18 at 10:38 a.m., the Director of Nursing stated that her expectation would be that nursing staff would notify Speech Therapy and the physician, and update the physician's order and the CCP. (10 NYCRR 415.11(c)(1)(2)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #9) of one resident reviewed for rehabilitation and restorative care, the facility did not provide the treatment and services in the resident's plan of care to maintain functional ability. Specifically, the resident was not consistently ambulated by staff per the resident's individualized plan of care. This is evidenced by the following: Resident #9 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/12/18, revealed the resident had severely impaired cognition and required the limited assist of one staff member to walk in her room but did not walk in the corridor at all during the period assessed from 10/6/18 through 10/12/18. Review of the Physical Therapy discharge summary, dated 11/3/17, revealed that the resident was able to ambulate greater than 150 feet, that caregiver training included safety precautions, the use of an assistive device (walker) to facilitate improved functional ability, and for staff to continue to encourage transfers and ambulation for safety. The current Comprehensive Care Plan revealed that the resident had an Activity of Daily Living (ADL) performance deficit and was at risk for falls due to dementia, non-compliance in asking for assistance, poor safety awareness and a history of falls. Interventions included, but were not limited to, ambulate the resident to the dining room at lunch and dinner. The current Certified Nursing Assistant (CNA) Bedside Kardex included to transfer the resident with one assist and a walker, to keep the resident in a populated area and to remove the wheelchair foot pedals as the resident attempts to get up unassisted. The Kardex did not include instructions for ambulating the resident. An undated sign posted in the nursing station included a list of residents, including Resident #9, who were to be ambulated to the dining room (approximately 80 feet) and back for lunch and dinner. Review of the ADL response history in the electronic medical record (system used by staff to record resident's daily ADLs) for the past 30 days revealed documentation that the resident was able to ambulate in her room on 22 of 30 days but ambulated in the hallway on just one day for the past 30 days. Review of the Resident Incident Investigations revealed that the resident had three falls in the past month while attempting to get up unassisted. The most recent Fall and Investigation Report, dated 10/20/18, resulted in an abrasion and a visit to the emergency room to rule out a fracture due to complaints of pain. The physician progress notes [REDACTED]. A Rehabilitation Referral for Therapy Services, dated 10/21/18 and signed by the Licensed Practical Nurse, included that the resident needed more assist with ADLs. During multiple observations daily from 10/29/18 through 11/2/18, the resident was sitting in a wheelchair in the hall outside her room. At no time was the resident observed ambulating. In an interview on 10/29/18 at 11:08 a.m., a visiting family member stated that the resident used to walk but the resident had recently gone downhill and the visitor did not think that staff walked the resident anymore. Interviews conducted on 10/31/18 included the following: a. At 12:23 p.m., the day shift CNA stated that the resident can walk from the bed to the toilet but no further. She said that if she has time she will walk the resident in the afternoon but most days it is just back and forth to the bathroom. She said she does not walk the resident to the dining room. b. At 3:33 p.m., the Director of Physical Therapy stated that the most recent therapy note was when the resident was discharged from therapy on 11/3/17. When asked if he had any other screens or evaluations for the resident since that time, the Director stated no. c. At 3:35 p.m., the evening shift CNA stated that the resident walks but not much since her fall a few weeks ago. She said the resident was too weak and walks a few feet from bed to chair or toilet but not more. Interviews conducted on 11/2/18 included the following: a. At 8:42 a.m., the Registered Nurse Manager stated that if staff are unable to complete tasks on the care plan they should notify the team leader. She said the resident was referred to therapy after the last fall but they were not able to see her until that week (after surveyor intervention). b. At 8:47 a.m., the Director of Physical Therapy said that therapy received the evaluation but had not been able to get to it until recently due to staffing issues. He said that the resident will be picked up for daily Physical Therapy, but he could not say if her decline was functional or due to her dementia. (10 NYCRR 415.12(a)(1)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #131) of two residents reviewed for indwelling urinary catheters, the facility did not ensure that the residents with a urinary catheter received the treatment and services needed to prevent infections to the extent possible. Specifically, the resident's indwelling catheter was not secured to prevent tension on the insertion site, and the tubing and drainage bag were observed on several occasions in a manner that could potentially predispose the resident to an infection. This is evidenced by the following: Resident #131 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/14/18, revealed that the resident had severely impaired cognition and was always incontinent of urine. The resident did not have a catheter at that time. The facility policy, dated as last reviewed (MONTH) 2012, Catheterization/Peri care, under guidelines included, but was not limited to, that the catheters must be ordered by a physician and include catheter and balloon size, that drainage bags need to have a blue drainage bag holder when in bed if the resident is in a high low bed, that the bag and tubing must not drag on the floor, must be free of kinks, and to secure the catheter by using a 'Cath-secure' band. The current Certified Nursing Assistant (CNA) Bedside Kardex included that the resident had a catheter, to position the bag and tubing below the level of the bladder and away from the room door entrance (for privacy), and to monitor for discomfort. It did not include the use of a leg strap. The current Comprehensive Care Plan did not include that the resident had an indwelling urinary catheter. Review of the nursing progress note, dated 9/29/18 and signed by the Licensed Practical Nurse, revealed that the resident did not void that shift, that a bladder scan was done revealing 350 cubic centimeters (ccs) of urine, and an indwelling catheter was inserted. Review of medical orders, dated 9/29/18, revealed an order for [REDACTED]. Observations conducted included the following: a. On 10/29/18 at 2:00 p.m., the resident was being wheeled in a geriatric chair. The catheter tubing was caught between the spokes of the wheel pulling back and forth as she was wheeled. b. On 10/30/18 at 9:24 a.m., the catheter drainage bag was on the floor uncovered, lying under a dirty fall mat, and was not secured to the bed or linens to prevent tension. c. On 11/1/18 at 8:58 a.m., the catheter drainage was attached to the resident's bed frame, was on the floor, uncovered, and able to be seen from the hallway. d. On 11/1/18 at 10:00 a.m. during incontinence and wound care, the drainage tubing was not secured to anything to prevent tension as the resident was turned back and forth several times for care with the tubing pulled across the body several times. Interviews conducted on 11/1/18 included the following: a. At 10:15 a.m., the Registered Nurse (RN) stated that the resident had not had a leg strap on to secure the catheter for several days. b. At 1:52 p.m., the CNA stated that the drainage bag should not be on the floor. She said the drainage should be in a protector bag and that the resident should have a leg strap on. c. At 2:19 p.m., the RN Nurse Manager stated that the catheter bag should never be on the floor. She said the resident should always have a strap on to secure the Foley. She said that the catheter was placed on 9/29/18 which was a weekend, but the complete orders were not written until several weeks later when it was noticed that there was no care guidelines and/or size ordered. (10 NYCRR 415.12)

Based on observation, interviews and record review conducted during the Recertification Survey, it was determined that for two (Residents #51 and #159) of four residents reviewed for respiratory care, the facility did not provide proper respiratory treatments and care consistent with professional standards of practice. Specifically, oxygen therapy was not provided per the physician order and/or the resident's respiratory status was not consistently monitored. This is evidenced by the following: Review of the facility policy, Oxygen Therapy, dated (MONTH) 2014, revealed oxygen was a drug and must be administered as prescribed. The policy included to monitor and document the effectiveness of oxygen therapy, check oxygen saturations levels every shift, and document on the vital signs sheet. The policy instructed to change the tubing every other Wednesday on the 3-11 shift. 1. Resident #51 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/7/18, revealed the resident was rarely/never understood, received oxygen therapy and required total assistance of staff for activities of daily living. The current physician orders included oxygen at 2 liters per minute via nasal cannula continuously (start date 8/23/18). Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed an entry to clean the oxygen contractor and filter every Saturday night and oxygen at 2 liters per minute continuously via nasal cannula. Review of the Oxygen Saturation Level Summary sheet revealed oxygen saturations were checked once daily on 8/29/18, 9/19/18, 10/2/18, 10/12/18 and 10/29/18. Review of nursing progress notes, from 10/21/18 through 10/29/18, revealed that on 10/29/18 at 4:00 p.m., vital signs were documented that included an oxygen saturation level that was 96 percent on 2 liters of oxygen, color was good, and skin was warm and dry. During an observation on 10/29/18 at 12:24 p.m., the resident was sitting in a Broda chair (specialized wheelchair) in the dining room. Staff was observed feeding the resident. The resident was wearing a nasal cannula, and the oxygen tank was on the back of the chair. The oxygen tubing was not connected to the oxygen tank. When interviewed at that time, Licensed Practical Nurse (LPN) #1 stated she did not know the oxygen tubing was not connected to the oxygen tank. She said she would need to check on the resident's order for oxygen. Another staff member stated the resident was on 2 liters, and the nurse then connected the tubing to the tank and administered oxygen at 2 liters. During an observation on 10/31/18 at 10:15 a.m., the resident was in bed receiving oxygen at 2 liters per minute via nasal cannula. The oxygen tubing was dated 10/17/18. When interviewed on 10/31/18 at 10:06 a.m., LPN #2 stated that the oxygen tubing was changed by the night nurse every week or two. During an interview on 11/1/18 at 11:15 a.m., the Registered Nurse Manager (RNM) stated she developed the resident's Comprehensive Care Plan (CCP). After review of the resident's CCP, the RNM stated oxygen therapy was not addressed on the CCP and it should have been. 2. Resident #159 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 9/28/18, revealed the resident had moderately impaired cognition and required oxygen therapy. The current physician orders and the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records included oxygen at 2 liters per minute continuously for [MEDICAL CONDITION]. During observations on 11/1/18 at 9:06 a.m. and 10:30 a.m., the resident was receiving oxygen at 3 liters per minute via nasal cannula and oxygen concentrator. In an observation with RNM #2, on 11/2/18 at 10:01 a.m., the resident was in bed and was receiving oxygen at 3 liters per minute via nasal cannula. When interviewed at that time, RNM #2 stated that the resident's oxygen was supposed to be set at 2 liters per minute. She said that the nurses are the only staff who adjust the resident's oxygen liter flow. (10 NYCRR 415.12(k)(6))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #48) of one resident reviewed for a death in the facility, the facility did not provide medically related social services to attain or maintain the highest practical, mental and psychosocial well-being of each resident. Specifically, there was a lack of social services for a resident and family during end of life care and related family interactions prior to the resident's death in the facility. This is evidenced by the following. Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated [DATE], revealed that the resident had severely impaired cognition, was totally dependent on staff for all activities of daily living and had occasional behaviors such as hitting and kicking. The resident expired in the facility on [DATE]. The current Comprehensive Care Plan included that the resident had a communication problem due to [MEDICAL CONDITION] (difficulty speaking) from a stroke, a cognitive loss due to dementia, and that the resident can be physically aggressive as evidenced by attempts to hit staff and family. Interventions included, but were not limited to, to anticipate and meet all needs and assist the spouse in addressing any concerns. The care plan did not include difficult family interactions and special visiting instructions that were in place for the resident's spouse. In an interview on [DATE] at 1:47 p.m., the resident's spouse stated that she was not allowed to visit her husband in his room for the past two months because she yelled at him a few times when he was attempting to hit her. She stated that they had been married for [AGE] years and that when she told him to stop hitting her and he realized who she was he was fine. She said the Social Worker told her she had to call ahead of time prior to her visits so staff could get the resident out of bed. The resident's spouse said she was told she could only visit with him in the hallway, including after he went on comfort care. She said sometimes he was up and sometimes he was not causing her visit to be cut short due to her transportation arrangements. She said she did not think the resident would be able to tolerate getting up much longer and her time with him was coming to an end. The resident's spouse said she asked if someone could be in the resident's room when she visited, and she was told no. The resident's spouse said she told the previous Director of Nursing (DON) about her concerns but nothing was changed, and she was not allowed private time prior to his death and that upset her. Review of the resident's electronic medical record revealed the following: a. The resident's spouse was listed as Health Care Proxy, Power of Attorney, Executer and primary emergency contact. b. Interdisciplinary progress notes from [DATE] through [DATE] revealed multiple notes of aggressive behavior of the resident towards staff that were sometimes re-directed with a calm approach and explanations. The notes also included that the resident's spouse was notified of any changes in the resident's condition. c. The most recent Social Work note, dated [DATE], included information related to a Medicaid application. There were no Social Work notes in the medical record related to visiting instructions for the spouse and/or support related to end of life care. d. Review of a physician progress notes [REDACTED]. e. Review of a progress note, dated [DATE] and signed by the Registered Nurse Manager (RNM), revealed that the RNM and the Social Worker met with the resident's spouse to discuss comfort care. Hospice services were offered and declined, and comfort care guidelines worksheet was filled out and initiated at that time. A summary signed by the Administrator, dated [DATE], revealed that on [DATE] the Administrator was notified that the resident's spouse was overheard being inappropriate and that the spouse was agreeable to a visitation plan. After an investigation, it was determined that there was no abuse, neglect or mistreatment and that the plan will be re-evaluated as needed. Interviews conducted on [DATE] included the following: a. At 8:51 a.m., the RNM stated that there were multiple issues with the family. She said other members of the family requested the visits be monitored due to concerns related to verbal abuse and so that plan was initiated. She stated she had a good rapport with the resident's spouse, that she was really trying and that she was not aware that the spouse was unhappy about visiting the resident only in the hallway. b. At 11:26 a.m., the Social Work stated that she received a call from another family member who was concerned with verbal aggression a few months ago. She stated she requested the spouse to meet with the resident in the hallway and that she thought she was ok with the plan. The Social Worker said that she had no documentation related to the issue and or the visitation rules that the facility set up. The Social Worker said that she had no further documentation since the [DATE] note and the [DATE] comfort care worksheet that she completed. In an interview on [DATE] at 11:30 a.m., the Administrator and the Director of Nursing stated that there was no formal investigation conducted or documented to rule out verbal abuse as it was just an informal discussion by staff and that they did not feel the spouse was verbally abusive. The Administrator stated that he had never had any conversations with the spouse or other family members related to the issue. (10 NYCRR 415.5(g)(1)(i-xv))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 740) completed on 1/24/18, it was determined that for two of three residents reviewed for abuse, neglect, or mistreatment, the facility did not ensure the residents were free from mistreatment and abuse. The issues were incidents involving Residents #1 and #2. This is evidenced by the following: The facility policy, Resident Abuse and Elder Justice Act, reviewed (MONTH) (YEAR), included investigation guidelines for abuse, neglect and mistreatment. Mistreatment is defined as the inappropriate use of medication, isolation or use of physical/chemical restraints, and neglect included failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/17/17, included that the resident had severely impaired cognition and physical behavioral symptoms directed toward others. Resident #1's Comprehensive Care Plan (CCP), initiated 4/27/17, included a history of delusions and agitated behaviors. Interventions included gentle reorientation with casual conversation and validation when resident expresses delusional thoughts. The Bedside Kardex Report, effective (MONTH) (YEAR), directed to use a calm approach, validation approach, do not attempt to reorient the resident and leave and return if agitated. Resident #2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/15/17, included that the resident had severely impaired cognition and physical and verbal behavioral symptoms directed towards others. Resident #2's CCP, initiated 11/8/16, included angry outbursts and combative behaviors. The Bedside Kardex Report, effective (MONTH) (YEAR), directed to use a gentle approach, calm voice and stop if resident becomes aggressive. Gain resident cooperation before resuming care and report behaviors to a nurse. The Health Electronic Response Data System, dated 12/28/17, revealed that on 12/27/17, a report was received from the Nurse Manager that an allegation of abuse occurred on 12/26/17 at 5:30 p.m. The allegation was that Certified Nursing Assistant (CNA) #1 told Resident #1 that she was going to drown her stuffed cats (Resident #1 believes the stuffed cats are real). During the investigation process, another allegation regarding CNA #1 surfaced involving CNA #1 tapping Resident #2 on the head with a pillow and/or Bible. CNA #1 admitted she threatened to drown Resident #1's cats and stated that she teasingly tapped Resident #2 with no intent to harm. The facility summary, dated 12/27/17, revealed that after interviewing all staff members, it appeared that CNA #1 used inappropriate language towards Resident #1 when she became agitated with Resident #1's behavior. Two additional witnesses corroborated the allegations. When interviewed on 1/11/18 at 11:40 a.m., the Administrator stated that allegations of abuse/mistreatment involving Residents #1 and #2 were reported by the Licensed Practical Nurse (LPN) on 12/27/17 at 3:00 p.m. The Administrator stated that the incident involving Resident #1 occurred on 12/26/17, and the incident involving Resident #2 occurred previous to that and the exact date was unknown. The Administrator stated that he spoke with staff regarding timely reporting, and directed staff to report if not sure and administration would investigate. When interviewed on 1/11/18 at 12:15 p.m., CNA #2 stated that around 12/19/17 at 9:30 p.m. when completing Resident #2's care with CNA #1, the resident became very combative, and CNA #1 placed a pillow over the resident's face using two hands for about three seconds. CNA #2 stated that Resident #2 tried to remove the pillow lifting with her right hand, but CNA #2 removed the pillow. CNA #2 stated that after removing the pillow, the CNAs tried to remove Resident #2's shirt, and CNA #1 picked up a Bible and hit Resident #2 on the middle of her forehead because CNA #1 was annoyed. CNA #2 stated that Resident #2 tried to remove the Bible from CNA #1's hand and tried to hit and spit, and CNA #1 placed the Bible on the table, and told Resident #2 that was not acceptable, covering the resident's mouth with her hand. CNA #2 stated that on 12/26/17, she observed CNA #1 take Resident #1's stuffed cats. CNA #2 said the resident thinks the cats are real. CNA #1 told the resident that she was going to throw the cats in the river. CNA #2 stated that the nurse was at the nurses' station at that time and could see and hear the interaction. CNA #2 stated that she asked CNA #1 why she said that, and CNA #1 said she did not know, she was just mad. When interviewed on 1/11/18 at 1:00 p.m., CNA #3 stated that around 12/21/17, she was providing care to Resident #2 with CNA #1, and the resident was trying to hit and was calling the CNAs names. CNA #1 took Resident #2's Bible and tapped the resident on her head. CNA #3 stated that was inappropriate but CNA #1 was not trying to do harm, she was annoyed and agitated with Resident #2. When interviewed on 1/11/18 at 1:50 p.m., CNA #1stated that for the incident involving Resident #1, the resident was throwing her stuffed animals and hitting and spitting at staff. CNA #1 told the resident that she cannot do that, it was not nice, and if she did not stop, CNA #1 would throw the cats in the river. CNA #1 stated that she heard the same thing said to the resident before, so it just came out. CNA #1 stated that she did place a pillow on Resident #2's head, kind of joking, adding that she bopped the resident with the pillow. CNA #1 stated that the facility protocol for agitated residents included walking away from the resident. CNA #1 said that she does not feel she received proper training for residents with combative behaviors. When interviewed on 1/11/18 at 2:50 p.m., the LPN stated that on 12/26/17, she saw CNAs #1 and #2 with Resident #1. CNA #1 leaned forward and was close to the resident's face and said she was going to take her cats and drown them in the river. The LPN stated that she saw CNA #1 place her full hand over the resident's mouth for a few seconds because the resident was spitting. The LPN said she told the CNAs to walk away from the resident. (10 NYCRR 415.4(b)(1)(i))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 740) completed on 1/24/18, it was determined that for two of three residents reviewed for abuse, neglect or mistreatment, suspicion of abuse, neglect and/or mistreatment was not reported by facility staff to administration in a timely manner. The issue involved delayed reporting of mistreatment/abuse/neglect incidents involving Residents #1 and #2. This is evidenced by the following: The facility policy, Resident Abuse and Elder Justice Act, reviewed (MONTH) (YEAR), included Investigation Guidelines for abuse, neglect and mistreatment. The policy included immediate investigation of all reports of suspected abuse or mistreatment by the on-site Administrative Authority and prompt contact of the Administrator and Director of Nursing (DON). Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/17/17, included that the resident had severely impaired cognition and physical behavioral symptoms directed toward others. Resident #2 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/15/17, included that the resident had severely impaired cognition and physical and verbal behavioral symptoms directed towards others. The Health Electronic Response Data System, dated 12/28/17, revealed that on 12/27/17, a report was received from the Nurse Manager that an allegation of abuse occurred on 12/26/17 at 5:30 p.m. The allegation was that Certified Nursing Assistant (CNA) #1 told Resident #1 that she was going to drown her stuffed cats (Resident #1 believes the stuffed cats are real). During the investigation process, another allegation regarding CNA #1 surfaced involving CNA #1 tapping Resident #2 on the head with a pillow and/or Bible. CNA #1 admitted she threatened to drown Resident #1's cats and stated that she teasingly tapped Resident #2 with no intent to harm. When interviewed on 1/11/18 at 11:40 a.m., the Administrator stated that allegations of abuse/mistreatment involving Residents #1 and #2 were reported by the Licensed Practical Nurse (LPN) on 12/27/17 at 3:00 p.m. The Administrator stated that the incident involving Resident #1 occurred on 12/26/17, and the incident involving Resident #2 occurred previous to that and the exact date was unknown. The Administrator said that the staff are expected to report suspicion of abuse/neglect or mistreatment immediately. When interviewed on 1/11/18 at 11:55 p.m., the DON stated that CNA #2 reported the incidents involving Resident #2 during the investigation process involving Resident #1's incident that occurred on 12/26/17, stating that CNA #2 felt tormented by the events involving Resident #2 and was losing sleep. When interviewed on 1/11/18 at 12:15 p.m., CNA #2 stated that around 12/19/17 at 9:30 p.m., when completing Resident #2's care with CNA #1, she observed CNA #1 place a pillow over the resident's face using two hands for about three seconds and hit Resident #2 on the middle of her forehead with a Bible because CNA #1 was annoyed. CNA #2 stated that on 12/26/17, she observed CNA #1 take Resident #1's stuffed cats. CNA #2 said the resident thinks the cats are real. CNA #1 told the resident that she was going to throw the cats in the river, and the nurse was at the nurses' station at that time and could see and hear this interaction. CNA #2 stated she did not report the incidents because she was afraid she would get in trouble. CNA #2 said that the nurse did not report the incident until 22 hours later, because she had 24 hours to report. When interviewed on 1/11/18 at 1:00 p.m., CNA #3 stated that around 12/21/17, she was doing care on Resident #2 with CNA #1. She said CNA #1 took Resident #2's Bible and tapped the resident on her head. CNA #3 stated that she was shocked by the situation and did not know what to do and reported the incident after another incident occurred involving CNA #1 and Resident #1 on 12/26/17. CNA #3 said that CNA #1 was doing other things to other residents. CNA #3 stated that abuse was supposed to be reported immediately to the nurse, but she felt intimidated by CNA #1. When interviewed on 1/11/18 at 1:50 p.m., CNA #1 stated that for the incident involving Resident #1, the resident was throwing her stuffed animals and hitting and spitting at staff. CNA #1 told the resident that she cannot do that, it was not nice, and if she did not stop, CNA #1 would throw the cats in the river. CNA #1 stated that she heard the same thing said to the resident before, so it just came out. CNA #1 stated that she did place a pillow on Resident #2's head, kind of joking, adding that she bopped the resident with the pillow. CNA #1 stated that the facility protocol for agitated residents included walking away from the resident. CNA #1 said that she does not feel she received proper training for residents with combative behaviors. When interviewed on 1/11/18 at 2:50 p.m., the LPN stated that on 12/26/17, she saw CNAs #1 and #2 with Resident #1. She said CNA #1 leaned forward and was close to the resident's face and said she was going to take her cats and drown them in the river. The LPN stated that she saw CNA #1 place her full hand over the resident's mouth for a few seconds because the resident was spitting. The LPN said that she told the CNAs to walk away from the resident. The LPN stated that after discussing the incident with another LPN, she was advised that this was abuse, it needed to be reported, and reported the incident on 12/27/17 at 3:00 p.m., when she returned to work. The LPN stated that she got mixed up with state reporting and reporting to facility supervisors, and did not report the incidents until 12/27/17 at 3:00 p.m. when she returned to work. When interviewed by telephone on 1/25/18 at 11:20 a.m., Registered Nurse (RN) #1 stated that she worked as a supervisor on the evening shift during the month of (MONTH) (YEAR), and was not notified of any allegations of abuse or mistreatment. She said if either incident was reported to her, she would have removed the staff involved from the unit. RN #1 stated that she makes rounds two to three times during the shift and talks with staff during rounds. When interviewed by telephone on 1/25/18 at 11:30 a.m., RN #2 stated that she heard about the incidents involving Residents #1 and #2 after the fact, and no one reported either incident to her when she worked the evening shift as supervisor in (MONTH) (YEAR). RN #2 stated that Resident #1 thinks her stuffed cats are alive and would be extremely upset if someone threatened to drown them. (10 NYCRR 415.4(b)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen and one of five nourishment rooms, the facility did not provide safe and sanitary food storage. Specifically, food in a freezer was potentially contaminated and refrigerators were not maintained at the required temperature. This is evidenced by the following: Observations on 6/20/17 at 10:45 a.m. revealed a temperature log attached to the side of the refrigerator in the sixth floor pantry showed daily temperatures between 50 and 60 degrees Fahrenheit (°F) from 6/13/17 through 6/20/17. Each entry on the log was initialed 'GH.' Further observations revealed both the upper and lower door seals were cracked and damaged, and the dial for the temperature setting was at the coldest setting. The internal thermometer showed 60°F and the refrigerator contained dozens of food items, including but not limited to, two half gallons of milk, macaroni salad, and chicken. A temperature of the Vitamin D milk was taken at that time and showed 48°F. In an interview at that time, the Lead Maintenance Worker II stated that dietary staff checks the refrigerators and they usually tell us if there is a problem. The Food Service Director then voluntarily discarded several of the items in the refrigerator. When interviewed on 6/21/17 at 1:25 p.m., the Dietary Aide, who recorded the temperatures of the sixth floor pantry refrigerator, said that she usually checks the temperatures in the morning. She said the temperature should be about 40°F. The Dietary Aide said that she did not tell anyone about the high temperatures. She said that she should have told the Food Service Director. During an observation on 6/20/17 at 11:39 a.m., there was frozen condensation icicles on the ceiling of the walk-in freezer and the temperature in the freezer upon entering was approximately 10°F. Multiple boxes and bags of food items were also observed to have frozen condensate on them, including but not limited to, an open bag of chicken, a box containing bags of chicken and a box with an open bag of green beans. A tray including an uncovered cake and a tray of uncovered hot dogs were also located under the condensate icicles. There was a buildup of ice below the entry door to the walk-in freezer located inside of the walk-in cooler. When interviewed at that time, the Production Manager stated that he believed that there was an issue with the defrost cycle running too long in the freezer. He said that he was going to ask the refrigeration technician about it. He said that the freezer was installed incorrectly because the walls were not supposed to be that high. He said that the freezer walls extended below the insulation. The Production Manager stated that the condensate would be distilled, so it would not be a contaminant to the food that it dripped on. When interviewed on 6/20/17 at 11:51 a.m., the Food Service Director stated that it was not ok for condensate to drip onto food items in the freezer. He said that it would be a potential source for contamination. He stated that he would throw away any items that had been dripped on. The Food Service Director said he had put in multiple work orders to have the freezer fixed dating back approximately two weeks. When interviewed on 6/22/17 at 2:07 p.m., the Lead Maintenance Worker II stated that there was no paper work for maintenance requisitions for the freezer. He said there was an issue with the timing of the defrost cycles. (10 NYCRR: 14-1.40(a), 14-1.44, 14-1.95)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of five residential sleeping units, the facility did not provide housekeeping services necessary to provide a sanitary, orderly and comfortable interior. Specifically, mold and mildew was found on ceiling heating panels in residential rooms. This is evidenced by the following: During an observation on 6/20/17 at 11:58 a.m., the ceiling in Resident Room #404 was noted to have brownish black debris on the ceiling tiles. Observations conducted on 6/21/17 between 12:45 p.m. and 1:04 p.m. revealed the following: a. In Resident Room #404, there was a large amount of black fungus like material found on the metal ceiling panels for the heating system. b. In Resident Room #406, there was black material around the holes in the metal ceiling pan. c. In Resident Room #415, there was black material around the holes in the metal ceiling pan. d. In Resident Room #310, there was black fungus like material around the holes in the metal ceiling panels. e. In Resident Room #309, there was a large amount of black fungus like material found on the metal ceiling panels. Interviews conducted on 6/21/17 included the following: a. At 1:05 p.m., Resident #182 stated that she had lived in Room #309 for approximately one year and that the black material had always been on the ceiling. The resident stated that she had wondered what the material was and that it looked dirty. b. At 1:15 p.m., Lead Maintenance Worker II stated that the metal panels are radiant heating panels. He said they have not had any issues with leaks in this system, but when the windows are opened they have had issues with condensation forming on the panels. He said they try to keep the windows shut for that reason. Lead Maintenance Worker II stated that they have not had issues with mold and mildew. He said they check for mold during the quarterly room audits, which were last done on Friday. He showed surveyor the quarterly room audit which did not mention any issues on the ceilings. c. At 1:31 p.m., Lead Maintenance Worker II used a paper towel and bleach and was able to easily clean the black material from the ceiling panel in Resident Room #309. At that time, he stated that they would have to get a list of the rooms to go around and clean them. He said he thought the black material was mildew. d. At 1:36 p.m., Housekeeper #1 stated that he had not cleaned the ceilings in about a year. He said he knows that when they are sweating, he has to clean them. The Housekeeper then stated that he cleans the ceilings when they catch his eye. He said that he should be looking at them weekly on the thorough cleaning day. When the surveyor showed the Housekeeper the ceilings in Resident Room #309 he stated that they should be cleaned. During an interview on 6/22/17 at 8:16 a.m., the Housekeeping Working Supervisor stated that if housekeepers see black stuff on the ceiling they need to clean it with bleach. The Housekeeping Working Supervisor stated that when the chiller is turned on the black stuff comes. She said it has happened for a long time, but she had not seen it yet this year. The Housekeeping Working Supervisor stated that if staff see the black stuff, they may not clean it right away, but they should return later when they have time and clean it. A review of the deep cleaning document provided by the Housekeeping Working Supervisor revealed that there was no procedure or policy regarding cleaning the ceilings in resident rooms. (10 NYCRR 415.5(h)(2))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 2 of 33 residents reviewed for Minimum Data Set (MDS) Assessments accuracy, the facility did not ensure the MDS Assessments accurately reflected the residents' status. Coding issues included dental (Resident #31) and weight loss (Resident #215). This is evidenced by the following: 1. Resident #31 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Dental Consults, dated 11/18/15 and 2/1/17, revealed that the resident was missing all upper teeth, ten lower teeth, and teeth #22 through #28 were fractured at the gum line. The Comprehensive MDS Assessments, dated 1/9/16 and 12/3/16, documented that the resident did not have any dental issues. When interviewed on 6/22/17 at 11:05 a.m., the Licensed Practical Nurse said that the resident has no upper teeth, does not allow them to put in the denture, and has only nubs at the gum line for lower teeth. When interviewed on 6/23/17 at 9:15 a.m., the MDS Registered Nurse (RN) said she would review the chart and complete an oral exam prior to completing the Dental Status section of the MDS Assessment. She said if the resident had fractured teeth, the MDS Assessment should be coded as obvious or likely cavity or broken natural teeth. The October 2016 MDS Manual defines broken natural teeth or tooth fragments as tooth broken off or decayed to the gum line, or broken teeth (from a fall or trauma) and directs to code if any are seen. 2. Resident #215 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/3/17, documented that the resident's admission weight was 150 pounds (lbs.). The MDS Assessment, dated 4/24/17, documented that the resident's weight was 141 lbs. Both assessments documented that there was no weight loss of 5 percent or more in the last month, or a loss of 10 percent or more in the last six months. Based on the documented weights on the MDS Assessments, the resident had a weight loss of nine pounds or 6 percent within 30 days. During an interview on 6/22/17 at 2:13 p.m., the MDS RN said the weight section of the MDS Assessment is completed by the Registered Dietician. She reviewed the MDS Assessment and stated that it should have been coded as a weight loss. The October 2016 MDS Manual definitions for 5 percent weight loss in 30 days included: start with the resident's weight closest to 30 days ago, and multiply it by .95 (or 95 percent). The resulting figure represents a 5 percent loss from the weight 30 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost more than 5 percent body weight. (10 NYCRR 415.11(b))

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for 2 of 33 residents reviewed for care planning, the facility did not revise the care plan to reflect the current status of a resident. Issues involved a serious head injury and laceration (Resident #123), and weight loss (Resident #215). This is evidenced by the following: 1. Resident #123 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/16/17, revealed that the resident's cognition is severely impaired and a history of falls. When observed on 6/20/17 at 11:57 a.m., the resident had an undated white gauze dressing that was clean and dry on her forehead, secured with paper tape. When observed again on 6/21/17 at 12:44 p.m. and 3:11 p.m., and on 6/22/17 at 8:08 a.m., the resident had the same white gauze dressing on her forehead. The Hospital Discharge Summary, dated 6/19/17, directed to change the dressing as needed and keep the area clean and dry. Review of the current Certified Nursing Assistant (CNA) Care Plan and the Comprehensive Care Plan (CCP) revealed no documentation of the forehead wound. Review of the physician's orders, Medication Administration Record [REDACTED]. Interviews conducted on 6/22/17 included the following: a. At 1:18 p.m., the Registered Nurse (RN) stated that she knew the resident had a dressing on the forehead. The RN said that she is not aware of any orders to monitor or change the dressing. The RN said she thinks there should have been an order to at least monitor the wound every shift. b. At 1:48 p.m. and 6/23/17 at 8:54 a.m., the RN Manager (RNM) said that she changed the resident's dressing on 6/19/17, when the resident was readmitted to the facility. The RNM said that she did not write an order for [REDACTED]. She said she should have updated the resident's care plan. 2. Resident #215 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/24/17, revealed that the resident's cognitive skills for daily decision making is severely impaired and the resident's weight is 141 pounds (lbs.). Review of the Weight Summary Report revealed the resident's weight on admission was 149.9 lbs. On 4/3/17, the resident's weight was 138.6 lbs. and on 6/1/17, the resident's weight was 138.8 lbs. There was a weight loss of 11.1 lbs. since admission. The Nutritional Assessment, dated 4/3/17, revealed that the resident required limited assistance with eating, consumed 75 to 100 percent of solids, and the resident's most recent weight was 149.9 lbs. The Nutritional Care Plan, dated 4/3/17, included a goal to maintain the resident's weight of 150 lbs. (plus or minus 5 percent). A RN documented on 4/13/17 that the resident fed himself after the tray was set up, and his weight was down since admission. There was no further documentation regarding weight loss through 6/23/17. The physician documented on 4/24/17 that the resident's weight was 140.6 lbs. Interviews conducted on 6/22/17 included the following: a. At 10:12 a.m., the Registered Dietician (RD) stated weights are completed every month and reviewed by dietary. She said any resident with a 5 lb. weight loss or gain is addressed in a progress note. The RD reviewed the progress notes and stated there was no documentation regarding weight loss. The RD stated that the resident's weight loss should have been addressed in the CCP. b. At 9:05 a.m., the Nurse Manager (NM) stated that the resident's care plan should have addressed the weight loss. She said a 10 lb. weight loss should be addressed by dietary and nursing. Review of the facility policy, Comprehensive Care Plan, dated October 2012, revealed that the Interdisciplinary Team will devise a CCP for each resident, which will be reviewed, updated and changed when there are major changes. The care plan will be revised to meet the status of the resident. (10 NYCRR 415.11(c)(3)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of two residents reviewed for food consistency, the facility did not ensure that the residential environment remained as free of accident hazards as is possible. The issue involved the lack of effective monitoring of mechanically altered diets for Residents #138 and #167. This is evidenced by the following: 1. Resident #138 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/2/17, revealed that the resident's cognition is severely impaired, requires supervision and set-up for eating, and receives a mechanically altered diet. The physician's orders, dated from 9/23/16 to current, included regular diet of mechanical soft texture. When observed on 6/20/17 at 12:31 p.m., the resident's lunch tray contained barbequed pork that was 3 inches long and stringy. Review of the tray ticket revealed the resident is on a mechanical soft diet with ground barbequed pork. The surveyor called over a Certified Nursing Assistant (CNA) before the resident started to eat to question whether this was an appropriate consistency. The CNA said the resident is on mechanical soft foods and the tray ticket included ground pork. The CNA said that she did not know, but did not think the meat was ground. At that time, the CNA called over the Licensed Practical Nurse (LPN) and asked if the pork was ground. The LPN stirred the meat around and said she did not think the pork was ground. The LPN said she would call the kitchen and ask. After calling the dietary office, the LPN removed the meat from the resident's tray and ground pork was later sent from the kitchen. 2. Resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/5/17, revealed that the resident is cognitively intact, eats with supervision and set-up assistance, and receives a mechanically altered diet. The physician's orders, dated from 9/22/16 to current, included regular diet of mechanical soft texture. When observed on 6/20/17 at 12:31 p.m., the resident's lunch tray contained barbequed pork that was 3 inches long and stringy. The tray ticket included mechanical soft diet and ground barbequed pork. This resident's meat was also removed by the LPN and replaced with ground pork. Interviews conducted on 6/22/17 included the following: a. At 11:21 a.m., the Food Service Director (FSD) said he was not aware of a problem with the barbequed pork delivered to the units in the wrong consistency on 6/20/17. He said that ground meat should be the size of a grain of rice. He said the person who puts the food on the tray checks the tray ticket for consistency. He said there is also a team leader at the end of tray line who checks each tray for accuracy. When interviewed at that time, the Baker said she was the person who logged in the call from the LPN who asked if the pork being served was ground. The Baker said she told the LPN no. She said the LPN asked for two servings of ground pork. She said at that time, the cook ground up two portions of pork. The Baker said that the LPN reported that two residents received the wrong consistency of pork. The Baker said she reported it to the Supervisor. b. At 11:32 a.m. the Supervisor said she was not made aware of this incident. c. At 11:34 a.m., the FSD said if he had known about this incident he would have started an investigation, looked at the tray tickets, looked at the production line sheets, and interviewed the cooks. d. At 11:40 a.m., the Dietary Aide said she was the one who served the hot foods on the tray line on 6/20/17 at lunch. She said she was also training another Kitchen Aide at that time. She said there were 10 residents who received ground barbeque pork. She said the pork was three inches or longer and stringy. She said that she thought that was ground consistency meat. e. At 11:46 a.m., the Dietician stated that for a mechanically soft diet the meat should be ground. She said that barbequed pork should not be 3 inches and stringy, it should be ground into very small pieces. The Dietician said that if a resident on a ground consistency diet ate whole pieces of meat, they could choke. When interviewed on 6/23/17 at 9:10 a.m., the Registered Nurse Manager said she expects that when staff set up trays, they make sure the food is the correct consistency. Review of the facility policy, Consistency Alterations, dated 2008, directed that for a mechanical soft diet the meat should be soft, tender, ground, shredded or chopped and well moistened with gravy or cream sauce. (10 NYCRR 415.12(h)(2))

Based on interviews and record reviews, it was determined that for one (Resident #75) of five residents reviewed for unnecessary medications, the facility did not provide services in accordance with the resident's written plan of care. Specifically, physician orders [REDACTED]. This is evidenced by the following: Resident #75 has a [DIAGNOSES REDACTED]. Review of the consultation record ([MEDICAL CONDITION] clinic), dated 1/6/16, revealed physician's orders [REDACTED]. If unable to do daily, please check at least weekly. Call with a weight gain of greater than 5 pounds in one week. The facility's physician order, dated 1/6/16, was written for weekly weights. Review of the Treatment Administration Record (TAR) revealed an entry for weekly weights; call the [MEDICAL CONDITION] clinic if the resident has a weight gain of 5 pounds or greater in one week. The entries on the TARs from 12/31/15 through 3/30/16 for weekly weights were not initialed as done for seven of ten scheduled weekly weights. Interviews conducted on 4/5/16 included the following: a. At 2:06 p.m., the Registered Nurse (RN) stated that weekly weights are obtained and recorded on the weight record. She said if the weights are not documented, then there is no way to determine if there has been a weight gain. b. At 2:07 p.m., the Licensed Practical Nurse stated that the Certified Nursing Assistants obtain the weights and record them on a daily vital sign board. She said the nurse then reviews the weight, records it on the weight record, and then signs off on the TAR that the weight has been completed. c. At 2:52 p.m., the RN Manager stated that she would expect weekly weights to be completed as ordered. She said the nurses should record the resident's weight on the weight log and compare weights for discrepancies. She said she monitors the Medication Administration Records for omissions and occasionally glances at the TARS. She said the TAR is a reminder to obtain the resident's weight. When interviewed on 4/6/16 at 2:24 p.m., the Director of Nursing stated that her expectation is that weekly weights are completed, documented, reviewed, and reported as needed. (10 NYCRR 415.11(c)(3)(ii))

Based on observations, interviews, and record reviews, it was determined that for one (Resident #132) of nine residents observed for medication administration, the facility did not ensure that residents were free of significant medication errors. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 3/26/15. Specifically, staff crushed an extended release tablet for administration. This is evidenced by the following: Resident #132 has [DIAGNOSES REDACTED]. Physician orders, dated 3/22/16, include [MEDICATION NAME]-Leva ER (extended release) for [MEDICAL CONDITION], 25/100 one tablet by mouth at 10:00 a.m., 1:00 p.m., 4:00 p.m., and 7:00 p.m. The order also included, Do not crush or chew. During observation of a medication pass on 4/5/16 at 3:26 p.m., Licensed Practical Nurse (LPN) #1 crushed the [MEDICATION NAME]-Leva ER tablet and administered it to the resident. In an interview on 4/6/16 at 3:15 p.m., LPN #1 stated she always crushes all of this resident's medications because she is a choking hazard, and she was told to crush the resident's medications when she started in October 2015. She added that the sheet on top of the medication cart indicates this resident takes her medications crushed. Interviews conducted on 4/6/16 included the following: a. At 3:18 p.m., LPN #2 stated that they crush all the medications except this one because the physician orders [REDACTED]. She added that this resident does fine with the medication whole in applesauce. b. At 3:26 p.m., the consulting pharmacist stated that an extended release tablet is released into the resident's system over a period of time. She said that crushing the medication would be a significant concern. She added that if the tablet was crushed, the resident would not have the medications in her system when she needed it. She said that if the resident was unable to swallow it whole, the medical team would have to reassess what to do. In an interview on 4/7/16 at 10:03 a.m., the Registered Nurse Manager stated that this medication should not be crushed, and the sheet taped to the top of the medication cart (a sheet identifying how each resident on the unit takes their medications, such as whole or crushed) could be misleading. (10 NYCRR 415.12(m)(2))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 439) completed on [DATE], it was determined that for one (Resident #1) of two residents reviewed for advance directives, the facility failed to provide services that met professional standards of quality. Cardiopulmonary resuscitation (CPR) was stopped prior to contacting a physician or emergency medical team. The resident expired This resulted in no actual harm with potential for more than minimal harm that is Immediate Jeopardy to the health and safety of the resident and Substandard Quality of Care, and is evidenced by the following: The Immediate Jeopardy was removed prior to entrance on [DATE]. The facility's CPR policy, revised in February 2012, directed that if a resident has no pulse, start giving external cardiac compressions along with artificial ventilations per current American Red Cross (ARC) guidelines. Continue CPR until spontaneous circulation and ventilation are restored or emergency personnel arrive. The ARC CPR for Professional Rescuers and Health Care Providers Handbook, copyrighted 2011, revealed the following: Do Not Stop CPR except in one of the following situations: obvious signs of life are seen, such as breathing; an automated external defibrillator is ready to use; another trained rescuer or advanced medical personnel takes over; the rescuers are too exhausted to continue; or the scene becomes unsafe. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders, dated [DATE], revealed that the resident is a full code. A Minimum Data Set Assessment, dated [DATE], revealed that the resident's cognitive abilities are severely impaired. Review of the [DATE] Fall and Behavior Investigation Report concluded that the resident choked, became unresponsive, and CPR was performed. The resident died . Review of the [DATE] Chronology of Events for the Incident Report revealed that CPR was started at 12:50 p.m. and stopped at 12:59 p.m. The nursing staff were having difficulty in administering respirations and chest compressions. The resident remained without a pulse or spontaneous respiratory effort. When interviewed on [DATE] at 9:10 a.m., the Director of Nursing (DON) stated that on [DATE], the resident choked on a breadstick during lunch. He was removed from the dining room and monitored. He laid down in bed on his side and was found unresponsive. CPR was administered but 911 was not called. The DON added that the head nurse directed that CPR could be stopped because it was ineffective (futile) and the two Registered Nurses (RN) performing CPR were exhausted. Interviews conducted on [DATE] were as follows: a. At 10:00 a.m., the head nurse stated that she was recently trained in CPR. She said on [DATE], when she was summoned to the resident's room, RN #1 was performing CPR on the resident and she took over compressions. The head nurse stated that she and RN #1 were both exhausted and had to stop. The head nurse stated she was never entirely clear on who determined CPR could be stopped. She added that no one officially called CPR off, but her expectation was that when she was tired, someone else would take over. b. At 10:55 a.m., Certified Nursing Assistant (CNA) #1 stated that while the nurses were performing CPR, the Licensed Practical Nurse (LPN) asked if she should call 911, and the head nurse said that the supervisor was on her way. c. At 11:20 a.m., the nursing supervisor stated that around 12:45 p.m. on [DATE], staff called her to the resident's room. The nursing supervisor stated that upon entering the room, the head nurse and RN #1 were performing CPR. The nursing supervisor stated that the head nurse looked at her and pointed to the resident's abdomen, meaning it was distended and CPR was not working. The nursing supervisor stated that CPR was then stopped. The nursing supervisor stated that no one said to stop CPR when she was in the room, and there was no conversation about calling 911. She said that 911 should have been called when the resident was found unresponsive. The nursing supervisor also said that CPR can only be stopped by the emergency medical team or a physician. d. At 11:45 a.m., CNA #2 stated that the nursing supervisor did not offer to relieve the nurses doing CPR. CNA #2 stated that he did not hear anyone say they were exhausted performing CPR. e. At 12:20 p.m., CNA #3 stated that during CPR, someone asked if 911 should be called, and the head nurse said to wait for the supervisor. CNA #3 said that one to two minutes later the nursing supervisor went into the resident's room and CPR was stopped. She does not know who made that the decision. f. At 1:10 p.m., the LPN stated that the head nurse told the nursing supervisor that the breaths were going to the resident's stomach, and CPR was stopped. The LPN stated that the nurses did not report they were exhausted while performing CPR. The LPN said she was waiting to take over. g. At 1:40 p.m., RN #1 stated that on [DATE] the resident was found lying on his back, gray in color, with no breathing or pulse present. She started CPR, and two to three minutes later, the head nurse entered and took over chest compressions. RN #1 stated that she told the head nurse that the breaths were not going in. She stated the head nurse looked at the nursing supervisor and stated CPR was not working, and they stopped at approximately 12:59 p.m. h. At 2:45 p.m., the Medical Director was interviewed by telephone and stated that the facility's policy for CPR directs nursing to call 911. He said it is his expectation that 911 be called when CPR is started. He said that the decision to stop CPR would be made by emergency personnel. The Immediate Jeopardy was past non-compliance and corrected, as evidenced by the following: 1. Inservice refresher training on CPR and Code Blue procedures (as of [DATE]) has been completed for 53 of 58 licensed nurses. No nurse will be allowed to work until in-service is completed. Training started [DATE] and will continue until all nurses are trained. 2. CPR policy and procedure has been reviewed and revised to add Code Blue procedures and clarification of emergency notification procedures to specify that any nurse or aide should contact emergency medical services when instructed to do so by the nurse who determined there was an emergency (completed [DATE]). 3. Code Blue drills have been conducted on all shifts, [DATE] to [DATE], and will be conducted on all shifts weekly for at least three months. Quality Assurance will review results of drills and determine whether to change frequency of drills. As of [DATE], there have been four drills. 4. Emergency notification numbers to contact emergency medical services along with paging instructions have been laminated and posted by each nursing station telephone, dining room telephone, and each medication cart and emergency cart on all five units (completed [DATE]). 5. CPR training curriculum has been revised to emphasize that the emergency notification procedures can be initiated by any staff member upon the order of the nurse who assessed that an emergency exists (completed [DATE]). (10 NYCRR 415.11(c)(3)(i))

Based on observations, interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 439) completed on [DATE], it was determined that for one (Resident #1) of two residents reviewed for Advance Directives, the facility failed to provide necessary care and services to maintain a resident's highest practicable physical well being. The issue is that cardiopulmonary resuscitation (CPR) was stopped prior to contacting a physician or Emergency Medical Team. The resident expired. This resulted in no actual harm with potential for more than minimal harm that is Immediate Jeopardy to the health or safety of the resident that is Substandard Quality of Care, and is evidenced by the following: The Immediate Jeopardy was corrected prior to entrance on [DATE]. The facility's CPR policy, revised in February 2012, directed that if a resident has no pulse, start giving external cardiac compressions along with artificial ventilations per current American Red Cross (ARC) guidelines. Continue CPR until spontaneous circulation and ventilation are restored or emergency personnel arrive. The ARC CPR for Professional Rescuers and Health Care Providers, copyrighted 2011, revealed the following: Do not stop CPR except in one of the following situations: obvious signs of life are seen, such as breathing; an automated external defibrillator is ready to use; another trained rescuer or advanced medical personnel takes over; the rescuers are too exhausted to continue; or the scene becomes unsafe. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders, dated [DATE], revealed that the resident is a full code. The Minimum Data Set Assessment, dated [DATE], revealed that the resident's cognitive abilities are severely impaired. Review of the [DATE] Fall and Behavior Investigation Report concluded that the resident choked, became unresponsive, and CPR was administered. The resident died . Review of the [DATE] Chronology of Events Incident Report revealed that CPR was started at 12:50 p.m. and stopped at 12:59 p.m. The nursing staff were having difficulty administering respirations and chest compressions. The resident remained without pulse or spontaneous respiratory effort. When interviewed on [DATE] at 9:10 a.m., the Director of Nursing (DON) stated that on [DATE], the resident choked on a breadstick during lunch. He was removed from the dining room and monitored. He laid down on his side and was found unresponsive. CPR was administered, but 911 was not called. She said that the nursing supervisor was paged overhead, but it was not a STAT (come immediately) page. The DON added that the head nurse directed that CPR could be stopped because it was ineffective (futile), and the two Registered Nurses (RN) performing CPR were exhausted. Interviews conducted on [DATE] were as follows: a. At 10:00 a.m., the head nurse stated that she was recently trained in CPR. She said on [DATE], when she was summoned to the resident's room, RN #1 was performing CPR on the resident and she took over compressions. The head nurse stated she asked if the nursing supervisor was called and then focused on the resident. The head nurse said that she noticed that the resident's abdomen appeared distended so she repositioned his head and resumed compressions. The head nurse stated that she and RN #1 were both exhausted and had to stop. She stated she was never entirely clear on who determined CPR could be stopped. The head nurse added that the RN supervisor came in and was talking on the telephone telling the Assistant Director of Nursing (ADON) that the compressions were ineffective, and the resident was gone. The head nurse stated that no one officially called CPR off, but her expectation was that when she was tired someone else would take over. b. At 11:20 a.m., the nursing supervisor stated that around 12:45 p.m. on [DATE], staff called her to the resident's room. The nursing supervisor stated that upon entering the room, the head nurse and RN #1 were performing CPR. The nursing supervisor stated that the head nurse looked at her and pointed to the resident's abdomen meaning it was distended and CPR was not working. The nursing supervisor stated that CPR was then stopped at 12:59 p.m. The nursing supervisor stated that no one directed to stop CPR when she was in the room, and there was no conversation about calling 911. The nursing supervisor said that 911 should have been called when the resident was found unresponsive. She stated that CPR can only be stopped by the emergency medical team or a physician. d. At 12:50 p.m., the ADON stated that the nursing supervisor notified her that the resident choked and was gone. The ADON stated that she did not know that CPR was initiated. She said there was no announcement for a code or call for help. The ADON stated that the nursing supervisor came to nursing administration 15 minutes or more after the incident and said that CPR was performed. e. At 1:10 p.m., the LPN stated that on [DATE], after she returned from lunch, RN #1 said that the resident had stuffed a breadstick in his mouth and might vomit. The LPN stated that five to ten minutes later, the CNAs were yelling to come to the resident's room. The LPN stated that she ran to the head nurse's office and informed her that CPR was being performed and, at sometime during the second round of CPR, she asked about calling 911. RN #1 responded that they were waiting for the nursing supervisor, and the head nurse acted like she did not hear what the LPN said. When questioned about why she did not call 911, the LPN stated that she was waiting for direction and expected someone to say call 911 or relieve the nurses' performing CPR. The LPN added that when the nursing supervisor came in the room, she was talking to someone on the telephone, but the LPN did not know who or what she was saying. The LPN stated the head nurse told the nursing supervisor that the breaths were going to the resident's stomach, and CPR was stopped. The LPN stated that the nurses did not report they were exhausted while performing CPR. The LPN said she was waiting to take over. f. At 1:40 p.m., RN #1 stated that on [DATE] during lunch, the resident grabbed a soft breadstick and shoved it in his mouth. RN #1 stated that the resident choked and coughed but he was able to clear the breadstick on his own. RN #1 stated that she heard staff calling for her at 12:50 p.m., and upon entering the resident's room, she found him lying on his back, gray in color with no breathing or pulse present. RN #1 stated that she yelled for someone to call the nursing supervisor, told the LPN that the resident is a full code, and CPR needed to be started. RN #1 stated she started CPR and two to three minutes later, the head nurse entered and took over chest compressions. RN #1 stated that she told the head nurse that the breaths were not going in. She said the head nurse looked at the nursing supervisor and said CPR was not working, and they stopped at approximately 12:59 p.m. g. At 2:30 p.m., the Administrator stated that he was made aware of the [DATE] incident on [DATE] and started the investigation and interviewing involved staff. The Administrator said that the Quality Assurance activity included inservicing staff, revision of the policy and procedure for full codes, and performing CPR. h. At 2:45 p.m., the Medical Director was interviewed by telephone and stated that he was made aware of the incident immediately after it happened and told of the circumstances. He said the facility policy for CPR directs nursing to call 911 and this was not done. The Medical Director stated that it is his expectation that 911 be called when CPR is started. He said the decision to stop CPR would be made by emergency personnel. i. At 2:50 p.m., the ADON stated that when CNA #3 paged for the nursing supervisor overhead, she did not indicate that it was a STAT or emergency call. The Immediate Jeopardy was past non-compliance and corrected, as evidenced by the following: 1. Inservice refresher training on CPR and Code Blue procedures (as of [DATE]) has been completed for 53 of 58 licensed nurses. No nurse will be allowed to work until in-service is completed. Training will continue until all nurses are trained. 2. CPR policy and procedure has been reviewed and revised to add Code Blue procedures and clarification of emergency notification procedures to specify that any nurse or aide should contact emergency medical services when instructed to do so by the nurse who determined there was an emergency (completed [DATE]). 3. Code Blue drills have been conducted on all shifts, [DATE] to [DATE], and will be conducted on all shifts weekly for at least three months. Quality Assurance will review results of drills and determine whether to change the frequency of drills. As of [DATE], there have been four drills. 4. Emergency carts have been inspected and reorganized (completed [DATE]). 5. Emergency notification numbers to contact emergency medical services along with paging instructions have been laminated and posted by each nursing station telephone, dining room telephone, and each medication cart and emergency cart on all five units (completed [DATE]). 6. CPR training curriculum has been revised to emphasize that the emergency notification procedures can be initiated by any staff member upon the order of the nurse who assessed that an emergency exists (completed [DATE]). (10 NYCRR 415.12)

Based on observation, staff interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 153) completed on 11/5/12, it was determined that for one (Resident #1) of three residents reviewed for accidents, the facility failed to provide adequate supervision to prevent accidents. The issue involved the lack of thorough and timely care planning for bed mobility that resulted in a fractured shoulder, lung contusion, and a hemothorax (a collection of blood between the chest wall and lung) requiring the resident to be hospitalized . This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #1 has [DIAGNOSES REDACTED]. The Fall Risk Assessment, last updated 7/16/12, scored the resident at high risk for falls. The resident Certified Nursing Assistant (CNA) care card, last dated 7/26/12, included one assist for bed mobility. The Minimum Data Set (MDS) Assessment, dated 7/28/12, revealed that the resident required extensive assistance and two-person physical assistance for bed mobility. The 8/29/12 nursing progress note revealed that the resident was assessed for stroke-like symptoms with right-sided weakness and left-sided facial drooping. There was no documentation found in the medical record to indicate that the resident was re-assessed for bed mobility following the 8/29/12 change in medical status. A nursing progress note and a Rehabilitation Referral, both dated 9/13/12, documented that the resident had sustained a decrease in Range of Motion in the right hand. Documentation on this Rehabilitation Referral included a possible cerebral vascular accident on 8/30/12 and that the resident was flaccid on the right side with increased pain upon movement of the right hand. A second Rehabilitation referral, dated 9/15/12, revealed that the physician wanted the resident seen to assess for right hand/arm Range of Motion exercises due to weakness. The 9/13/12 and 9/15/12 therapy referrals did not address the resident's bed mobility. A new order was received on 9/17/12 for Occupational Therapy evaluation and treatment as appropriate due to a decrease in self care related to the new onset of right upper extremity weakness. The 9/30/12 fall/behaviors investigation report revealed that a CNA was providing the resident morning care at 10:15 a.m. When the CNA turned the resident to the side to provide incontinence care, the resident rolled off the side of the bed toward the cupboard. The investigation summary, dated 10/1/12, included to provide two assist for care while in bed and a lip mattress on the bed following the resident's return to the facility. During an observation on 10/12/12 at 1:15 p.m., the resident had a lip mattress and low bed, and floor mats. The CNA care card posted on the wall indicated two assist for bed mobility. When interviewed on 10/12/12 at 8:45 a.m., the Director of Nursing (DON) stated that on 9/30/12, the resident rolled off the side of the bed during care provided by CNA #1. The DON stated that the resident's MDS Assessment indicated two plus persons for bed mobility and once two assist is used to position a resident, the MDS Assessment will show two plus persons, but not on the CCP because the resident can help himself. The DON added that the resident should have been two assist. In an interview on 10/12/12 at 1:40 p.m., CNA #2 stated that since the resident had his stroke, he is hard to position or move in bed alone, especially when rolling to his left side because he cannot stay on his left side. CNA #2 added that she had reported this to nursing, including the Nurse Manager (NM), and the CCP was not changed. The 10/15/12 hospital discharge summary [DIAGNOSES REDACTED]. In an interview on 10/16/12 at 10:30 a.m., the Registered Nurse (RN) charge nurse stated that residents with weaknesses were to be two assists, and she was aware of the resident's stroke in August 2012. The charge nurse added that the resident's CCP was not changed to two assist for bed mobility due to an oversight. Interviews on 10/18/12 revealed the following: a. At 9:30 a.m., the RN supervisor stated that she was not aware of concerns voiced by CNAs about the resident's bed mobility. She added that the resident definitely should have been two assist for bed mobility because of his size and diagnoses. b. At 10:45 a.m., CNA #1 stated that the resident would not have fallen off the bed if another CNA was on the other side of the bed. When interviewed on 11/5/12 at 1:30 p.m., the DON stated RNs can change bed mobility status with PT assessment. After the resident's fall on 9/30/12 and return from the hospital on [DATE], the resident's CCP was changed to two assists for bed mobility. During interviews on 11/5/12 at 1:40 p.m., the PT and Occupational Therapist (OT) said that neither was made aware of a change in the resident health status or his cerebral vascular accident symptoms noted by nursing on 8/30/12. A referral for PT/OT assessment was not received until 9/13/12 for decreased Range of Motion of the right hand. (10 NYCRR 415.12(h)(2))