Every finding on record at Church Home of the Protestant Episcopal Church

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for one of one main kitchen the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, potentially hazardous foods were not cold held at or below 45 degrees Fahrenheit ( F), and a refrigerator was not maintained in good working order. The findings are: Observations in the main kitchen on 1/3/24 at 9:14 AM included a Hoshizaki brand stand up two door refrigerator marked with a #5 on the door and two thermometers inside of the left door displaying 48 F. At this time the kitchen thermometers and the surveyors' Thermapen were checked for proper calibration using a cup of ice and water and read 32 F. Observations on 1/3/24 at 9:28 AM included the temperatures of the following items within the Hoshizaki cooler were measured by the surveyor as follows: Carrots 49 F, rice 48 F, vegetables soup 53 F, six hamburgers 51 F, gravy 48 F, bologna 48 F, a partial package of Turkey 51 F, eight sausage links 53 F, and Swiss cheese 50 F. Each of these items were observed to be stored in small stainless containers that measured six-inches wide by six-inches deep and were voluntarily discarded by the Kitchen Manager. In an interview at this time the Kitchen Manager stated that they called their service guy, and they should have the cooler taken care of by tomorrow. Additionally, the Kitchen Manager stated that they do sometimes have problems with this cooler, especially in hot weather. Review of a work order dated 1/3/24 revealed that the unit (Hoshizaki cooler) was out of temperature upon arrival and that it had a very slow leak for over a year. Record review on 1/5/24 at 10:20 AM revealed the temperature log for cooler #5 included AM and PM temperatures recorded for January 1, 2024, of 21 F and no entries for January 2-5. In an interview at this time the Kitchen Manager stated everyone should do this. 10NYCRR: 415.14(h); 10NYCRR: Subpart 14-1.40(a), 14-1.95

Based on interviews and record review conducted during the Recertification Survey, it was determined that for three (Employees #2, #4, and #5) of seven newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and/or misappropriation of resident property related to screening of prospective employees. Specifically, a nurse aide registry abuse screening was not completed for newly hired employees prior to starting work. The findings are: On 1/5/24 from 1:30 PM to 2:45 PM, newly hired employee files were provided to the surveyor for review and included the following: Employee #2 was hired on 9/20/23 as a Unit Secretary and the nurse aide registry screen for prior abuse findings was not completed until 1/5/24. Employee #4 was hired on 10/17/23 as a Food Service Worker and the nurse aide registry screen for prior abuse findings was not completed until 1/5/24. Employee #5 was hired on 12/4/23 as an Environmental Services Worker and the nurse aide registry screen for prior abuse findings was not completed until 1/5/24. During an interview on 1/5/24 at 2:00 PM and 2:10 PM, the Director of Talent Development stated that they did not have a nurse aide registry check for Employee #2 or Employee #4. During an interview on 1/5/24 at 2:01 PM, the Senior Talent Acquisition Specialist stated that did not realize that they needed to run a nurse aide registry screen for everyone, including the Unit Secretary position but that they were checking Certified Nursing Assistants. 10 NYCRR: 415.4(b)

Based on observations, interviews and record review conducted during the Recertification Survey it was determined that for one (Resident #12) of six residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the Activities of Daily Living services required to maintain good nutrition. Specifically, Resident # 12 was not consistently provided with the amount of assist required during mealtimes. This is evidenced by the following: Resident #12 had diagnoses that included adult failure to thrive, macular degeneration (an eye disease that causes vision loss), and hearing loss. The Minimum Data Set assessment dated [DATE], revealed the resident was severely impaired cognitively, that their vision was highly impaired, and they required substantial/maximal (helper does more than half the effort) assistance with eating. Review of the Comprehensive Care Plan (CCP), revised on 12/18/23 revealed Resident #12 was at risk for alteration in nutrition with staff interventions that included to describe the resident's items on their meal tray, make updates as needed, review oral intake, obtain the resident's weights, and consult speech and occupational therapy as needed. Review of the current Certified Nurse Assistant Care Card (specific instructions for daily care) revealed Resident #12 required meal set up due to vision loss and encouragement to self-feed. During an observation and interview on 1/5/24 at 12:29 PM, Resident #12 was lying in bed with their meal tray in front of them. The lids had been removed from the food containers by Certified Nurse Assistant #1 and the resident's Boost (a high calorie supplement) had been opened but no other assist was observed prior to Certified Nurse Assistant #1 leaving the room. When interviewed at this time Resident #12 stated they could not see their food and was feeling around the meal tray. During an interview on 1/5/24 at 12:39 PM, Certified Nurse Assistant #1 said that when they go in Resident #12's room, they remove all the lids and tell the resident what they have on their meal tray. Certified Nurse Assistant #1 said they had offered to help the resident with their food, but the resident declined. During an interview on 1/5/24 at 12:44 PM, Licensed Practical Nurse #1 said they had spoken with the nurse manager about listing (on the Certified Nurse Assistant Care Card) Resident #12 as being in need of more feeding assistance and that Resident #12 had done well with eating but had required encouragement. During observations and interviews on 1/8/24 at 9:01 AM, Certified Nurse Assistant #2 delivered Resident #12's breakfast tray and told the resident their tray was there but did not describe the food items on the tray or location of the each food. Certified Nurse Assistant #2 removed the lids from the food and beverage containers and left the room. At 9:11 AM, Resident #12 remained lying in bed with their head of bed lowered less than 30 degrees, their food tray was untouched, and the resident did not appear to be able to reach their meal tray to feed themself. The resident was unsuccessfully attempting to operate their bed controller to raise the head but was lowering the height of the bed instead. During an interview and observation on 1/8/24 at 9:16 AM, Certified Nurse Assistant #2 said when they enter Resident #12's room, they introduce themself, turn on the light, and explain to the resident what was on their meal tray. Certified Nurse Assistant #2 said the resident loved to eat, sometimes consumed 75-100% and was blind but would feel for items on their table. Certified Nurse Assistant #2 then returned to Resident #12's room to collect their meal tray which was untouched other than the nutritional supplement drink and one bite of egg and asked Resident #12 if they wanted more to eat and Resident #12 replied that they could not see their food. During an interview with Minimum Data Set Coordinator #1 and Minimum Data Set Coordinator #2 on 1/8/24 at 10:16 AM, Minimum Data Set Coordinator #1 said that Resident #12 had a significant change resulting in the resident requiring substantial/maximal assistance with eating and that their level of care had been updated effective 12/18/23. Minimum Data Set Coordinator #1 said they look at staffing notes and what the resident had been doing for the prior seven-day period which included more assist than previously. The Minimum Data Set Coordinator #1 said the resident's Comprehensive Care Plan and the Certified Nurse Assistant Care Card should have reflected that the resident needed more assistance once the resident had a significant change (now on Hospice). During an interview on 1/8/24 at 10:39 AM, the Registered Dietician said if Resident #12 was taking in less than 25% of their meals staff would need to assist the resident as needed. During an interview with the Director of Nursing and the Assistant Director of Nursing on 1/8/24 at 11:15 AM, the Director of Nursing said staff should start by setting the resident's tray up, and as a second approach, staff should come back and offer more assistance to the resident such as offering to feed them if they did not accept the first approach. The Director of Nursing said the second approach was not on the care plan, but that staff should know the expectation. Additionally, the Director of Nursing said if the resident required more assistance, the resident's care plans should list the same. The Assistant Director of Nursing said it was their responsibility to update the care plans once changes were made. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for one (Resident #109) of one resident reviewed, the facility did not manage the resident's pain to the extent possible in accordance with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Specifically, there was insufficient evidence that the resident's pain was effectively monitored and treated despite numerous complaints of pain. Additionally, Resident #109's Comprehensive Care Plan did not include that the resident had chronic pain with goals and interventions related to pain management. This is evidenced by the following: The facility's Pain Assessment and Management policy dated last reviewed December 2022, included the purpose of the policy was to help staff identify pain in a resident, to develop interventions that are consistent with the resident's goals and needs and address the underlying causes of pain. The policy included to assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. The Certified Nursing Assistants should report any signs or symptoms of pain or resident complaints of pain to the team leader/nursing leadership. The Team Leader should observe each resident for signs or symptoms of pain or acknowledge resident complaints of pain each shift. Resident #109 had diagnoses that included post traumatic stress disorder, chronic pain, and unspecified dementia. The Minimum Date Set Assessment, dated 10/30/23, revealed the resident was cognitively intact, experienced pain occasionally, rated their pain seven (out of ten), and was on a scheduled pain regimen with as needed pain medication. During an interview on 1/3/24 Resident #109 stated they always have pain to their face and that the get Tylenol or something stronger. When asked how they rated their pain (0 being no pain and 10 being the worst pain) , Resident #109 said higher that 5 and that they have had pain for a while Resident #109's current Comprehensive Care Plan did not include they had any pain, or any goals or interventions (pharmacological or non-pharmacological) related to pain. Review of current Physician orders included acetaminophen (Tylenol) 1,000 milligrams three times a day, Bengay arthritic pain cream three times a day to neck, back and shoulders, tramadol 25 milligrams twice a day as needed for chronic facial pain, and acetaminophen 500 milligrams every six hours as needed for pain or fever. Review of the Medication Administration Records for December 2023 and January 2024 revealed Resident #109 received their scheduled acetaminophen and Bengay three times a day as ordered. Additionally, Resident #109 received their as needed acetaminophen dose and a dose of tramadol on one occasion in December 2023 and the acetaminophen on one occasion in the 8 days reviewed for January 2024. Review of the electronic medical record for the past month revealed the resident's daily pain was assessed and/or monitored for effectiveness of current pain measures and Physician orders twice in the last month. Additionally, the pain scale section under vital signs was blank (no documented values) for the full month reviewed. In a request for all pain assessments for the past several months, the facility provided a pain assessment form dated 11/7/23. Registered Nurse Manager #1 documented that Resident #109 had pain occasionally and rated their pain as a seven consistently over the past five days. Review of the Nursing 30/60 Day (Physician visit) form signed on 12/6/23 by Registered Nurse Manager #1 included that Resident #109's family was asking about the resident's facial pain and understood that it had been ongoing which they attributed it to fibromyalgia. Additionally, the Physician Notes section signed by physician on 12/7/23 included that Resident #109 continued to have chronic mouth/jaw pain, which was suspected to be due to irritation from dentures, and used tramadol and acetaminophen occasionally for pain. During an interview on 1/3/24 at 10:50 AM, Resident #109 stated that they always have pain to their face and have had the pain for a while. Resident #109 stated they would rate their pain higher than a five but would not give a specific number. Resident #109 stated they thought they took Tylenol and a something stronger for the pain. During an interview on 1/5/24 at 1:10 PM, Resident #109 stated their back hurt, they had received some pain medication and it had gotten better. During an interview on 1/8/24 at 1:01 PM, Resident #109 stated they called for the nurse at 6:00 AM (earlier that morning) because they were having pain and could not move (due to the pain). Resident #109 said staff came in, got them cleaned and up and then the nurse came in and gave them pain medication. Resident #109 said they were not sure what pain medicine they had been given, but they think they get it three times a day. Resident #109 said they were not able to get extra pain medication if they have been given the three times a day dose, and if they complain of pain, staff will tell them they just had their pain medication. Resident #109 was not able to verbalize their current pain level at the time of the interview. In a Nursing Progress Note dated 1/8/24 Registered Nurse Manager #1 documented that Resident #109's health care proxy voiced concerns regarding the resident's facial and jaw pain. Registered Nurse Manager #1 documented that they spoke with Resident #109, who initially denied being in pain, but then proceeded to complain of pain to the jaw and cheek bones. The progress note included that Resident #109 had the same pain concerns in the past and that acetaminophen and tramadol were available. During interviews on 1/8/24 at 1:31 PM and again on 1/9/24 at 11:37 AM, Registered Nurse Manager #1 stated the monitoring of residents' pain included quarterly pain assessments as part of the Minimum Data Set Assessment. Registered Nurse Manager #1 said if they see that a resident has increased pain, they will notify the medical provider. Registered Nurse Manager #1 said there is no standard process for nursing staff to ask residents about their pain every shift or every day. Registered Nurse Manager #1 stated Resident #109 requested the as needed medications when they needed it. Registered Nurse Manager #1 said Resident #109's pain issue should be added to their care plan. During an interview on 1/9/24 at 11:27 AM, Licensed Practical Nurse #2 said Resident #109 was always in pain and had acetaminophen and tramadol ordered (for pain). Licensed Practical Nurse #2 said Resident #109 will call and voice when they are in pain. Licensed Practical Nurse #2 said when they first entered Resident #109's room that morning, the first thing the resident said was that they were in pain. Licensed Practical Nurse #2 stated they told Resident #109 to let them know if they still had pain following their scheduled dose. During an interview on 1/9/24 at 12:39 PM, the Director of Nursing said there is an informal process for monitoring residents' pain day to day. The Director of Nursing said if a resident voices pain or via nonverbal (cues), staff would report it to the team leader, who would look at the resident's electronic health record to determine if any as needed pain medications were available. If as needed pain medications were not ordered for the resident, it would then be passed on to a Registered Nurse, who would assess the resident and notify a medical provider. The Director of Nursing stated they would expect pain and related interventions to be included on a resident's care plan (if they had pain). During an interview on 1/9/24 at 2:03 PM, Certified Nursing Aide #6 stated the past few mornings, when they entered Resident #109's room the resident had complained of back pain and requested pain medication and that [NAME] had come around to administer any. Certified Nursing Aide #6 said that they offered the resident a shower (to help with the pain), but on the way to the shower, the resident started crying and that their back hurt so the shower was not provided and they had relayed this information to Registered Nurse Manager #1. 10 NYCRR 415.12

Based on observations, interviews, and record review conducted during a Recertification Survey, it was determined that for two (Residents #8 and #79) of 12 residents reviewed, the facility did not provide special eating equipment for residents who need them to maintain or improve the residents' ability to eat and drink independently. Specifically, Resident #8 and Resident #79 were observed on multiple occasions consuming soup from a bowl instead of a mug as recommended by Occupational Therapy. This is evidenced by the following: 1.Resident #8 had diagnoses including stroke with hemiplegia (paralysis and weakness on one side of the body), adult failure to thrive, dementia, and dysphagia (difficulty swallowing). The Minimum Data Set Assessment, dated 12/2/23, revealed that Resident # 8 had moderate cognitive impairment of cognitive function and required supervision or touching assistance for eating. Resident #8's current Comprehensive Care Plan included providing adaptive equipment per Occupational Therapy recommendations. Review of Resident #8's Occupational Therapy note dated 10/19/23 revealed a recommendation for set-up, food cut up, a lip plate (specialized plate), soup served in a mug and supervision. Resident #8's current Care Card (care plan used by Certified Nursing Assistants for daily care) dated 1/5/24 did not include any adaptive equipment required for eating. A Care Plan Summary Clinical Note dated 12/5/23 and authored by Social Services included that Resident #8 required a lip plate, soup in a mug, set up, cut up and supervision at meals. During an observation on 1/3/24 at 12:37PM, Resident #8 lunch tray was delivered and their soup served in a bowl (versus a mug). Resident #8 was drinking the soup from the bowl raised to their mouth. Review of the resident's meal ticked at this time included that soup should be served in a mug. During an observation on 1/8/24 at 12:39PM, Resident #8 was sitting at the dining table for lunch drinking their soup from a bowl raised to their mouth and causing some spillage. Review of the resident's meal ticket instructed to serve soup in a mug. During an interview on 1/8/24 at 1:26PM, Registered Nurse Manager #1 stated the kitchens staff were responsible for ensuring specific items listed on the meal tickets were provided to the resident, and the Certified Nursing Assistants are a second set of eyes to check on consistency and assistive wear. Registered Nurse Manager #1 observed Resident #8's meal tray and stated that the soup was in a bowl and not in a mug as listed on the meal ticket. 2. Resident #79 had diagnoses that included Alzheimer's disease, muscle weakness, and glaucoma. The Minimum Data Set assessment dated [DATE] included that Resident #79 required supervision and touching (hands on) assist with eating. Review of Resident #79's current Comprehensive Care Plan included to provide the resident setup with meals, supervision, and soup in a mug. Review of an Occupational Therapy note dated 11/17/23, included Resident #79 needed assistance with foods requiring the use of utensils, and did best with finger foods and soup in a mug. During an observation on 1/8/24 at 12:41PM, Resident #79 was observed in dining room during lunch, with their soup in a bow. Review of the resident's lunch meal ticket listed soup in a mug. Review of Resident #79's current Comprehensive Care Plan included to provide the resident setup with meals, supervision, and soup in a mug. During an interview on 1/9/24 at approximately 10:30AM the Occupational Therapist stated that serving soup in a mug is an intervention that comes from Occupational Therapy and that the goal is for the resident to get the intake they need. If a resident is unable to get soup from the bowl to the mouth and it spills then I would recommend serving the soup in a mug. Whoever sets the tray up should be checking the tickets and if they don't have the equipment, they should let us know so can get more. During an observation on 1/8/24 at 12:41pm, Resident #79 was observed in the dining room during lunch, with their soup in a bowl. Review of the resident's lunch meal ticket listed soup in a mug. During an interview on 1/9/24 at 9:11AM, Food Service Kitchen Staff #1 stated that any special instructions and special equipment on the meal ticket is reviewed while plating a resident's meal. Food Service Kitchen Staff #1 said once everything is plated, a re-check should be done and if something is missing it is put on the tray. During an interview on 1/9/24 at 10:01AM, Certified Nursing Assistant #4 stated that the equipment a resident would need should be listed on their meal ticket, and that Certified Nursing Assistants should review each resident's meal ticket to make sure everything is on the tray. Certified Nursing Assistant #4 said if the tray is not right, the tray is taken back to the kitchen (on the unit). During an interview on 1/9/24 at 10:15AM, the Manager of Dietary and Catering stated the kitchen aides will review the meal tickets prior to proceeding to the resident's units to identify available inventory (or lack thereof) and if adaptive equipment is needed. The Manager of Dietary and Catering said adaptive equipment and special instructions for residents are printed and highlighted on the top of the meal tickets. The Manager of Dietary and Catering stated a new process was recently implemented for setting up meal trays because it was identified that items were being missed. The Manager of Dietary and Catering said that kitchen staff were to call down directly to the kitchen or supervisor if assistive equipment was not available. The Manager of Dietary and Catering stated that Resident #8 should not have received their soup in a bowl, as the meal ticket listed soup in a mug. The Manager of Dietary and Catering said they spoke with the involved staff member (who Plated Resident #8's tray during lunch), who stated they were nervous while plating lunch. 10 NYCRR 415.14(g)

Based on observations, interviews and record reviews, conducted during the Recertification Survey, completed on 3/11/22, it was determined that for one of one main kitchen, the facility failed to store, prepare, distribute and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were multiple undated and unlabeled food items, dented cans, and a high temperature automatic dishwashing machine that did not meet temperature sanitizing standards. This is evidenced by the following: The undated facility policy titled 'Food Storage', included that plastic containers with tight-fitting covers must be used for storing cereals, cereal products, and broken lots of bulk foods and must be accurately labeled and dated. The policy also included that food items should be dated as it is placed on shelves and date marking should be done to indicate the date or day by which ready-to-eat, potentially hazardous foods should be consumed, sold, or discarded and will be visible on all high-risk foods. All foods should be covered, labeled and dated. The facility policy, 'Cleaning Dishes/ Dish Machine', revised January 2013, included that dish machines will be checked prior to meals and throughout the cycle to assure proper functioning and appropriate temperatures for cleaning and sanitation. The policy included that for a high temperature dishwasher the wash temperature should be 150 degrees Fahrenheit (°F) to 165°F and the final rinse temperature should be 180°F. Observations during the initial brief tour of the main kitchen on 3/7/22 from 8:31 a.m. to approximately 9:30 a.m. revealed the following: a. A large bag of fried chicken patties open and undated, in the walk-in freezer. b. Two large bags of raw chicken wings unlabeled and undated, in the walk-in cooler. c. Two half gallon containers of fat free milk located in the walk-in cooler were open and partially full with no open date. One container was marked with a 'sell by' date of 2/27/22 and another with a 'sell by' date of 3/3/22. d. There was a pound of margarine open and in plastic wrap, with no open date, in the walk-in cooler. e. There was an undated and opened stack of Swiss cheese covered in plastic wrap, in a side by side refrigerated unit. f. There was a large jar of peppers, horseradish, hot sauce, and Worcestershire sauce open, partially used and undated in a side by side refrigerated unit. g. There was a gallon-size containers of: barbeque sauce, sesame dressing, Italian dressing and Greek dressing. All were open, partially used and undated in a side by side refrigerated unit. h. A small jar of Vegenaise (vegan mayonnaise) opened and undated and marked with a 'best by' date of October 2021. i. Two small bowls of prepared tossed salad in plastic wrap undated in the walk-in produce cooler. j. A large bag of diced potatoes, a bag of shredded carrots, a bag of romaine lettuce hearts, and a storage container of shredded romaine opened, undated and unlabeled in the produce walk-in cooler. k. Two storage containers of prepared tuna salad and applesauce that were unlabeled, undated, and identified by the kitchen manager in the walk-in produce cooler. Signage on the door of walk-in produce cooler included Please date all food items in fridge. Observations during the follow up tour of the main kitchen on 3/9/22 at 11:22 a.m. revealed the following: a. Five dented #10 cans (pizza sauce, spaghetti sauce and three butterscotch pudding) in the dry storage area. b. A large undated, open bag of confectioner sugar in plastic wrap and a large undated open bag of breadcrumbs, also in plastic wrap, in the dry storage area. c. The high temperature automatic dishwashing machine temperature gauge was approximately 110°F for the wash cycle and 135°F for the rinse cycle, when run by the kitchen manager. A temperature log for the dishwashing machine, completed 3/1/22 through 3/7/22, recorded 155°F for the wash cycles and 185°F for the rinse cycles. The temperature log was not completed 3/8/22 and 3/9/22. During an interview on 3/9/22 at 11:22 a.m., the Kitchen Manager stated that the food vendor took back the dented cans and that the kitchen staff should know not to use dented cans. The Kitchen Manager stated they do not have a dedicated staff member to check deliveries and put the items away but that staff should have checked them and set them aside. During an interview on 3/9/22 at 12:04 p.m., the Kitchen Aide stated they ran the dishwashing machine, and that the temperature varied. The Kitchen Aide was unable to recall the proper wash and rinse cycle temperatures. During an interview on 3/9/22 at 12:05 p.m., the Kitchen Manager stated they have trained all the new kitchen staff on the proper dishwashing machine temperatures and the Kitchen Aide, who has worked here for [AGE] years, should be able to report if something was wrong. The Kitchen Manager stated the wash cycle should be at least 150°F and the rinse cycle should be 180°F for a high temperature dishwashing machine and that the dishwashing machine is maintained monthly by an outside company. 10NYCRR: 415.14(h), 10NYCRR: 14-1.10, 14-1.112, U.S. Food and Drug Administration's (FDA) Food Code Centers for Disease Control and Prevention's (CDC) food safety guidance

Based on observations, interviews and record review, conducted during the Recertification Survey, completed on 3/11/22, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment for one of twenty-four residents reviewed. Specifically, Resident #120 was observed on multiple days in a soiled Broda (type of geriatric positioning chair) chair. This is evidenced by: Resident #120 had diagnoses that included [CONDITION(S)], [CONDITION(S)] (loss of muscle function on one side of the body) and adult failure to thrive. The Minimum Data Set Assessment, dated 2/15/22, documented that per staff assessment, Resident #120 had poor memory, poor recall and severely impaired decision-making skills. The resident also required total dependence on staff for bathing, extensive assist of staff with personal hygiene and dressing and was independent with eating after set up. The Resident Care Card (care plan used by the Certified Nursing Assistants (CNAs) for daily care), dated 3/11/22, documented that Resident #120 was non-ambulatory and used a Broda chair. During observations on 3/7/22 at 12:39 p.m, on 3/8/22 at 12:28 p.m. and on 3/9/22 at 8:14 a.m., Resident #120 was observed sitting in their Broda chair which was covered in multiple dried and crusty white and brown debris on both sides of chair, on the arm cushioning and on the seat cushion. The Broda chair wheel housing compartments were covered with a crumbling white debris and had a ball of hair wrapped around one back wheel. During an interview on 3/9/22 at 8:22 a.m., The CNA stated Resident #120's Broda chair appeared covered in milk. The CNA was not aware of any cleaning schedule for the Broda chairs. During an interview on 3/9/22 at 8:25 a.m., the Licensed Practical Nurse (LPN) stated the night shift cleaned the chairs. The LPN stated Resident #120's chair was gross. The LPN was unable to identify what the chair was soiled with. During an interview on 3/9/22 at 8:27a.m., the Registered Nurse Manager (RNM) stated the facility did not have a process for washing the Broda chairs, as they do not fit in the chair wash machine and would have to be scrubbed down separately. The RNM stated that some of the white debris on the arm cushioning of Resident #120's Broda chair appeared to be residue from cleaning wipes but was unable to identify the remaining spots or debris covering the chair. The RNM reported the chair should have been cleaned. 10NYCRR 415.29(j)(1)

Based on observation, interviews, and record review conducted during the Recertification Survey, completed on 3/11/22, it was determined for one (Resident #2) of one resident reviewed for communication, the facility did not ensure the resident had the right to be informed of, and participate in their treatment in a language that they could understand. Specifically, Resident #2 who had little understanding of the English language was not provided with the opportunity to communicate and be communicated with in a language they could consistently understand. The findings are: Resident # 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 11/24/21, documented that Resident #2 was severely impaired cognitively, that their ability to understand others was sometimes understands, and their ability to make themself understood was sometimes understood. The MDS Assessment documented that the resident's preferred language was other than English and that the resident required an interpreter to communicate with health care staff. Review of the current Comprehensive Care Plan and the Resident Care Card (care plan used by the Certified Nursing Assistant (CNA) for daily care), revealed under special needs & instructions that the resident spoke (language other than English) and required the use of a picture board when communicating and to encourage the resident to point to the pictures as tolerated, call the housekeeper to translate or call the family. During multiple observations from 3/7/22 through 3/11/22 day shifts, Resident #2 did not have a communication board or pictures in their room. During an interview on 3/8/22 at 11:46 a.m., the CNA stated that Resident #2 used to have communication pictures on their wall, and they were unsure as to why they were removed. The CNA stated that in order to communicate with the resident without the use of a communication board they would continue to point to things until the resident shakes their head yes or no. The CNA stated the facility does not have an interpreter that they were aware of. The CNA said that they would know if the resident was in pain if they pointed to a specific area on their body while moaning. During an interview on 3/8/22 at 1:32 p.m., the Recreation Therapist (RT) stated that Resident #2 does not speak any English and only knows a couple of words. The RT stated that the resident used to come to activities and was very social but not verbally. Resident #2 has since made it known that they did not want to come any more and has decided to stay in their room. The RT stated that they have attempted to use the communication board with the resident in the past, but the resident laughed at the photos. The RT then stated that communication with the resident is now done solely through a facility housekeeper or the resident's family. During an interview on 3/9/22 at 10:37 a.m., the Director of Nursing (DON) stated that their current interventions for communicating with Resident #2 included using a facility's housekeeper (who speaks the language), who was not a certified translator, and the resident's family. The DON stated the facility has a language line, but they do not have it set up nor do they use it because they felt the family understood the resident more. During an interview on 3/9/22 at 3:32 p.m., Resident #2's family member stated that the resident does not understand the staff and the staff does not understand the resident. The family member stated the facility calls family in an emergency to translate. The family member stated they were not aware of the facility using a housekeeper to translate and that they had not agreed to this arrangement. The family member said that Resident #2 has voiced to them that they are frustrated with the staff's inability to understand them and that they do not get to go out and sit with the other residents in the common area because they do not speak English. During an attempt to interview Resident #2 on 3/10/22 at 8:36 a.m., the Surveyor requested the assistance of the housekeeper to assist with translation but was told by the Unit Receptionist that the housekeeper was off. During an interview on 3/10/22 at 8:43 a.m., Resident #2 (with a family member translating) stated they only understand hi or hello from the staff and have to use gestures a lot. Resident #2 stated that the housekeeper speaks Hindi which is a different language than they speak but that the housekeeper can somewhat understand them. Resident #2 stated they cannot explain themself regarding the type of food that they want, or basic communication needs. Resident #2 wished someone could take them for walks once a day around the unit. Resident #2 stated that while they do not want to go out to the lobby every day, a couple of days a week to be with other residents would be good. Resident #2 also stated their feet hurt and would like to receive therapy so they could be out (of their room) more. 10 NYCRR 415.12(a)(2)

Based on observations, interviews and record review conducted during the Recertification Survey, completed on 3/11/22, it was determined that for two (Resident #2 and Resident #60) of seven residents reviewed for investigations, the facility did not thoroughly investigate injuries of unknown origin in order to rule out abuse, neglect or mistreatment. The issues involved the lack of an investigation for bruises of unknown origin for Resident #60 and lack of a thorough investigation of a fractured heel of unknown origin for Resident #2. This was evidenced by the following: 1.Resident #60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 1/13/22, revealed the resident was moderately impaired of cognitive function and required extensive assistance of staff with bed mobility and total dependence with personal hygiene. The current Resident Care Card included that Resident #60 was at risk for falls due to [CONDITION(S)] and required the assistance of two staff for transfers using a mechanical lift. The Care Card included that the resident was non-ambulatory and used a Geri chair for comfort and positioning. Review of a wound assessment progress note, dated 1/31/22, revealed that Resident #60 had a reddish-purple bruise to the left axilla (armpit) and left breast, painful and tenderness to touch, that was identified during care. The resident was unable to state how the bruising had occurred due to dementia. Review of a wound assessment progress note, dated 2/11/22, included that no abuse or neglect was suspected because of the probable cause being that the resident sleeps in their Geri chair while leaning over the side. The note included that Resident #60 had stated that it hurts a little when put in the hoyer lift. During an observation on 3/9/22 at 11:12 a.m., and again on 3/10/22 at 9:25 a.m., Resident #60 was observed sitting in their Geri chair in an upright position with a pillow supporting their back. The resident was not observed to be leaning over the chair at any time during the observations. Review of Incident/Accident (I/A) reports provided for the past six months revealed investigations for falls on 1/3/22, 2/7/22, and 9/11/21. The facility was unable to provide any investigation related to the resident's bruises that were noted on 1/21/22. Review of a nursing progress note, dated 2/6/22, revealed Resident #60 had complained of pain in the left upper extremity during care and again later that day during bedtime time care and was accusing staff of hurting them. The note included that the resident was given [MEDICATION(S)] (an antipsychotic medication used for for agitation). Review of a nursing progress note, dated 2/9/22, revealed that the resident was sleeping in the dining room and was leaning to the right side of their chair. During an interview on 3/9/22 at 10:37 a.m., the Director of Nursing (DON) stated if a resident had an injury of unknown origin, they would look back in the record to rule out probable cause first. The DON stated if they are unable to rule out probable cause they would conduct a three-day interview with the staff members involved in the resident's care. When asked if an investigation into Resident #60's bruises was conducted in order to rule out abuse, neglect or mistreatment, the DON stated that they did not conduct a formal investigation due to determining the probable cause. The DON stated that the probable cause is based off the nurse's interpretation of the resident's behaviors and that the Registered Nurse (RN) on shift would ask staff members if they have seen the bruises on the resident. When requested, the facility was unable to provide documentation regarding any interviews with staff. The DON stated all interviews with staff are conducted verbally and not documented. The DON stated that probable cause was ruled out for this resident because nursing staff reported that Resident #60 favors their left side. During an interview on 3/9/22 at 3:11 p.m, the Licensed Practical Nurse (LPN) stated the residents' bruises was brought to their attention that day and that they had notified the medical team and had filled out an investigation form. The LPN stated that the conclusion of the incident was that the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 2.Resident # 2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment included that Resident #2 required an interpreter in order to speak with health care workers due to their preferred language as other. Review of the Resident Incident Reporting Form, dated 1/18/21, and signed by RN #1 revealed that the writer had received a phone call from Resident #2's family requesting that Resident #2's right heel be examined due to the resident's complaint of pain to the area. When assessed RN #1 wrote that the resident's heel had a dark purple bruise that was warm to touch with [CONDITION(S)] (swelling), rotated inwardly and per the resident, painful. RN#1 telephoned a family member to interpret due to a language barrier and the family member related that Resident #2 had told them that while walking with a nurse, they had stepped on something sharp like a needle' that pricked their foot causing Resident #2 to twist their ankle. RN #1 notified the medical team, and an x-ray was ordered which confirmed a right heel fracture. There was no further investigation notes regarding the incident provided. During an interview on 3/9/22 at 9:57 a.m., RN #1 (Unit Manager) stated they did not know how Resident #2 had sustained the injury and was not aware that the resident was in any pain until notified by family. RN #1 stated they could not recall if a formal investigation was conducted regarding the incident. During an interview on 3/9/22 at 10:37 a.m., and again on 3/10/22 at 8:21 a.m., the DON stated they if a resident has an injury of unknown origin, they attempt to rule out probably cause by reading back in the medical record. If unable to identify probable cause, then they would conduct three days of interviews with staff members caring for the resident and determine probable cause based on staff interpretation of the resident's behavior. The DON stated that they had not been made aware of Resident #2 pricking their foot on something but that she should have been notified and further investigation to determine how the resident was injured. The DON said that further investigation and interviews with staff should have been conducted. [10 NYCRR 415.4(b)(3)]

Based on interviews and record reviews conducted during the Infection Control COVID-19 Focused Survey, the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation and misappropriation of resident property related to screening prospective employees. Specifically, a Nurse Aide Registry abuse screening was not completed prior to hire for three (Employees #1, #2, and #4) of five employee files reviewed. This is evidenced by the following: On 11/24/20 the Administrator provided the surveyor with a facility policy, Pre-employment Background/Reference Checking/Credentialing, dated and signed 4/18/18. The policy included: the procedure will adhere to all state and federal regulations for pre-employment screening and background checks, and, the procedure for unlicensed candidates includes a check of the New York State Nurse Registry (Pro-metric). On 11/24/20 from 11:45 a.m. to 12:10 p.m. the surveyor was provided documentation related to five newly hired employees. The files included that Employees #1, #2, and #4 were hired as: Environmental Services, Social Worker, and Maintenance Mechanic respectively. The files showed that Employees #1, #2, and #4 were hired on 10/19/20, 9/28/20, and 11/9/20 respectively and are all still employed by the facility. The documentation provided did not include a Nurse Aide Registry check for Employees #1, #2, and #4, nor did it show that any of these persons were licensed. During a phone interview with the Vice President of Human Resources and Human Resources Assistant on 11/24/20 at 2:12 p.m. it was revealed that the Nurse Aide Registry check was not done for Employees #1, #2, and #4 because they are not nurses. (10 NYCRR 415.4(b))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of two residents reviewed for hospice, the facility did not ensure that a Significant Change in Status Minimum Data Set (MDS) Assessment was completed. Specifically, Resident #81 did not have a Significant Change Assessment completed following the start of hospice services, and Resident #59, did not have a Significant Change Assessment completed within the required timeframe following the start of hospice services. This is evidenced by the following: The Facility Resident Assessment Instrument 3.0 User's Manual Version 1.16, dated (MONTH) (YEAR), reveals that a Significant Change in Status Assessment (SCSA) is required to be performed when a terminally ill resident enrolls in a hospice program. The Assessment Reference Date must be within 14 days from the effective date of the hospice election. A SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. 1. Resident #81 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/8/19, revealed that the resident had moderately impaired cognition. Review of the medical record revealed the resident signed on to hospice services on 8/29/19. When interviewed on 10/7/19 at 12:31 p.m., the Licensed Practical Nurse (LPN) Clinical Documentation Specialist stated a Significant Change MDS would be completed if the resident's decline in care needs began within 14 days of signing onto hospice. Following review of the MDS Manual, the LPN stated a Significant Change MDS should have been completed for the resident. When interviewed on 10/7/19 at 12:55 p.m., the Director of Social Work stated when a resident signs on to hospice services, a Significant Change MDS needs to be completed and the interdisciplinary team updates the care plan. 2. Resident #59 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/30/19, revealed that the resident had moderately impaired cognition and was receiving hospice care. Review of the medical record revealed that the resident was enrolled in hospice care effective 7/8/19. When interviewed on 10/8/19 at 10:00 a.m., the LPN Clinical Documentation Specialist stated that the Significant Change MDS should be completed by the 14th day following sign on to hospice services. She said the resident's assessment was not completed within the required timeframe. (10 NYCRR 415.11 (a)(3)(ii))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #33 and #51) of five residents reviewed for non-pressure related skin conditions, the facility did not thoroughly investigate skin injuries in order to rule out abuse, neglect or mistreatment. Specifically, the facility was unable to provide documentation that a thorough investigation was completed to support the probable causes for unwitnessed skin injuries. This is evidenced by the following: Review of the undated facility policy, Investigation of Unwitnessed Injury, revealed that all unwitnessed resident injuries involving bruises will be investigated to determine if the elements of abuse or mistreatment are present. The injury is to be assessed by a Registered Nurse (RN) to rule out possible abuse, neglect, or mistreatment. The RN will interview the resident and staff. If the resident is unable to explain what happened, determine if there is documentation in the chart to identify the source of the injury or if the injury was observed. Upon RN assessment, if no abuse, neglect, or mistreatment is evident an RN assessment of the [MEDICAL CONDITION] will be documented, and a summary and conclusion will be documented in the comment section of the Wound Assessment form. An Incident and Accident form will not be generated. 1. Resident #33 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 7/23/19, revealed that the resident had moderately impaired cognition and had not received an anticoagulant (blood thinner) in the previous seven days. The Wound Assessment form, dated 9/15/19, revealed that the resident had a 4 centimeter (cm) x 6 cm red purple color bruise on the right forearm. The resident was unable to state how it happened. The resident sits in a straight back chair in the dining room and was on an anticoagulant which may cause easy bruising. The affected area may have had direct contact with the armrest of the chair. The probable cause was that the resident bumped his forearm on the chair arm and no abuse, neglect, or mistreatment was suspected. Subsequent documentation on that same form on 9/26/19 and 10/3/19 revealed the bruise was fading. The facility was unable to provide any additional documentation related to the resident's bruise and or investigation. The current physician orders did not include the use of an anticoagulant. When observed on 10/2/19 at 1:42 p.m., the resident was sitting in a chair in his room, and a dark purple area was noted on the right hand at the base of the right thumb extending towards the wrist. When interviewed at that time, the resident stated he did not know how the bruise occurred. He said that he had bruises on both arms. He stated that if staff grab him tight, he turns black and blue. When interviewed on 10/4/19 at 1:56 p.m., the RN Manager stated that when a bruise is identified, the nurse measures the area and gathers information to document on the Wound Assessment form. He stated that staff try and determine the cause of the injury and if they come up with a probable cause a formal investigation is not completed. The RN Manager said that staff that had contact with the resident within the last 72 hours should be interviewed. He said that he has not actually completed an investigation and was unaware of the paperwork involved. The RN Manager reviewed the documentation related to the bruise on the resident's forearm, and then stated the resident was not on an anticoagulant and staff had not reported that the resident was hitting his arms on the dining room chairs. The RN Manager stated the investigation was incomplete. 2. Resident #51 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/25/19, revealed the resident had severely impaired cognition. A medical note, dated 10/2/19, revealed no documented skin issues. The Wound Assessment, dated 10/2/19, revealed a small purple bruise on the top of the resident's left hand was noted on 10/1/19. The resident was unable to state the cause. The probable cause was the bruise was consistent with the bottom of the dining table, and there was no evidence of abuse, neglect, or mistreatment. A progress note, dated 10/2/19, documented a new bruise on the top of the resident's hand. The facility was unable to provide any additional documentation related to the resident's bruise and or investigation. When interviewed on 10/4/19 at 1:56 p.m., the RN Manager stated that he did not do a complete investigation of the resident's bruise. He stated he did not know how long the resident had the bruise and he had never seen her hit her hands on the dining table. During an interview on 10/4/19 at 3:11 p.m., the Director of Nursing (DON) stated when a bruise is identified, the RN completes an assessment. She said if the RN can determine a probable cause or the resident can state how the bruise occurred, an investigation was not done. She said, for example, if a resident's bruise lines up with the arm of a chair, staff assume that the resident bruised their arm on the chair. The DON stated the RN would need to interview staff to determine a probable cause. She reviewed the Wound Assessment form for Resident #51 and stated the investigation was incomplete. She stated she did not have evidence to support the probable cause documented. When interviewed on 10/7/19 at 3:48 p.m., the Administrator stated that when an injury was identified and the resident could not answer how it had occurred, the Nurse Manager or Clinical Coordinator would interview staff that had worked with the resident to try to determine how the injury occurred. The Administrator said the injury and interviews would be documented in the medical record. The Administrator stated a skin injury investigation only needed to include a probable cause. The Administrator said she was unable to provide documentation to support the probable causes documented in Resident #33 and Resident #51's medical records. (10 NYCRR 415.4(b)(3))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for enteral nutrition (tube feeding), the facility did not provide appropriate treatment and services to prevent complications and or have a mechanism in place to ensure periodic evaluation of the amount of tube feeding being administered. Specifically, Resident #95's tube feeding orders were incomplete and did not include the total volume of tube feeding to be administered, and daily intakes were not recorded or consistently monitored. This is evidenced by the following: Resident #95 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/20/19, revealed the resident had severely impaired cognition and received 51 percent or more of their calories through the tube feeding. The facility policy, Enteral Nutrition-Feeding Tube, dated (MONTH) 2019, revealed as recommended by the Registered Dietician (RD), the physician order [REDACTED]. If delivering via pump follow the directions for setting the rate per hour and the total volume. The current physician orders [REDACTED]. The tube feeding [MEDICATION NAME] 1.2 will run continuously from 4:00 p.m. to 9:00 a.m. at 80 cc with instructions to add enough feeding for the shift. Discard the tubing and bag when the feeding is complete at 9:00 a.m. The (MONTH) 2019 Treatment Administration Record (TAR) included entries that directed to start the tube feeding of [MEDICATION NAME] 1.2 at 4:00 p.m. and run it continuously at 80 cc an hour until 9:00 a.m. with instructions to add enough [MEDICATION NAME] 1.2 for the shift. There were no specific instructions for the volume to be provided each shift or documentation of the volume total each shift or the total volume of tube feeding provided. The Dietician quarterly assessment, dated 8/29/19, revealed that the resident required 10 percent of nutrition via tube feeding and received [MEDICATION NAME] 1.2 at 80 cc an hour from 4:00 p.m. to 9:00 a.m. for a total volume of 1,360 cc, with water flushes of 100 cc five times per day. In an observation on 10/2/19 at 10:00 a.m., the resident was in bed, the tube feeding was off, and the feeding bag contained 300 cc. The bag was labeled as started on 10/1/19 at 7:00 p.m. and down at 9:00 a.m. During an observation on 10/4/19 at 8:16 a.m., the resident was in bed and the tube feeding was infusing via a pump. The bag was labeled [MEDICATION NAME] 1.2 and dated, 10/3 at 4:00 p.m. The pump was set to infuse at 80 cc per hour, and the pump display revealed that the total volume infused was 2,385 cc. There was about 100 cc of feeding left in the bag. When interviewed at 8:52 a.m., Licensed Practical Nurse (LPN) #1 stated that she needed to leave the feeding up longer as it went up late the night before. She said that she did not know what period of time the total volume infused covered. She stated she would have to do the math to determine if the volume infused on the pump was what was supposed to be infused from 4:00 p.m.to 9:00 a.m. LPN #1 stated the tube feeding infused at 80 cc per hour and there was no specific amount to be infused on her time. She stated nursing does not monitor the intakes for feeding tubes. LPN #1 stated she did not record the amount of feeding the resident had received on her time. She said that she only records the time the feeding was stopped. LPN #1 stated when she started her shift at 7:00 a.m. she had not added any feeding to the bag as there was enough in the bag to run until 9:00 a.m. In an observation on 10/4/19 at 4:00 p.m., a sign was posted on the resident's wall, to the left of the head of the bed behind the feeding pump and instructed staff to only use enough feeding for each shift. Each container contained 237 cc and the evening staff (4:00 p.m. to 11:00 p.m.) was responsible for 560 cc or 2.5 containers, but were directed to add three boxes of feeding (711 cc). The night staff (11:00 p.m. to 7:00 a.m.) was responsible for 640 cc or 2.7 containers but were directed to add three boxes of feeding around midnight (711 cc). The day shift (7:00 a.m. to 9:00 a.m.) was responsible for 160 cc or one container. There was a note for the day shift do not add unless necessary as there should be enough to complete the infusion. The RD recommended 1,360 cc over 24 hours, and the amounts directed in the instructions above total 1,422 cc for the day and evening shift (six containers of 237 cc). During an interview on 10/4/19 at 4:00 p.m., LPN #2 stated the Clinical Coordinator had posted a sign in the resident's room on the wall that instructed how much feeding was to be added to the bag each shift. She stated each container of [MEDICATION NAME] 1.2 was 250 cc. She stated she clears the pump when she started the feeding. When interviewed on 10/7/19 at 10:16 a.m., the Clinical Nutrition Manager stated she reviews the medical record for weight loss and to ensure the tube feeding are administered as ordered. She stated she was told that day there was a chart in the room instructing staff on how much tube feeding should be administered each shift. The Clinical Nutrition Manager stated the physician's orders [REDACTED]. (10 NYCRR 415.12(g)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #136) of three residents reviewed for skin conditions, the facility did not thoroughly investigate a skin tear to rule out abuse, neglect, or mistreatment. This is evidenced by the following: Resident #136 was admitted to facility on 4/18/16 with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/5/18, revealed that the resident had severely impaired cognition, rejected care, required extensive assistance for all activities of daily living, and had skin tears. Review of the facility policy, Investigation of Unwitnessed Injury, dated (MONTH) 2014, directed Registered Nurse (RN) Leadership to assess the injury to rule out possible abuse, neglect, or mistreatment, to interview the resident and staff, and determine the initiation of an Accident and Injury Report. The policy included that for a resident unable to recount an incident, if no abuse, neglect, or mistreatment is evident the RN assessment of skin injury will be documented in the Skin and Wound section of Electronic Medical Record (EMR). A summary of the RN conclusion and assessment of probable cause of injury will be documented in the comment section of the Skin and Wound entry. The Current Care Plan, dated 3/15/18, included that the resident had the potential for skin alteration related to decreased mobility, incontinence of bowel and bladder, and impaired cognition. Goals and approaches were related to avoidable pressure ulcers and did not address other problems with skin integrity. A Progress Note, dated 3/7/18, revealed that a left-hand skin tear had reopened with a moderate amount of bleeding and was discovered that morning by a Certified Nursing Assistant. The documentation included that the Clinical Coordinator was notified and treatment was initiated. Skin and Wound Notes, dated 3/7/18, revealed that the resident had a skin tear to the back of her left hand. The documentation included an RN assessment and treatment of [REDACTED]. A Skin and Wound Note, dated 3/12/18, revealed that the skin tear to the back of her left hand was assessed and treated by an RN. The documentation did not include information about the probable cause of the injury. A Skin and Wound Note, dated 3/18/18, revealed that the skin tear to the back of her left hand was healed but did not include information about the probable cause of the injury. In an observation on 3/15/18 at 9:30 a.m., the resident was found to have a skin injury to her left hand. There was a bandage partially covering the wound with old, dried blood and Steri-Strips exposed beneath the bandage. When interviewed at that time, the resident did not know how she sustained the injury and stated that she must have burned herself. In an interview on 3/20/18 at 1:19 p.m., the Director of Nursing (DON), stated that investigations for skin tears would be documented in the Skin and Wound section of the EMR. Upon reviewing the documentation for the left-hand skin tear discovered on 3/7/18, the DON stated that it did not appear that an investigation of what may have caused the wound was done. On 3/20/18 at 1:41 p.m., the RN Manager (RNM) and DON presented to the surveyor a completed Skin and Unwitnessed Injury Checklist with the resident's name written at the top of the document. The document was not dated and did not include where the assessed wound was located. When interviewed at that time, the RNM stated that the Clinical Coordinator assessed the skin tear to the resident's left hand on 3/7/18. The RNM stated that she saw the resident on 3/12/18 at which time she assessed the wound and completed the Skin and Unwitnessed Injury Checklist presented to the surveyor at that time. The RNM stated that she forgot to document the results of her investigation in the Skin and Wound section of the EMR. When interviewed on 3/20/18 at 3:45 p.m. the RNM stated that a newly identified skin injury would be assessed by the RN with the assessment, investigation and family notification being documented in the Skin and Wound section of the EMR. The RNM stated that the Skin and Unwitnessed Injury Checklist is a worksheet and is not a part of the medical record. In an interview on 3/21/18 at 2:18 p.m., the DON stated that the RN should initiate the investigation for an injury of unknown origin at the time it is identified. The DON stated the Skin and Unwitnessed Injury Checklist was used as a guideline for the investigation and she would expect the RN to interview staff as a part of the investigation. The DON said that the Skin and Unwitnessed Injury Checklist was not a part of the medical record and she would expect that the RN assessment and investigation findings were documented in the Skin and Wound section of the EMR. (10 NYCRR 415.4(b)(3))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #47) of three residents reviewed for pain, there was no documented evidence that the facility notified the legal representative in a timely manner of a resident's fall or the discontinuation of routine Tylenol. This is evidenced by the following: Resident #47 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/15/18, revealed the resident was severely cognitively impaired, did not reject care, required extensive assist of two staff for transfers and bed mobility, had functional limitation in range of motion on both upper and lower extremities, had one fall without injury, and was receiving a scheduled pain medication. The undated facility policy, Incident and Accident Report, directed that the responsible party is to be notified of an accident unless otherwise specified on the Medical Record Face Sheet or in the care plan. The Comprehensive Care Plan, last updated 3/18/18, included that the resident was at risk for falls due to a previous fall with fracture prior to admission and poor safety awareness. The resident was also at risk for pain due to surgical repair of the hip and staff were to provide medications per the orders, monitor effectiveness and report to medical. An Incident and Accident Report, dated 2/26/18, included that the resident was observed lying on the floor with his back up against the low bed during the 4:00 a.m. safety rounds with no apparent injuries. The report did not include whether the family was notified. A Physician Assistant (PA) Note, dated 10/11/17, included that the resident's pain had been well controlled with as needed Tylenol and [MEDICATION NAME], but the [MEDICATION NAME] was to be discontinued due to poor renal effects it can have in the elderly. The as needed Tylenol may need to be increased once the resident is working with therapy. A 12/11/17 physician note included that the resident has [MEDICAL CONDITION] to multiple sites and has used as needed Tylenol often for pain with good results. The as needed Tylenol was changed to a scheduled dose to improve comfort. A 2/21/18 PA note included that the resident's pain was well controlled with routine Tylenol per nursing. A 2/26/18 nursing note did not include any information about a fall nor about contacting the family. A 3/1/18 physician note included the resident did not appear to have any pain at that time and will attempt to discontinue routine Tylenol in an effort to minimize medications. The physician note and nursing notes did not include whether the family was notified of the change in the medication dosing. A physician order, dated 3/1/18, included to change Tylenol from routine 1,000 milligrams three times a day to as needed. When interviewed on 3/15/18 at 2:45 p.m. and 3/19/18 at 12:07 p.m., the resident's family member said that the resident has pain and says, Oh, my back! all the time, especially when in the gerichair. The family member said that the resident used to receive Tylenol and no one ever told her why it was taken away. The family member also said that the last time the resident fell at 4:00 a.m., the staff did not call her right away and no one told her about it when she came in that day. The family member said that she was at the facility every day from 12:00 p.m. to 7:00 p.m. and did not get a message until she returned home. When interviewed on 3/20/18 at 4:24 p.m., the Registered Nurse Manager said she could not locate any documentation that showed she spoke with or left a message for the family about the fall or the medication changes. She said she may have left a message with the family member that she would follow up with her when she comes in to the facility, but then may never have actually done so. When interviewed on 3/21/18 at 11:14 a.m., the physician said he will contact a family himself to discuss changes in sensitive medications or if the family is more resistive to changes in medications. The physician said he explains his philosophy of minimizing the number of medications with the family when he first speaks with them. He said otherwise nursing will call the family based on what he writes on the Communication Worksheets. The physician said he could not recall if he spoke with this resident's family about the changes in Tylenol but someone should have talked to the family about the medication change. (10 NYCRR 415.3(e)(2)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #47) of five residents reviewed for Activities of Daily Living, the facility did not provide the necessary care and services to maintain personal hygiene. Specifically, nail care was not provided in a timely manner. This is evidenced by the following: Resident #47 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/15/18, included the resident was severely cognitively impaired, did not reject care, and required the extensive assist of two staff persons for personal hygiene. The (MONTH) (YEAR) facility policy, Care of Fingernails, directed that full nail care was to be completed by the Certified Nursing Assistant (CNA) with the weekly shower/bath unless written for the nurse to cut the nails. The CNA is responsible for checking the resident's fingernails daily with activities of daily living for cleanliness, jagged edges, and addressing any findings as needed. The team leader is to document in the medical record that nail care was completed. The Comprehensive Care Plan, last updated 3/18/18, revealed that the resident needed staff assistance to complete his care. The CNA Care Card, dated 3/16/18, included under Standards of Care that nail care should be done with weekly shower/bath. The resident's scheduled shower day was Monday during the evening shift. Progress notes reviewed from 3/15/18 to 3/20/18 revealed no documented evidence that nail care was provided or any refusals of care. When observed on 3/15/18 at 9:33 a.m. and on 3/19/18 at 11:59 a.m., the resident had long fingernails with dark brown debris under them and some jagged nails. Observations and interviews conducted on 3/20/18 included the following: a. At 9:12 a.m., the resident had long nails with brown debris under them. The CNA did not provide nail care after morning care was completed. b. At 10:04 a.m., the Licensed Practical Nurse (LPN) said that something needed to be done with the resident's nails as they are dirty and should be filed. The LPN said she would assist the resident after breakfast. At 11:30 a.m., the LPN said she completed the resident's nail care and the resident's nails were observed to be trim and clean. c. At 11:38 a.m., the CNA said the resident was supposed to have nail care completed on his shower day, which was the previous evening. She said that the resident needed nail care. d. At 4:24 p.m., the Registered Nurse Manager said nail care should be completed on shower days including cleaning and trimming nails so there are no jagged edges and debris is removed. (10 NYCRR 415.12(a)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #3) of 31 residents reviewed for care planning, the facility did not provide services in accordance with the resident's written plan of care. Specifically, the resident was not wearing compression stockings (TED) per plan of care. This is evidenced by the following: Resident #3 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/12/18, revealed that the resident's cognitive skills for daily decision making were severely impaired, does not reject care, and required supervision with dressing and personal care. Physician orders, dated 12/5/17, instructs to apply TED stockings with morning care and remove with evening care. The Comprehensive Care Plan, dated 3/15/18, and the Certified Nursing Assistant (CNA) Care Card, dated 3/16/18, both include to apply TEDS in the morning and remove in the evening. Progress notes reviewed from 3/1/18 through 3/20/18 did not include refusal of TED stockings. The resident was observed on 3/19/18 at 12:01 p.m., at 1:08 p.m., and on 3/20/18 at 8:27 a.m., completely dressed and without TED stockings. On 3/20/18 at 1:55 p.m., the resident was lying on top of the bed, completely dressed, wearing regular dark socks. The resident said she has not had TED stockings in a long time. The resident sat up and pressed on her ankle and said that it felt better down deep when she wore the TEDS. She said there was less inflammation and her ankles did not hurt. Interviews conducted on 3/20/18 included the following: a. At 3:49 p.m., the assigned evening CNA said if a resident refuses treatment she would tell the nurse. The CNA said she was unsure if the resident was wearing TED stockings. The resident was observed by the CNA and she was not wearing TED stockings. b. At 4:16 p.m., the Licensed Practical Nurse (LPN) said the TED stockings are on the Care Card and the evening shift should make sure they are removed. The LPN was unaware that the resident was not wearing the TEDS. The LPN found the TEDS in the resident's dresser drawer. The LPN asked the resident if he could apply the TEDS and the resident agreed. c. At 4:24 p.m., the Registered Nurse Manager (RNM) said the CNAs are to apply the TED stockings with care in the morning. She said if the TEDS are not applied for any reason, staff are to notify the nurse. The RNM was unaware the resident had not been wearing the TED stockings. (10 NYCRR 415.11(c)(3)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (South 2) of six residential dining units and one of one main kitchen, the facility did not prepare, store, and serve food under sanitary conditions. Specifically, time/temperature controlled for safety (TCS) foods were held for service at temperatures below 140 degrees Fahrenheit (°F) and water dripping from an evaporator fan in a freezer resulted in ice build-up on boxes of food items. This is evidenced by the following: 1. Observation in the main kitchen on 3/15/18 at 1:03 p.m. revealed that the walk-in freezer evaporator lines were frozen over. There was also thick ice on a box of Rich's 4-inch Best Wishes Cakes, an open box of Sara(NAME)Layer Cakes, a box of 10-inch pre-sliced pies, and boxed apple pies. In an interview at that time, the Regional Maintenance Manager stated that the freezer probably needs to be defrosted. Also at that time, the Director of Dining Services (DDS) was told that there was ice on the food boxes, to which the DDS stated that they would move the food boxes. When asked if they would need to do anything else with the food that had ice on the boxes, the DDS stated that as long as it did not seep through the box they do not need to do anything else with the food items. 2. Observations in the South 2 kitchenette on 3/19/18 at 12:08 p.m. revealed a chicken breast fillet and a hot dog hot holding on the steam table at 108°F. In an interview at that time, the Dining Services Worker (DSW) who was preparing to serve stated that he took a temperature of the chicken around 11:45 a.m. and the chicken was 100°F. The DSW stated that the chicken was fully cooked when it was brought from the kitchen, and their process is to let items that are not up to temperature sit on the steam table until they are hot enough. The DSW stated that he would not serve the chicken until it was above 145°F. In an interview on 3/19/18 at 12:16 p.m., the Crew Leader stated that the DSW should have called down to the kitchen and they would have gotten the temperature back up. The Crew Leader stated that they would not serve the chicken or hot dog. In an interview on 3/19/18 at 12:41 p.m., the Director of Dining Services stated that 108°F would not be the proper hot holding temperature. The DDS stated that it is not their process to reheat the food items on the steam table. She said if it was below the holding temperature, the food should have been sent back to the kitchen and reheated to 160°F or thrown away. 3. A review of the facility policy, Holding Hot Food, directed that hot food items may not fall below 135°F after cooking, unless it is an item which is to be rapidly cooled to below 41°F and reheated to at least 165°F prior to serving. Tray line and alternative meal preparations and service areas will avoid the following methods: holding foods in the temperature danger zone (41°F to 135°F) or using the steam table to heat foods. (10 NYCRR 14-1.40(a), 14-1.95)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 2 of 29 residents reviewed for professional standards, the facility did not provide services consistent with professional standards of quality. The issues involved a subtherapeutic lab result that was not reviewed timely for Resident #82, and a physician's orders [REDACTED].#33. This is evidenced by the following: 1. Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/16/18, revealed that the resident had severely impaired cognition. Physician orders, dated 3/1/18, included [MEDICATION NAME] (blood thinner), and on 3/8/18 to discontinue PT/INR ([MEDICATION NAME] Time (PT), which measures how long it takes blood to clot and International Normalized Ratio (INR) which are PT lab results expressed as a ratio. The test is used if a resident is taking a blood thinning medication such as [MEDICATION NAME]. The resident's current [MEDICATION NAME] Log Sheet revealed that the next PT/INR was scheduled for 3/15/18. Review of the Medication Administration Record [REDACTED]. Review of laboratory results, dated 3/8/18, revealed the resident's PT/INR was 1.3 and therapeutic levels are between 2.0 and 3.0. When interviewed on 3/16/18 at 3:04 p.m., the Nurse Practitioner (NP) stated that the resident did not receive [MEDICATION NAME] from 3/6/18 through 3/11/18. The NP said she became aware of that issue on 3/12/18 when the resident had reports of dizziness accompanied by a low blood pressure reading. The NP stated she did not review the lab results for the resident on 3/8/18 because she was not expecting the lab to be drawn since she discontinued the PT/INR for that day. Interviews conducted on 3/19/18 included the following: a. At 9:10 a.m., Registered Nurse Manager (RNM) #1 said there was a [MEDICATION NAME] Log Sheet that tracks [MEDICATION NAME] dosage and lab orders for residents who receive [MEDICATION NAME]. She said after the lab technician obtains the blood, the results are documented in the computer and the Registered Nurse (RN) then informs medical staff about the PT/INR results. RNM #1 said that on 3/8/18, she texted the NP and informed her there were other laboratory results in the computer that required her attention. RNM #1 said that she was aware of the resident's PT/INR results, but she was not specific about which resident when she texted the NP. RNM #1 said she thought the NP looked at the labs for the resident because she can view the lab results in the computer. b. At 9:33 a.m., the NP said that the resident had a PT/INR drawn on 3/8/18. The NP said she normally uses the [MEDICATION NAME] Log Sheet to determine whose INRs to address daily. She stated that when RNM #1 said there were other [MEDICATION NAME] orders on 3/8/18 that needed to be reviewed, she just looked at the [MEDICATION NAME] Log and did not review the lab results in the computer. c. At 1:04 p.m., the Director of Nursing (DON) said she understands that the resident's lab was drawn on 3/8/18 and reviewed on 3/12/18 because the resident was having an episode of dizziness accompanied by a low blood pressure reading. She stated that when she completed the root cause analysis, her primary focus was on the transcription error. At 3:17 p.m. the DON stated the facility did not have a policy regarding provider responsibility for laboratory results. When interviewed on 3/21/18 at 11:13 a.m., the Unit Secretary stated that when the labs results come to the unit via fax, she immediately hands the results to the RNM or Clinical Coordinator. 2. Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/28/17, revealed that the resident had severely impaired cognition, unclear speech, and he is sometimes understood and sometimes understands. The Speech Therapy Clarification Order, dated 1/24/17 and signed by the physician on 1/31/17, recommended nectar thick liquids. The Speech Therapy Clarification Order, dated 2/22/17, included thin liquids. physician's orders [REDACTED]. Review of the Certified Nursing Assistant (CNA) Care Card revealed nectar thick liquids and the current Comprehensive Care Plan (CCP) revealed thin liquids. When observed and interviewed on 3/15/18 at 12:04 p.m., the resident received his lunch tray in his room and proceeded to show the surveyor that his beverages were thickened. He appeared angry and upset, gesturing wildly and turned each drink upside down showing how thick the fluids were. The resident put the three beverages (milk, coffee, and water) on his windowsill. At that time, the resident's breakfast tray was on the windowsill and the coffee, water, and orange juice cups were full. When questioned about how long he had been on thickened liquids, the resident pulled a tray ticket out of a large stack of them that he had saved and the one dated 3/5/18 did not include thickened liquids. The current lunch tray ticket included nectar thickened liquids. When asked why it was changed, the resident said he did not know. When asked if he had choked or had pneumonia recently, he said no. When asked if he reported that he does not like the thickened liquids, he said why, they see the tray. When observed on 3/16/18 at 3:21 p.m., the resident's lunch tray was still in his room and there were three nectar thickened liquids (water, coffee, and orange juice) that were untouched. When observed on 3/20/18 at 1:19 p.m. with RNM #2, the resident's lunch tray was still at his bedside and the water and coffee were untouched and the orange juice was half empty. RNM #2 asked the resident if he was done and he said yes and she removed his tray from the room. Interviews conducted on 3/21/18 included the following: a. At 2:19 p.m., RNM #2 said she was confused and did not know what liquids the resident should be on because the CCP has thin liquids and the orders do not include liquids. b. At 2:25 p.m., the Registered Diet Technician/Director of Dining and Nutritional Services stated that the resident had been on thin liquids until 3/13/18 when she received an order to change him to nectar thick liquids. She said that she did not know the reason for the change. She said that staff did not report to her that the resident was not happy with the thickened liquids. c. At 3:40 p.m., the full-time evening CNA stated that the resident will not drink the thickened water or coffee but sometimes he will drink the thickened juice. She said he never complained to her because he wants her to enter the room, drop off the tray, and leave. She said the resident does not really talk to her. d. At 3:45 p.m., RNM #2 stated that she considered what happened and that she had made a mistake. She said that on 3/13/18 she was doing an audit on the chart and looked at the 1/31/17 Speech Therapy recommendation for nectar thickened liquids and then wrote the physician's orders [REDACTED]. She said that the 1/31/17 Speech Therapy form was misfiled so she did not see the subsequent recommendation for thin liquids on 2/22/17. RNM #2 said she was not aware that the resident was not happy with the thickened liquids. When interviewed on 3/22/18 at 9:08 a.m., the full-time day CNA said she takes care of the resident regularly but he does not talk to her. She said she always asks the resident if he is finished with the meal tray before removing it. She said since he was started on thickened liquids she has not seen him drink any of them, but he does not complain to her because he does not talk to her. She said she did not report to anyone that the resident was not drinking. On 3/22/18 at 10:00 a.m., the DON was interviewed and she stated that the nurse had made a mistake by looking at a Speech Therapy recommendation that was more than a year old. She said if the nurse had looked more closely she would not have made the mistake. (10 NYCRR 415.11(c)(3)(i))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 2 of 31 residents reviewed for care plan revisions, the facility did not ensure that a resident's care plan was revised to reflect the resident's current condition. The issues involved lack of care plan revisions for Occupational Therapy recommendations for the use of a beveled mattress to prevent falls and use of an egg crate cushion for positioning (Resident #47), and skin tears including goals and approaches to prevent the development of further skin injury (Resident #136). This is evidenced by the following: 1. Resident #47 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/15/18, included that the resident was severely cognitively impaired, did not reject care, required extensive assist of two staff for bed mobility and transfers, had functional limitation in range of motion on both upper and lower extremities, and had one fall without injury. An Occupational Therapy (OT) Note, dated 2/23/18, revealed that the resident's room was assessed for increased safety due to recent falls out of bed and being extremely impulsive. Recommendations included a beveled mattress. The family had stated that the geri-chair was somewhat uncomfortable and caused the resident some lower back pain. It was recommended that the resident have an egg crate cushion (sponge support) behind him for comfort. An Incident and Accident report, dated 2/26/18, included that the resident was found on the floor next to the bed. Interventions and revisions of the care plan did not include a beveled mattress. The Certified Nursing Assistant (CNA) Care Card, dated 3/16/18, did not include the use of a beveled mattress or egg crate cushion. The Comprehensive Care Plan (CCP), last updated 3/18/18, included that the resident was at risk for falls due to a fall with fracture prior to admission and poor safety awareness with interventions including fall matt, low bed and the left side of the bed against the wall. It did not include a beveled mattress. Additionally, the CCP included that the resident was at risk for pain and staff were to encourage nonpharmacological methods including repositioning to decrease discomfort. It did not include the use of an egg crate cushion for positioning. When interviewed on 3/15/18 at 2:45 p.m., the family member said that the resident did not have an egg crate cushion for the gerichair, only a thin seat cushion. The family member said she was told that the resident would have an egg crate cushion behind his back but it never came. During an interview on 3/15/18 at 2:49 p.m., the Registered Nurse (RN) Coordinator said that the resident had fallen five times. She said he was used to a bigger bed at home and he rolls over and out of the bed. She said the resident was supposed to get a beveled mattress but it never came. During an observation on 3/16/18 at 9:46 a.m. and 3/19/18 at 11:59 a.m., the resident did not have an egg crate cushion applied to the gerichair. When interviewed on 3/19/18 at 12:07 p.m., the family member said that the resident has fallen out of bed several times. She said she has requested a bed with a lip on it but it still had not been brought in. On 3/19/18 at 1:17 p.m., the Maintenance Work Orders were reviewed with the RN Manager (RNM). The work orders did not include a new mattress for the resident. During observations on 3/20/18 at 9:20 a.m. and 11:38 a.m., the resident was transferred to the geri-chair from the bed and complained that his back was hurting. The CNA placed a pillow behind his mid back and he continued to complain of discomfort. The CNA said the resident never had an egg crate cushion. Additionally, the CNA said that the resident does not have a beveled mattress on the bed frame. The CNA said the resident has had the same mattress for at least the past three weeks that she has been caring for him. When interviewed on 3/20/18 at 11:26 a.m., the RNM said that OT recommendations are placed in the file in the Nurses' Office on the unit and then nursing adds the recommendations to the CCP and Care Card. The RNM was unable to locate the use of the egg crate cushion and beveled mattress on either document. The RNM said it should be documented on the CCP and Care Card so staff can ensure they are in place. When she observed the resident's room, the RNM said the resident does not have a beveled mattress or an egg crate cushion. When interviewed on 3/20/18 at 12:00 p.m., the Director of Therapy said that the OT who assessed the resident found that the egg crate cushion covered the resident's entire back and provided support. At 12:09 p.m., the Director of Therapy assessed the resident and said that he needed the longer egg crate cushion to provide more support. 2. Resident #136 was admitted to facility on 4/18/16 and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/5/18, revealed that the resident had severely impaired cognition, rejected care, required extensive assistance for all activities of daily living, and had skin tears. Review of the facility policy, Investigation of Unwitnessed Injury, dated (MONTH) 2014, directed RN Leadership to update interventions to care card and care plan as necessary. The Current CCP, dated 3/15/18, included that the resident had the potential for skin alteration related to decreased mobility, incontinence of bowel and bladder, and impaired cognition. Goals and approaches were related to avoidable pressure ulcers and did not address other problems with skin integrity. The CNA Care Card, dated 3/16/18, did not address interventions or preventative skin measures for skin tears. A Progress Note, dated 3/7/18, revealed that a left-hand skin tear reopened with a moderate amount of bleeding and was discovered that morning by a CNA. Skin and Wound Notes, dated 3/7/18 and 3/12/18, revealed that the resident had a skin tear to the back of her left hand. The documentation included an RN Assessment and treatment of [REDACTED]. In an observation on 3/15/18 at 9:30 a.m., the resident was found to have a skin injury to her left hand. There was a bandage partially covering the wound with old, dried blood and Steri-Strips exposed beneath the bandage. When interviewed at that time, the resident did not know how she sustained the injury and stated that she must have burned herself. When interviewed on 3/20/18 at 3:45 p.m. the RNM stated that the resident does not have good skin turgor (the degree of skin elasticity) and has refused geri sleeves in the past. Upon review of the CCP, the RNM stated that there was a care plan for pressure ulcers but not for skin tears. She said that it would be important to have a CCP in place for a resident who had frequent skin tears. In an interview on 3/21/18 at 2:18 p.m., the Director of Nursing (DON) stated that she would expect there to be a CCP in place for a resident who had a history of [REDACTED]. When interviewed on 3/21/18 at 2:36 p.m., the Assistant DON stated that nearly every resident in the facility would have a CCP that addressed skin integrity. She said that documentation for interventions or preventative measures would be documented in the Skin and Wound section as part of the investigation. (10 NYCRR 415.11(c)(2)(iii))