Every finding on record at Clifton Springs Hospital and Clinic Extended Care

Based on interviews and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, for one (Resident #93) of nine residents reviewed, the facility did not ensure that the medical team was notified in a timely manner following a significant medication error. Specifically, the medical team was not notified timely when a medication had not been administered according to physician's orders resulting in potentially serious side effects. This is evidenced by the following: The facility policy Event Reporting revised October 2023, documented the definition of an error was a mistake in process that was made, regardless of impact to the patient, that should not have been present and caused harm. Examples of errors includes medication variances. Any error, close calsl, or other safety event should be reported and appropriate follow-up services as necessary. Resident #93 had diagnosis including hypertension (high blood pressure), transient ischemic attack (mini stroke), and myocardial infarction (heart attack). The Minimum Data Set Resident Assessment, dated 09/03/2024, documented the resident was cognitively intact and had orthostatic hypotention (low blood pressure with position changes). Medical orders, dated 07/24/2024 and signed by Nurse Practitioner #1, included midodrine for orthostatic hypotention 2.5 milligrams three times daily and to hold the medication if the resident's systolic blood pressure is greater than 140 or their diastolic blood pressure is greater than 80. Review of the resident's Medication Administration Record, dated 08/21/2024, documented midodrine 2.5 milligram tablet was administered at 9:20 PM. Review of the Default Flowsheet Data (vital signs record) in the resident's electronic medical record revealed on 08/21/2024 at 9:20 PM, Resident #93's blood pressure was 165/100. A progress note written by Registered Nurse #1 on 08/21/2024 at 9:28 PM documented Resident #93 received their midodrine 2.5 milligram tablet, their blood pressure was 165/100, and the supervisor was notified. A progress note written by Registered Nurse Clinical Leader #1 on 08/21/2024 at 9:33 PM documented they were notified Resident #93 was administered midodrine with a blood pressure of 166/98 and the provider was notified via a communication log (a book on the unit for staff to leave messages for the medical team to review the following day). A progress note written by Licensed Practical Nurse #3 on 08/22/2024 at 2:45 AM documented the resident requested their blood pressure to be taken as they felt it was high and complained of nausea and feeling flushed. Resident #93's blood pressure was 198/116 which was rechecked 10 minutes later and was 188/118. Resident #93 began to complain of chest pressure and heart palpitations, the provider was notified, and the resident was transported to the emergency department. During an interview on 11/15/2024 at 9:23 AM, Registered Nurse Clinical Leader #1 stated nurses should let the provider know of medication errors as soon as they are aware of the error. If midodrine was given out of physician's parameters as ordered, the nurse should let the provider know right away as it could raise the resident's blood pressure even more than it already was. Registered Nurse Clinical Leader #1 said Resident #93's blood pressure should have been monitored. During an interview on 11/15/2024 at 11:20 AM, the Director of Nursing stated the communication log is seen by the provider the next day, writing the error in the communication log would not have notified the provider timely, and they were unsure why this was not done immediately. 10 NYCRR 415.3(f)(2)(ii)(a)

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, for one (Resident #16) of nine residents reviewed, the facility did not ensure each resident received adequate supervision to prevent accidents. Specifically, Resident #16 was identified to be a high risk for aspiration (accidental inhalation of food or drink into the airway) that required full supervision with meals and was observed not supervised at mealtime. This is evidenced by the following: The facility policy Aspiration Precautions/Dysphagia dated March 2024, included residents with dysphagia (difficulty swallowing) and/or at risk for aspiration are assessed and appropriate resident centered interventions are incorporated into the resident's care plan. Enteral feed/ventilator/tracheostomy residents must be on aspiration precautions and the care plan team will determine what mealtime supervision the resident requires, considering any recommendations from the speech therapist, and the registered nurse will add the mealtime supervision requirement to the care plan and care card. Resident #16 had diagnoses that included a stroke, dysphagia, and cerebral palsy (a group of neurological disorders that affect a person's ability to swallow, move, balance, and maintain posture). The Minimum Data Set Resident Assessment, dated 10/03/2024, documented Resident #16 was cognitively intact, had a tracheostomy (a surgically created opening in the neck and into the windpipe to help with breathing and remove secretions), and was on a mechanical ventilator (a medical device that helps a person breathe by moving air into and out of their lungs). Review of the physician orders, dated 09/03/2024, revealed a mechanically altered diet, no straws, nectar thick liquids, chopped meats, and that the resident had feeding guidelines. Review of the facility document Recommended Feeding Guidelines signed by Speech and Language Therapist #1 on 08/30/2024, revealed Resident #16 had multiple feeding recommendations including, but not limited to the following: 1. Mechanical soft diet with nectar thick liquids. 2. Out of bed for meals. 3. No straws. 4. Full supervision. 5. Set me up for oral care at least twice daily. 6. Encourage me to alternate solids/liquids. 7. Encourage me to use small bites/sips. 8. Encourage me to use a slow rate of intake. The Interdisciplinary Care Card (a care plan used by the Certified Nursing Assistants for daily care), dated 9/03/2024, included Resident #16 required full supervision for meals. During an observation on 11/12/2024 at 8:14 AM, Resident #16 was in a recliner chair in their room eating breakfast. No staff were in the room to provide supervision. During a continuous observation on 11/12/2024 from 11:42 AM to 12:17 PM, Resident #16 received their lunch tray, had their tray set up by a Certified Nursing Assistant, and ate their lunch. There were no nursing staff in the resident's room or visible in the hallway to provide full supervision during the meal. During an interview on 11/12/2024 at 11:58 AM and again at 12:59 PM, Certified Nursing Assistant #1 stated Resident #16 was on their assignment and they review the resident's care cards daily to review how to take care of each resident. They also stated the care cards included diet consistency and any guidelines or recommendations made by the speech therapist. Certified Nursing Assistant #1 stated full supervision would mean a staff member should be present with the resident for the entirety of the meal. They also stated they had not been in Resident #16's room during their meal, but should have been. During an interview on 11/12/2024 at 1:18 PM, Licensed Practical Nurse #4 stated Resident #16 had a history of aspiration, was a high risk for choking, and often needed to be suctioned after meals. Additionally, Resident #16 required full supervision for meals, the assigned Certified Nursing Assistant should have provided supervision per the care card, and the assigned nurse is responsible to ensure supervision is occurring. Licensed Practical Nurse #4 stated they were not aware Resident #16 had not received full supervision with their meals. During an interview on 11/15/2024 at 1:55 PM, Speech and Language Therapist #1 stated residents on the ventilator with a trach (tracheostomy) were at a very high risk for aspiration and were assessed by speech therapy to determine safety and develop recommendations and guidelines for feeding. Additionally, Resident #16 received a lot of speech therapy in order to eat, was at high risk for aspiration and potential complications related to aspiration, and needed to have a staff member in the room at all times while they were eating. Speech and Language Therapist #1 stated staff members should encourage and cue the resident to follow the speech therapy recommendations and guidelines and should observe for resident safety so they can respond promptly to any issues or concerns. During an interview on 11/15/2024 at 10:35 AM, Registered Nurse Manager #1 stated nursing staff are expected to follow the care plan and interdisciplinary care card including supervision with meals and speech therapy recommendations and guidelines. 10 NYCRR 415.12(h)(2)

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, the facility did not ensure that services were provided to meet professional standards of quality for one (Resident #93) of two residents reviewed during medication administration pass. Specifically, Resident #93 had a medication signed off as administered but was omitted during the observed medication pass. Additionally, Resident #93 had multiple doses of a medication that had been signed off as administered, but were not administered, due to not being available, with no evidence that the medical team had been notified. This is evidenced by the following: The facility policy Medication Administration revised February 2020, included the six rights of medication administration as the right patient, right medication, right dose, right time, right route, and right documentation. Resident #93 had diagnoses that included stroke, diabetes, and constipation. The Minimum Data Set Resident Assessment, dated 09/03/2024, revealed Resident #93 was cognitively intact. Current physician's orders included polyethylene glycol 17 grams daily scheduled at 9:00 AM for constipation and brinzolamide (Azopt) 1% ophthalmic suspension one drop to the right eye three times a day ordered on 08/12/2024 for glaucoma and may use resident's own medication. The eye drops were scheduled for 9:00 AM, 1:00 PM, and 5:00 PM daily. During observation of medication administration pass on 11/13/2024 at 8:30 AM, Licensed Practical Nurse #1 stated Resident #93's brinzolamide eye drops were not available, the medication was not carried by the facility's pharmacy, and they were waiting for the resident's relative to pick it up and bring to the facility (from an outside pharmacy). Additionally, Licensed Practical Nurse #1 did not prepare and administer the polyethylene glycol dose scheduled to be given at 9:00 AM. Review of the Medication Administration Report from 11/05/2024 to 11/13/2024, revealed out of 25 opportunities for administration of brinzolamide eye drops, 19 opportunities were documented as not given, including all three doses on 11/07/2024, 11/08/2024, and 11/09/2024. Licensed Practical Nurse #2 documented that on 11/10/2024 and 11/11/2024, the 5:00 PM dose of the brinzolamide eye drops were administered but the 9:00 AM and 1:00 PM doses on those days were documented as not given, not available. Additionally, Licensed Practical Nurse #1 documented the polyethylene glycol dose on 11/13/2024 was administered at 8:42 AM. The brinzolamide was documented as not given. Review of Interdisciplinary Progress Notes, dated 11/01/2024 to 11/13/2024, revealed no documented evidence that a covering medical provider had been notified that Resident #93's brinzolamide eye drops were not available. During an interview on 11/13/2024 at 11:57 AM, Licensed Practical Nurse #1 stated if a medication was due to be given and was not available, they would indicate this in the electronic Medication Administration Record, send a message to Pharmacy that the medication was missing, and let Registered Nurse Clinical Lead #1 know the medication was unavailable. Licensed Practical Nurse #1 stated there should be documentation in the medical provider book (if the provider was notified of an unavailable medication), which they thought was done, but could not recall when. Licensed Practical Nurse #1 also stated they did not know how long the eye drops had been unavailable, and that the Assistant Director of Nursing was aware they were unavailable. Licensed Practical Nurse #1 stated they could not remember if they gave Resident #93 the polyethylene glycol (on 11/13/2024 during morning medication pass). Review of the medical provider book from 11/10/2024 to 11/13/2024 revealed no entries related to Resident #93's brinzolamide eye drops being unavailable. During an interview on 11/13/2024 at 12:27 PM, Registered Nurse Clinical Leader #1 stated entries in the medical provider book are usually shredded when they are a week old because there are a lot of entries. Registered Nurse Clinical Leader #1 stated they had trouble getting the brinzolamide eye drops, and they were not sure how long it had been unavailable, but they were working on it. During an interview on 11/14/2024 at 8:42 AM, Resident #93 stated they did not like to take the polyethylene glycol and had told them (nurses) that they do not want it. Resident #93 stated they received three different eye drops to their right eye and could not remember which eye drops were given. During an interview on 11/14/2024 at 4:26 PM, Licensed Practical Nurse #2 stated they worked the evening shifts on 11/10/2024 and on 11/11/2024, and did not give the brinzolamide eye drops and must have (accidently) documented them as given. During an interview on 11/15/2024 at 8:32 AM, the Assistant Director of Nursing stated when administering medications, the nurse should give the medication and then document it was given. They also stated if a medication was due to be given and it was unavailable, the nurse should attempt to find out why, contact the pharmacy to see if they could get it, and check the satellite pharmacy (Omnicell, an automatic medication dispensing machine). The Assistant Director of Nursing stated if a medication was consistently unavailable, the medical provider should be notified to see if something different (alternative medication) could be ordered. During an interview on 11/15/2024 at 11:21 AM, the Director of Nursing stated the nurses should document after a medication is given to the resident (to ensure accurate documentation) and should not expect a nurse to document that a medication was given if it was not administered. During an interview on 11/15/2024 at 12:01 PM, Nurse Practitioner #1 stated Resident #93 had come from the emergency room with the brinzolamide eye drops which the facility was going to use since they did not carry the medication. Nurse Practitioner #1 also stated they were not aware that Resident #93 had not been receiving the brinzolamide eye drops, and if they had been made aware, they would have ordered a comparable medication. 10 NYCRR 415.11(c)(3)(i)

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/07/2024 to 11/15/2024, for three (Residents' #16, #43, and #86) of 23 residents reviewed, the facility did not develop and/or implement comprehensive person-centered care plans that included measurable goals and interventions to meet the residents' medical, nursing, and psychosocial needs as identified in their comprehensive assessments. Specifically, the comprehensive care plan for Resident #16 did not include goals or interventions related to their respiratory function and tracheostomy (a surgically created opening in the neck and into the windpipe to help with breathing and remove secretions). For Residents #43 and #86, the comprehensive care plan did not include measurable goals or interventions related to active skin impairments. This is evidenced by the following. Review of the facility policy Comprehensive Person-Centered Care Planning Process, dated March 2024, included a comprehensive person-centered interdisciplinary care plan will be developed for each individual receiving care, which includes measurable objectives and timetables to meet an individual's medical, nursing, nutritional, rehabilitative, cultural, psychosocial, and as applicable trauma informed needs and preferences that are identified in the comprehensive assessment. All Care Area Assessments that are triggered by the Minimum Data Set Assessment will require a care plan to be developed or an explanation in writing of why it was determined not to proceed. Care needs or risks identified through the Minimum Data Set process that do not trigger a Care Area Assessments will also require a care plan to be developed or an explanation in writing of why it was determined not to proceed. 1. Resident #16 had diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure, and cerebral palsy (a group of neurological disorders that affect a person's ability to swallow, move, balance, and maintain posture). The Minimum Data Set Resident Assessment, dated 10/03/2024, documented Resident #16 was cognitively intact, had a tracheostomy and was on a mechanical ventilator (a medical device that helps a person breathe by moving air into and out of their lungs). Review of the current Comprehensive Care Plan did not include any measurable goals or interventions related to the resident's tracheostomy and ventilator use, monitoring of, or complications to monitor for. The current Interdisciplinary Care Card (care plan used by the Certified Nursing Assistants) included oxygen therapy with interventions to maintain oxygen saturation above 90%, to provide tracheostomy care in the AM and PM and as needed, and full ventilator support at night. During an interview on 11/15/2024 at 10:49 AM, Registered Respiratory Therapist #1 stated residents who have a tracheostomy and are on the ventilator should have their own person-centered care plan as the care and needs they have may be very different based on their individual needs. During an interview on 11/15/2024 at 11:06 AM, Registered Nurse Manager #1 stated Resident #16 should have a care plan specific to their respiratory needs that included the tracheostomy and ventilator, their specific problem, goals, and interventions including what staff should monitor and report. 2. Resident #86 had diagnoses that included a stroke, chronic respiratory failure, and obesity. The Minimum Data Set Resident Assessment, dated 10/10/2024, documented the resident had severely impaired cognitive skills and a deep tissue injury. During an observation on 11/12/2024 at 11:09 AM, Resident #86 had an unstageable (wound unable to be staged due to the presence of dead tissue) pressure injury approximately one inch by one inch to the left buttocks. Review of the Comprehensive Care Plan and Interdisciplinary Care Card included interventions to prevent skin breakdown. The Care Plans did not include Resident #86 had a current pressure injury, goals, and/or interventions for monitoring the pressure injury, or reporting issues with the pressure injury. During an interview on 11/15/2024 at 11:06 AM, Registered Nursing Manager #1 stated Resident #86 had the skin breakdown since admission from the hospital (approximately a month ago) and had not been care planned for the skin impairment at that time nor when it worsened (10/17/2024). They also stated they should have implemented and started a care plan for the actual skin impairment at the time of admission and updated the care plan as needed. 3. Resident #43 had diagnoses that included meningioma (a benign tumor that grows in the membranes that surround the brain and spinal cord), mechanical ventilator dependence, and obesity. The Minimum Data Set Resident Assessment, dated 10/01/2024, documented the resident was moderately impaired of cognitive skills. During an observation on 11/07/2024 at 3:20 PM, Resident #43 had a quarter-sized, red, open skin impairment to the right temple. Review of Resident #86's electronic medical record revealed they had been followed by dermatology (skin doctor) since June 2021 for a lesion on the right side of the head that was potentially a basal cell carcinoma (skin cancer). Documented communication with Resident #86's family on 11/30/2021 revealed the family declined to biopsy the lesion and would continue conservative treatment. Review of the Comprehensive Care Plan and Interdisciplinary Care Card did not include that the resident had a skin lesion, goals, or interventions related to the skin impairment to the right temple, or potential skin cancer. During an interview on 11/15/2024 at 11:06 AM, Registered Nurse Manager #1 stated Resident #86 should have had a care plan for the skin lesion and potential skin cancer that included measurable goals and interventions for the lesion, what to monitor for, and when and to whom to report any changes or concerns. During an interview on 11/15/2024 at 10:42 AM, Certified Nursing Assistant #3 stated they used the Interdisciplinary Care Cards to know how to take care of each resident and everything they needed to know and monitor should be on the care cards. They also stated if they did not see something on the care card, they would not know what to do without asking. During an interview on 11/15/2024 at 10:35 AM, Licensed Practical Nurse #5 stated the Comprehensive Care Plans and the Interdisciplinary Care Cards are important because they tell you how to take care of each resident and the services and care they need. They stated the nurse manager completes the Comprehensive Care Plan. During an interview on 11/15/2024 at 11:55 PM, the Director of Nursing stated care plans should be created from the Minimum Data Set Resident Assessment as well as based off each resident's needs and history. They also stated each care plan needed to be specific to the resident and include the problem, measurable goals, and interventions. Additionally, residents with a tracheostomy and using a ventilator and residents with active skin impairments should have specific care plans for those issues. 10 NYCRR 415.11(c)(1)

Based on observations, interviews, and record reviews conducted during a Recertification Survey from 11/07/2024 to 11/15/2024, the facility did not ensure the daily nurse staffing information was consistently posted to include the daily resident census, the total number and actual hours worked by the licensed and certified nurses at the beginning of each shift on a daily basis, and that they were readily accessible to residents and visitors. Specifically, the nursing staff information was not posted in a readily accessible location for all residents and visitors, the information was not completed or updated for night shift and on weekends, and the information posted was not updated or consistently accurate. This is evidenced by the following: The facility policy Long Term Care Nursing Services - Posting of Nurse Staffing Information dated October 2024, included the posting will include the total number and actual hours worked of licensed and unlicensed staff directly responsible for resident care per shift, the facility will post the nurse staffing data on a daily basis at the beginning of each shift, and the data will be posted in a prominent place readily accessible to residents and visitors. During observations on 11/07/2024 at 12:10 PM and 11/12/2021 at 11:01 AM, the posted nurse staffing numbers were located in the second-floor hallway prior to entering the 2200 resident care unit. Residents and visitors for resident care units 2300 and 2400 on the second floor and resident care units 3100, 3200, and 3300 on the third floor would not pass the posting or be able to visualize the posted nursing staffing unless going to the 2200 resident unit. Review of the posted daily nurse staffing information from 11/01/2024 to 11/13/2024 revealed 6 of 11 days did not include the accurate number of Licensed Practical Nurses and/or Certified Nursing Assistants when reviewed with the staffing schedules for those days. Review of the posted daily nurse staffing information from 08/01/2024 through 11/14/2024 revealed no documented evidence that the required nurse staffing information had been completed for any weekends during that time. During an interview on 11/12/2024 at 1:32 PM, the Nursing Staffing Coordinator stated they are responsible for completing the posted nursing information and posting the information. They stated they complete the information for all shifts and update day shift and evening shift as needed; they do not update the night staffing information. The Nursing Staffing Coordinator also stated the posted staffing is not updated for the night shift and is not completed when they are not in the building (weekends or vacations). The Nursing Staffing Coordinator stated the information is not easily accessible to residents and visitors on the third floor or for resident care units 2300 and 2400. During an interview on 11/15/2024 at 11:55 AM, the Director of Nursing stated they are not involved with the posted nursing information and were not aware of any issues with the postings. During an interview on 11/15/2024 at 12:18 PM, the Operations Supervisor stated they occasionally help cover the posting when the Nursing Staffing Coordinator is not available, and were not aware of any issues with updating or posting the information. 10 NYCRR 415.13

Based on observations, interviews and record review conducted during the Recertification Survey completed on 3/3/23, it was determined that for two of six residents reviewed for accidents, the facility did not ensure that the resident's environment remained as free of accident hazards as possible. Specifically, Resident #36 was not appropriately assessed, and care planned to have medications left at their bedside for self- administration and Resident # 28 was served and consumed a meal tray that contained an inaccurate diet consistency. This is evidenced by the following: 1.Resident #36 had diagnoses including end stage renal disease requiring dialysis, hypertension, diabetes, and depression. The Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #36 was cognitively intact. Record Review on 3/1/23 of Resident #36's Comprehensive Care Plan (CCP) revealed no information, including goals, interventions, or assessments for safe self-administration of medications or for medications left at the bedside. During an observation on 3/1/23 at 8:57 a.m. Resident #36 was in bed eating breakfast. During an observation on 3/2/23 at 9:47 a.m., approximately nine or ten pills were observed in a medicine cup at Resident #36's bedside table while they were asleep in bed. There was no staff in the room. During an interview on 3/2/23 at 10:48 a.m., Licensed Practical Nurse (LPN) #1 stated that they had left Resident #36's morning medications at their bedside and thought the resident was care planned for such. Additionally, when asked, LPN #1 stated that there were three residents who wanders on the unit and specified that one of the residents is likely to go into other resident's rooms. Review of Resident #36's Medication Administration Record revealed their morning medications included but not limited to, Florastor (a probiotic) with physician instructions to wear gloves and wash hands when administering, Effexor (anti-depression medication) with physician instructions to give daily with breakfast, and Synthroid (scheduled for 6:00 a.m.), three different cardiac medications and a medication for diabetes. Synthroid was signed off as given on 3/3/23 at 6:07 a.m. and the rest of the medications were signed off as administered at 7:32 a.m. When interviewed on 3/2/23 at 11:34 a.m., and again on 3/3/23 at 8:50 a.m., Resident #36 said that they had asked the nurses not to wake them but to leave their medications at their bedside. Resident #36 stated the pills included their Synthroid (from night shift), Effexor, a diabetes pill, their blood pressure pills and Tylenol among others. Resident #36 said that no one had ever discussed with them the safety of leaving medications at their bedside. Resident #36 said that last week another resident, who was friendly but confused, came in their room uninvited and sat on their bed and they had to call staff to come and remove the resident. When interviewed on 3/3/23 at 9:18 a.m., the Director of Nursing (DON) said that Resident #36 had been self-administering medications for a long time per the resident's preference but could not confirm that the Interdisciplinary Team (IDT) had assessed the resident to self-administer medications safely or have them left at their bedside. The DON said that they would expect that before leaving medications at the bedside unsupervised, the IDT would have assessed the resident for safety and education along with ensuring the safety of other residents on the unit since there were wanderers. 2.Resident #28 had diagnoses including Parkinson's disease, bipolar disorder (form of mental illness), hypertension, and a risk for malnutrition. The MDS assessment dated [DATE] documented that Resident #28 was severely impaired cognitively. Review of current the physician's orders revealed a diet order for puree food with nectar thickened liquids. The CCP dated 2/21/23 and the current Certified Nursing Assistant (CNA) care plan documented that Resident #28 was at risk for malnutrition, was on aspiration precautions and required total feeding assistance. Interventions included pureed diet with nectar thick liquids and to follow recommendations from Speech Therapy (ST). Review of Recommended Feeding Guidelines, dated 12/16/22 revealed Resident #28 was recommended a pureed diet and out of bed with head elevated 90 for feeding. Review of a ST Discharge Summary dated 12/26/22 revealed that Resident #28 had been evaluated for dysphagia (difficulty swallowing) and included that Resident #28 was without teeth or dentures and due to the resident swallowing the food whole and chewing either very minimally or not at all, mechanical soft foods are a choking hazard at this time and with increased risk for aspiration. Discharge level of diet was pureed food with nectar thick liquids. During an observation on 3/1/23 at 12:11 p.m., CNA #1 came out of Resident #48's room carrying a meal tray and said that Resident #48 had eaten their lunch. The meal ticket on the tray included Resident #28's name and the diet listed as pureed. Further investigation revealed that CNA #1 had fed Resident #48 with Resident #28's meal tray, and Resident #28 was fed Resident #48's meal tray which was a mechanical soft diet. When observed at this time the mechanical soft diet tray consisted of sliced carrots, mashed potatoes (not pureed), chopped up chicken tenders, fruit cocktail, nectar thickened dairy drink and an eight-ounce cup of creamy, white in color liquid that was half- spilled on tray. During an interview on 3/1/23 at 12:16 p.m. and 12:56 p.m., CNA #1 stated that they accidentally gave Residents #28 and #48 the wrong trays but that Resident #28 did not each much. CNA #1 stated that they were not normally assigned to this unit, but that CNAs should check the binder with the resident care cards to know what the residents' needs are. LPN #2 stated at this time that CNAs need to read the tickets for each resident prior to giving it to the resident. During an interview on 3/1/23 at 2:04 p.m. the Speech Pathologist (SP) stated that Resident #28's was edentulous (without teeth) and did not have dentures. Resident #28 had been ordered a mechanical soft diet but could not chew their food and that mechanical soft foods were identified as high risk for aspiration. The SP said that if a resident with a puree diet was given mechanical soft foods, they could choke or also pocket food in their mouth causing bacteria to form, leading to aspiration pneumonia. During an interview on 3/3/23 at 12:36 p.m., the Registered Nurse Manager (RNM) said they would expect that when delivering meal trays, staff read the names carefully to ensure that each resident receive the correct tray, and all residents who are supposed to be out of bed for meals are seated in the dining room. During an interview on 3/3/23 at 1:30 p.m., the DON said they would expect that residents with aspiration precaution be fed according to feeding guidelines. They would also expect staff to know what contributes to aspiration and report any concerns. 10 NYCRR415.12(h)(1)

Based on observations, interviews and record reviews conducted during the Recertification Survey, completed on 5/19/21, it was determined that for one of one resident (Resident #44) the facility did not provide care and services consistent with professional standards of care to meet the needs of a resident on [CONDITION(S)]. Specifically, the facility did not monitor the resident's fluid restriction os ordered and did not provide ongoing monitoring and care of the resident's vascular access. This is evidenced by the following: A facility policy, Hemodialysis Guidelines, dated April 2017, directs staff that upon the residents return from [CONDITION(S)] and at least daily, to feel lightly with fingertips over the fistula (a surgical graft used for [CONDITION(S)]) for a thrill (vibration) and auscultate (listen) for a bruit (swishing sound). Staff should document on the treatment sheet that both are present. If there is no bruit and/or thrill present, they should notify the medical provider. Staff are to monitor the site after each [CONDITION(S)] treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident has a dressing over the fistula when returning to facility, it can be removed the following day. Monitor and record intake daily if the resident is placed on a fluid restriction. Resident #44 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 4/5/21, revealed the resident was cognitively intact, required set up assist for eating and was receiving [CONDITION(S)] treatments. Current Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Comprehensive Care Plan (CCP) and Bedside Kardex (directs daily care) included that Resident #44 was at risk for fluid imbalance. Interventions included to monitor labs and hydration status, to provide a renal diet of low potassium, controlled carbohydrate, and 1500 mls fluid restriction daily, and has [CONDITION(S)] treatments three days per week. Neither care plan directed staff to monitor the bruit and thrill or the fistula site for complications. Review of fluid intake flowsheets (in the electronic medical record), and the floor intake/output (I/O) sheets (on paper), dated 4/15/21 to 5/15/21, revealed incomplete or no documentation of the resident's fluid intake or 24-hour totals for 30 of 31 days. Review of Resident #44 medical record (electronic and paper) revealed no documentation that the resident's bruit and thrill or the fistula site were being checked or monitored on a consistent basis. In an interview on 5/18/21 at 11:05 a.m., Resident #44 said they are on a fluid restriction, but they do not know specifically what that amount is. The resident said they could have three cups a day pointing to a 16-ounce cup. Resident #44 added that the nurses do not check their fistula for bruit or thrill. In an interview on 5/18/21 at 11:08 a.m., Certified Nursing Assistant (CNA) #1 and CNA #2 both said the resident is on a fluid restriction of 1500 mls per day and they document on the I/O sheets after each meal. A review of the I/O sheets at this time revealed fluid documentation for each meal but did not include any fluid intake with medication pass or other fluids given between meals. In an interview on 5/18/21 at 12:07 p.m., and again at 3:33 p.m., the Registered Nurse Manager (RNM) said nursing should document the bruit and thrill in the electronic medical record (EMR) and after review, said it was incomplete and not documented since 4/3/21. He said the facility staff do not do anything with the bandage, only [CONDITION(S)] staff and that dietary is responsible to monitor the daily fluid intake. In an interview on 5/18/21 at 12:35 p.m., the Director of Nursing (DON) said she expects the fluid restriction, which is on the care plan, to be implemented and monitored by staff. She said nursing staff records the fluid intake using a combination of electronic and paper charting and the evening or night nurse should be reviewing the daily 24 hour intake to see if the resident is meeting or exceeding the fluid restriction and to notify a medical provider and dietary if not. The DON said the facility is currently trying to find a new, more simple standardized fluid intake recording system to use to but has not found one yet. She said she expects the bruit and thrill to be monitored once a shift at the facility. In an interview on 5/18/21 at 12:47 p.m., Registered Dietitians (RD)#1 and RD#2 both said Resident #44 gets a total of 720 mls per day with their meals and nursing should use the remaining fluid allowance for medication pass and between meal drinks. They said typically fluid intakes are documented on the floor I/O sheets not the computer and that nursing reviews them. In an interview on 5/18/21 at 1:32 p.m., and at 2:52 p.m., Licensed Practical Nurse (LPN)#1 said the CNAs document fluids on the I/O sheets, but the night nurse uses a different form known as the breakfast-lunch-dinner-medications sheet. LPN#1 said the evening nurse is supposed to review these sheets and enter the information into the computer and report pertinent information to the next shift. LPN #1 said no one has directed her to check the bruit, thrill, or the fistula site. In an interview on 5/18/21 at 1:49 p.m., the [CONDITION(S)] Registered Nurse Clinical Manager said Resident #44 is on a 1500 mls fluid restriction daily. She said facility staff should check the fistula bruit and thrill once daily and check the site for complications after removal of the bandage at bedtime. She said Resident #44's fluid intake has been manageable so far despite coming to [CONDITION(S)] every Monday with excess fluids related to the weekend intake. [10NYCRR 415.12]

Based on observations, interviews and record reviews conducted during the Recertification Survey completed on 5/18/21, it was determined that for one (Resident #22) of three residents reviewed, the facility did not provide the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #22 did not receive nail care or shaving per their preferences. This is evidenced by the following: Resident #22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 2/23/21, documented that Resident #22 was cognitively intact and required assistance of one person for grooming and personal hygiene. The facility policy Quality of Life and Quality of Care , dated January 2020, included the resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good grooming and personal and oral hygiene. Review of the current Comprehensive Care Plan and the Certified Nursing Assistant (CNA) Care Card included the resident required assistance of one staff for personal hygiene. During observations on 05/13/21 at 12:32 p.m., on 05/14/21 at 01:49 p.m., and on 05/17/21 at 10:44 a.m., Resident #22 was observed with long, untrimmed, and jagged fingernails on both hands with dark brown debris underneath them. The resident was also unshaven with elongated facial hair stained yellow in places. During an interview and joint observation on 05/17/21 at 10:44 a.m., the CNA, after observing the resident's nails and facial hair, stated that the resident's nails on both hands were long and dirty and that the resident needed to be shaved. When interviewed at this time, Resident #22 stated their nails were dirty and needed to be cleaned and that they had asked staff to shave their beard, but no one has done it yet. When interviewed on 05/17/21 at 12:55 p.m., the Nurse Manager (NM) stated it was the expectation that staff perform nail care and shave the residents unless the resident refuses. The NM stated that if the resident is a one assist staff should assist the resident in completing task that they cannot do for themselves on a daily basis and follow the care plan at all times. [10NYCRR 415.12(a)(3)]

Based on observations, interviews and record review conducted during the Recertification Survey completed on 5/19/21, it was determined for one (Resident #18) of one resident reviewed the facility did not review and revise the resident's care plan (with input from the resident or resident representative, to the extent possible), if necessary to meet the resident's needs. Specifically, Resident #18 complained to the facility that they required more assist with brushing their teeth than staff were providing, and the resident's care plan was not revised to meet the resident's needs. This is evidenced by the following: Resident #18 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set Assessment, dated 5/8/21, revealed the resident was cognitively intact, required set up help for personal hygiene, and no rejections of cares. The resident's current Comprehensive Care Plan and the Interdisciplinary Care Card (both direct daily care), for oral care included that the resident had their own teeth, was independent with brushing after set up, for staff to please cue the resident morning and evening, observe for any bleeding and if any to report it. Review of dental notes, dated 3/26/21 and 4/30/21, included that the resident had advanced gum disease and that better oral care was discussed with the resident and with staff. Review of a Grievance Resolution Letter, dated 5/4/21, revealed that on 4/19/21, Resident #18 filed a grievance that included they were not receiving staff assistance with teeth brushing. The facility response was to update the care plan to reflect the assistance needed for teeth brushing. In an observation and interview on 5/14/21 at 9:23 a.m., Resident #18 was dabbing a tissue against their teeth that was soiled with blood. Resident #18 said they have very sensitive teeth and was told by a dental hygienist to brush at least once a day with staff assistance. Resident #18 said the staff should help them, but they do not. There was an empty tube of toothpaste and two dry toothettes observed in the bathroom at this time. In an observation and interview on 5/17/21 at 11:45 a.m., Resident #18 had a tissue on the overbed table that was spotted with blood. Resident #18 said that they did not brush today as they could not get any toothpaste out of the tube. The resident again stated that staff are supposed to help them. Observation at this time revealed whitish orange creamy debris or plaque around both upper and lower teeth. In an interview on 5/17/21 at 11:51 a.m., Certified Nursing Assistant (CNA)#1 said Resident #18 usually does their own oral care and calls for help if needed. CNA#1 said she was not aware of any update to assist the resident with tooth brushing but that she knows the resident has trouble getting the toothpaste out of the tube. In an interview on 5/17/21 at 12:00 p.m., CNA#2 said she had not provided any help to Resident #18 this morning as they can brush their own teeth. CNA#2 said she was not aware that the resident's oral care needs had changed as the CNA care card did not reflect that. In an interview on 5/18/21 at 10:21 a.m., the Social Worker said the Grievance Resolution Letter is given to the Registered Nurse Manager (RNM) in order to implement and change the resident's care plan and direct staff of the care the residents require. In an interview on 5/18/21 at 10:24 a.m., the Dentist said that the registered hygienist had recently seen Resident #18 on 4/30/21 and had advised staff to assist the resident with oral care. He said updating the resident's care plan is essential. In an interview on 5/18/21 at 11:42 a.m., the RNM said he did get an email to update Resident #18's care plans but did not update them because he thought that it had already been done. [10NYCRR 415.11(c)(2)(i-iii)

Based on interviews and record reviews conducted during the Recertification Survey completed on 5/18/21, it was determined for one (Resident #31) of one resident reviewed the facility did not notify the resident of new treatment plans. Specifically, test results and treatment plans were not reviewed with the resident following a cardiology consult. This is evidenced by the following: Review of a facility policy, Notification of Changes in Resident Status, dated February 2018, included to notify residents, families and/or the resident representative, according to their authority, of changes in the resident's status and that the facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative (s) regardless of resident's competency when there is a need to alter treatment significantly. A need to alter treatment significantly means a need to stop a form of treatment or commence a new form of treatment to deal with a problem. The notification will be documented in the interdisciplinary progress notes and is to include date, time and person notified. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 3/4/21, revealed the resident was cognitively intact and was on an anticoagulant medication (used to prevent blood clots) daily. In a cardiology consultation note, dated 4/23/21, the cardiologist documented that Resident #31 was to be scheduled for an echocardiogram (ECHO) (an advanced test to show the internal structure of the heart) and a nuclear stress test. The cardiologist wrote that if there were areas of ischemia (inadequate blood supply) around the heart, an angiogram would need to be considered. Review of facility interdisciplinary progress notes, dated 4/23/21 to 5/17/21, revealed that the ECHO was completed on 4/26/21 with the report to follow. There was no documented evidence that the resident was notified of the test results or of any future tests being scheduled. During an interview on 5/14/21 at 10:21 a.m., Resident #31 said communication at the facility was a problem. Resident #31 said they had an electrocardiogram (EKG) and thought they were supposed to have another test (stress test) but that no one had told them when it was scheduled or came to get them and it was missed. In an interview on 5/17/21 at 3:38 p.m., the Director of Nursing (DON) said she expects that someone would have reported the results of the ECHO and the follow up plan to the resident. The DON said either the cardiologist or the unit secretary will usually schedule follow up appointments. She added if the cardiologist or one of the facility medical providers did not talk with the resident, the nurse manager would do that. In an interview on 5/18/21 at 11:07 a.m., the Registered Nurse Manager (RNM) said it is the responsibility of the facility medical team to notify residents of test results and follow up appointments and document the conversation in a progress note. The RNM reviewed progress notes and said there was no documentation that the resident was notified of any results or future tests. He said the cardiology notes did not include resident notification either. The RNM also said that the ECHO report did not have any provider initials or date on it to represent it was reviewed by the facility medical provider. In an interview on 5/18/21 at 11:15 a.m., the Physician's Assistant (PA) said a follow up visit and stress test that had been scheduled had to be pushed out till 6/17/21. She said the tests were to determine the need for an angiogram. She said the facility procedure is for cardiology to fax test results and notes directly to the medical providers so that results can be discussed with the resident and this was not done. [10NYCRR 415.3(c)(2)(ii)(c)]

Based on interviews and record reviews conducted during the Recertification Survey completed on 5/18/21, it was determined for two (Resident #7 and #91) of two residents reviewed, the facility did not ensure the residents or the resident's representatives were notified of the facility's bed hold policy per the regulations. Specifically, the residents were transferred to the hospital and there was no documented evidence that the residents or their representatives were notified of the facility's bed hold policy at the time of their hospitalization s. This is evidenced the following: The facility policy Notice of Transfer, Discharge or Bed Hold, dated May 2018, included the nursing home must issue a valid discharge notice to the resident, and if known, to a family member or legal representative of the resident. For urgent transfers out of the facility: a copy of the notice of discharge form should be sent with the resident at the time of transfer/discharge, Social Work or Nursing should notify the resident's responsible party via phone of the discharge and document notification or attempt to notify in the medical record, and Social Work will follow up with the resident or representative on the next business day with a phone call to discuss bed hold options. The Social Worker will also mail a copy of the discharge notice to the resident/responsible party and document the notification in the medical record. 1. Resident #7 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 5/4/21, revealed the resident had moderately impaired cognition. Review of the medical record revealed Resident #7 was transferred to the hospital on 4/13/21 and again on 4/25/21. The Urgent Notice of Transfer, Discharge, Therapeutic Leave forms, dated 4/13/21 and 4/25/21, included that a transfer or discharge to the hospital was required by the resident's medical needs but did not include information regarding the facility's bed hold policy. The resident was unable to sign the form at the time of discharge. Review of the medical record from 4/13/21 to 4/30/21 did not include any evidence that Resident #7 or their representative was notified of the facility's bed hold policy at the time of the resident's hospitalization s. 2. Resident #91 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 4/27/21, revealed the resident may have difficulty making decisions in new situations. Review of the medical record revealed the resident was transferred to the hospital on 4/2/21. An Urgent Notice of Transfer, Discharge, Therapeutic Leave form, dated 4/2/21, revealed a transfer or discharge to the hospital was required by the resident's medical needs but did not include information regarding the facility's bed hold policy. The form was signed by a facility staff member. Review of the resident's medical record did not include any evidence that Resident #91 or their representative was notified of the facility's bed hold policy at the time of the resident's hospitalization . When interviewed on 5/18/21 at 11:25 a.m., the Social Worker (SW) stated that a copy of the bed hold policy is provided to all residents at the time of admission and a copy also goes along with the written transfer notice by mail to the family at the time of a transfer. The Social Worker stated that there was no evidence that the bed hold policy was provided for these residents. [10NYCRR 415.3(h)(4)(i)(a)]

Based on interviews and record reviews conducted during the Recertification Survey, completed on 5/18/21, it was determined for two of two residents, the facility did not ensure that the residents or resident's representatives were notified in writing of the reason for a transfer or discharge from the facility. Specifically, Resident #7 and Resident # 91 were transferred to the hospital and there was no documented evidence that the residents or their representatives received a copy of the written transfer notice. The facility policy Notice of Transfer, Discharge or Bed Hold, dated May 2018, included the nursing home must issue a valid discharge notice to the resident, and if known, to a family member or legal representative of the resident. For urgent transfers out of the facility: a copy of the notice of discharge form should be sent with the resident at the time of transfer/discharge. Social Work or Nursing should notify the resident's responsible party via phone of the discharge and document notification or attempt to notify in the medical record and Social Work will follow up with the resident or representative on the next business day with a phone call to discuss bed hold options. The Social Worker will also mail a copy of the discharge notice to the resident/responsible party and document the notification in the medical record. 1. Resident #7 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 5/4/21, revealed the resident had moderately impaired cognition. Review of the medical record revealed Resident #7 was transferred to the hospital on 4/13/21 and again on 4/25/21. The Urgent Notice of Transfer, Discharge, Therapeutic Leave forms, dated 4/13/21 and 4/25/21, included that a transfer or discharge to the hospital was required by the resident's medical needs. The resident was unable to sign the form at the time of discharge. Review of the medical record from 4/13/21 to 4/30/21 did not include any documented evidence that the resident or resident's representative was notified in writing of the reason for the transfer or discharge to the hospital. 2. Resident #91 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 4/27/21, revealed the resident may have difficulty making decisions in new situations. Review of the medical record revealed Resident #91 was transferred to the hospital on 4/2/21. The Urgent Notice of Transfer, Discharge, Therapeutic Leave form, dated 4/2/21, included a transfer or discharge to the hospital was required by the resident's medical needs. The form was signed by a facility staff member. Review of the medical record from 4/1/21 to 4/3/21 did not include any documented evidence that the resident or resident's representative was notified in writing of the reason for the transfer or discharge to the hospital. When interviewed on 5/18/21 at 11:25 a.m., the Social Worker (SW) stated that she provides a copy of the written notice of a transfer to resident's families by mail. The SW stated that there was no documented evidence that the written notice of the transfer was provided for these two residents. When interviewed on 5/18/21 at 2:30 p.m., the Administrator stated that Social Work is responsible for ensuring that the transfer notice is done, but there is no process in place to ensure that a written copy of the notice is provided to the resident or representative. [10NYCRR 415.3 (h)(1)(iii)(a-c)]

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not store, distribute, or serve food under sanitary conditions. The issue was improper cooling of temperature controlled for safety TCS) foods. This is evidenced by the following: The New York State Sanitary Code, Subpart 14-1 included that potentially hazardous foods requiring refrigeration are to be cooled by an adequate method so that every part of the product is reduced from 120 degrees Fahrenheit to 70 degrees Fahrenheit within two hours and to 45 degrees Fahrenheit or below within four additional hours. Review of the tray-line truck delivery schedule for Unit 2200 revealed that the meal trays are delivered at approximately 12:20 p.m. During an observation on 3/12/19 at 1:10 p.m., a resident's lunch tray was on the counter in the kitchen galley. At 2:15 p.m., the lunch tray remained on the counter, and the surveyor used the(NAME)Aquatuff 351 thermometer to check the food temperatures. The spaghetti with meat sauce was 87.7 degrees Fahrenheit and the chocolate pudding was 72.3 degrees Fahrenheit. When interviewed on 3/12/19 at 2:25 p.m., the Certified Nursing Assistant (CNA) said the resident had to leave for an appointment about ten minutes before the trays arrived on the unit, so she saved his tray. The CNA said she was going to reheat the resident's food at that time. The surveyor intervened and told her the food on the tray had not been cooled and stored properly. The CNA agreed and called for another tray. Interviews conducted on 3/13/19 included the following: a. At 9:58 a.m., CNA #2 said if a resident goes out for an appointment, the resident's tray is saved in the galley and reheated when they return. She said two hours is too long to hold a tray. CNA #2 said that she would worry about salmonella or bacteria growing. b. At 10:07 a.m., the Food Service Manager said if a resident is not available at meal time for more than 15 to 30 minutes, then staff are supposed to call the kitchen for another tray c. At 10:26 a.m., the Registered Nurse Manager stated if someone is going out for an appointment, their tray should be put in the refrigerator. She said when the resident returns, the staff heat up the resident's tray. She said that was standard practice. (14-1.40(b))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen remained free from unnecessary medications. Specifically, there was a lack of a specific [DIAGNOSES REDACTED].#24 and #56). Additionally, a resident did not have a follow up visit with psychiatry (Resident #24), and a resident did not have a care plan for the use of [MEDICAL CONDITION] medications (Resident #56). This is evidenced by the following: 1. Resident #24 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED].>[MEDICAL CONDITION], dementia, and [MEDICAL CONDITION]. The Minimum Data Set (MDS) Assessment, dated 6/12/18, revealed the resident had severely impaired cognition, verbal behaviors one to three days, other behaviors, rejection of care, and no [MEDICAL CONDITION] (hallucinations/delusions). The current Comprehensive Care Plan (CCP), revealed that the resident used [MEDICAL CONDITION] medications for depression with [MEDICAL CONDITION]. Approaches included psychiatric evaluation as ordered and monitor mood and behavior for problems. A medical note, dated 5/17/18, documented that the resident's mood was stabilized and at present, she was alert, oriented to person, place, time and health conditions. Affect was normal, judgment and insight are normal, and the plan was to monitor the resident's mood, behaviors, and follow up with psychiatry. The resident is on [MEDICATION NAME] for mood stabilization which appears effective at present and current dose is being tolerated. Physician orders, dated 6/1/18, included [MEDICATION NAME] (an antidepressant medication) every evening. Review of the progress notes, from 5/1/18 through 6/20/18, included five behavior notes, three of which were refusals of showers or care. A progress note, dated 5/10/18, revealed that the resident was restless asking, Where do I go, what should I do? When the nurse asked the resident to sit in the chair, the resident slapped the nurse in the arm. After the resident's medications were given and she ate dinner she was calm. A progress note, dated 6/7/18, revealed that the resident was yelling at staff and other residents about work, getting paid, and going home. The resident pounded her hands on the counter demanding to be told what to do and was unable to be redirected. The psychiatrist notes, dated 6/19/18, included that the resident was being hostile and angry, insisting there was no reason for her to be at the nursing home. She also believed her family was plotting against her to get rid of her, and she did not know why that was happening and is angry and upset. The psychiatrist was unable to reorient the resident. Recommendations included because the patient is clearly experiencing psychotic symptoms, she needs medication that can help with this as well as augment the antidepressant. [MEDICATION NAME] ([MEDICATION NAME] - an antipsychotic medication used to treat certain mental disorders) was recommended to be given daily at bedtime. Physician orders, dated 6/19/18, included [MEDICATION NAME] daily for psychoses (losing touch with reality with main symptoms being hallucinations and delusions). The medication was transcribed as daily at 9:00 a.m. A nursing note, dated 6/20/18, included that the resident had a shower, was medicated for leg pain, and was started on [MEDICATION NAME] for psychoses. The resident slept the remainder of the shift. Review of progress notes, from 6/21/18 through 2/27/19, revealed 16 behavior notes, in which 14 were refusals of care and or medications. A nursing note, dated 7/5/18, revealed that the resident was hallucinating, wandering, and was easily redirected by staff. The resident went to bed and remained there without any issues. A nursing note, dated 11/7/18, included the resident refusing medications and said the nurse was trying to poison her. A physician note, dated 2/2/19, documented that the resident was on [MEDICATION NAME] and reviewed behaviors with nursing behaviors. Discuss with pharmacy, follow behaviors and attempt to wean in the future. The resident was observed on 03/7/19 at 12:46 p.m., and 12:58 p.m., lying in bed asleep with her untouched lunch on the tray table. The resident was also observed on 3/11/19 at 9:41a.m., 11:09 a.m., and 2:59 p.m., asleep in her room. During an interview on 3/11/19 at 12:07 p.m., the Student Practical Nurse said she was very familiar with the resident as she has cared for this resident during her clinical rotation. She said the resident can become agitated during care and needs to be re-approached. She said the resident responds well to a calm approach and talking her through the care being provided. She said the resident feels that people are invading her space. She said the resident spends most of her day in bed and asleep. Interviews conducted on 3/12/19 included the following: a. At 3:58 p.m., the evening Licensed Practical Nurse (LPN) said the resident was sometimes resistive with cares, and if you push the issue the resident will strike out. She said the resident has always had these behaviors daily and there has been no change in the past year. The LPN said that she does not document unless something is out of the ordinary, like if re-approaching the resident does not work. b. At 4:04 p.m., the evening Certified Nursing Assistant (CNA) said the resident sleeps a lot. She said every now and then she refuses care but if staff go back later, she is fine and allows staff to provide care. The CNA said the resident responds well if you ask her to calm down and she loves to look out the window. She said she has cared for this resident for the past two years and her behavior has never changed. Interviews conducted on 3/13/19 included the following: a. At 12:16 p.m., the Physician's Assistant (PA) said the resident would be hallucinating or delusional if having psychoses, seeing or hearing things that are not there. She said she would not characterize the resident's behaviors as psychoses according to the notes in the chart from 5/1/18 through 6/20/18. The PA said it would be dementia with behaviors. She said one or two behavior notes would not be an indication to start a resident on [MEDICATION NAME]. She said the [MEDICATION NAME] order has the wrong indication, it should be for sleep, and therefore given at bedtime not at 9:00 a.m. The NP said she now knows why the resident has been so sleepy during the day. The PA also said the nursing notes are not capturing all the resident's behaviors, and they should be documenting if she is having any behaviors. She said she believes the staff are used to her regular behaviors so there is no charting unless it is out of the ordinary, like the evening nurse said. b. At 12:44 p.m., the day CNA said sometimes the resident is combative and it is best to let her sleep if she wants. She said she sleeps a lot. She said that when the resident is combative she will hit and scratch. She said that she was not aware of the resident ever hallucinating. c. At 12:47 p.m., the day LPN said the resident stays in her room most of time. A couple of times she has become aggressive and once she got in my face and tried to punch me. She said the resident was redirected and went back to bed. She said that was about a month ago, and it should be documented. After reviewing the documentation in the record, she said it was not documented as it is normal behavior. She said that she should have documented. The LPN said she was not aware of any hallucinations. d. At 1:35 p.m., the Assistant Director of Nursing (ADON) said, after reviewing progress notes in the record, the notes represent what she has known of the resident and her behaviors. She said she knew the resident had some bouts of physical aggression but did not think it was captured in the notes in the record. The ADON said that the nurses should be documenting what is happening with the resident. 2. Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/8/19, revealed the resident was cognitively intact, had no behaviors, and received a daily antipsychotic. The MDS Assessment, dated 10/11/18, also revealed no documented behaviors. Physician orders, dated 3/5/19, included Quetiapine [MEDICATION NAME] ([MEDICATION NAME] an antipsychotic) three times a day for combative behavior. Review of the pharmacy medication regimen reviews revealed on 10/7/16 the resident failed a GDR of the [MEDICATION NAME] because of persistent worries of her health issues. Review of the progress notes, from 4/12/18 through 3/13/19, revealed that on 6/16/18 the resident was yelling most of the shift. A note, dated 10/30/18, revealed that the resident had continuous complaints of eyes burning, yelling, and demands to staff. An 11/4/18 note documented that the resident had been yelling out most of the shift, at one point demanding a second glass of water. When told she would have to wait a minute, she dumped the current glass of water on the floor. On 11/7/18, a note revealed the resident was yelling out and repeating words, requested eye drops for eyes burning like fire. There were no other behaviors documented. The resident's CCP, dated 1/15/19, included disruptive behavior related to history of long-standing anxiety worries on health issues, becomes anxious and agitated when she perceives that her needs are not being met. There was no care plan for the use of an antipsychotic medication. A medical progress note, dated 1/15/19, revealed no significant change in cognition. The resident's mood was stable and reports she feels well. The resident is alert and oriented to person, not place or year, affect is normal, and judgement and insight are slightly impaired. Past medical history included depression, anxiety, and history of frequent health complaints. The resident had a 2/26/16 trial dose reduction of her [MEDICAL CONDITION] medication, and is still anxious, continue the current [MEDICAL CONDITION] medications. Consider GDR in the future if the resident has improvement in symptoms. During an observation on 3/11/19 at 9:59 a.m., the resident was in bed sleeping. At 1:34 p.m., the resident was in bed and said she was not feeling well that day as her stomach was upset so she ate breakfast and went back to bed. On 3/12/19 at 9:47 a.m., the resident was in bed asleep. On 3/13/19 at 11:05 a.m., the resident was wheeling out of the dining room, was able to make her needs known, and she asked to be taken to the bathroom. Interviews conducted on 3/13/19 included the following: a. At 11:17 a.m., the Clinical Leader said that she could not find a care plan for combative behavior or the use of the [MEDICATION NAME]. She said she was unable to find any notes for the (YEAR) GDR other than the pharmacy review. b. At 11:28 a.m., the Nurse Manager said the resident failed a GDR in (YEAR) but she did not have any information on why it failed. c. At 11:33 a.m., the Nurse Practitioner (NP) said that the resident perseverates on her health. She said after reviewing the medical record, that she could not disagree with a GDR. The NP said she was able to find notes about anxiety but no other notes on behaviors. When asked what the specific [DIAGNOSES REDACTED]. She said she does not see any current documentation for the use of the antipsychotic or a reason it could not be reduced. The NP said she was not sure why it was not done. d. At 1:15 p.m., the pharmacy consultant said she did not know that the resident did not have documented behaviors. She said she was going to recommend a GDR in (MONTH) 2019 for the antipsychotic. (10 NYCRR 415.12(l)(1-2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #92) of three residents reviewed for pressure ulcers, the facility did not ensure the implementation of each resident's care plan. Specifically, the resident did not have documentation of wounds per the physician orders. This is evidenced by the following: Resident #92 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/27/18, revealed the resident's cognition was severely impaired and there were no pressure ulcers. The current Comprehensive Care Plan for pressure ulcers includes to monitor for any changes. A nursing progress note, dated 8/2/18, revealed that the resident had [MEDICAL CONDITION] (swelling in the arms or legs) with both legs weeping. A nursing note, dated 9/6/18, revealed the resident obtained a skin tear from the walker to the left lateral knee, which measured approximately 2 centimeters (cm) x 2 cm and a treatment was applied. Padding was placed on the walker to protect the resident's fragile skin. A plastic surgery consult, dated 9/12/18, included their assessment and wound care instructions to be done daily. Physician orders, dated 9/20/18, included a new daily treatment order to the left lateral knee wound, with instructions to document the description of the wound for every dressing change. The orders for the treatment was transcribed to the Treatment Administration Record (TAR). However, the instructions to document the description of the wound for every dressing change was not included on the TAR. A plastic surgery consult note, dated 9/26/18, included a description of the left lateral knee wound, which is now smaller in size, and a second wound on the left lower tibia. Instructions and orders, dated 9/26/18, include a daily dressing change to that area. The next plastic surgery consult note, dated 10/10/18, included the left lateral knee wound was healed, and they did not assess the left lower tibia wound as a [MEDICAL CONDITION] wrap was in place. Review of progress notes, from 9/20/18 through 10/10/18, revealed that there was no documentation of the appearance of these wounds. When observed on 3/13/19 at 10:23 a.m., the resident had a healing right ankle wound and no [MEDICAL CONDITION] in the legs. During an interview on 3/12/19 at 1:43 p.m., the charge Licensed Practical Nurse said the wounds on the resident's left leg were vascular and it was difficult to tell when all the resident's wounds developed and progressed. When interviewed on 3/13/19 at 1:51 p.m., the Assistant Director of Nursing said that the notes should show how the wounds developed, progressed, healed, and staff should be following the physician orders. (10 NYCRR 415.11(c)(2)(ii))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 602) completed on 4/9/18, it was determined that for one (Resident #1) of three residents reviewed for professional standards, the facility did not provide services consistent with professional standards of quality. Specifically, the care plan for the resident's transfer status was not clearly written to ensure staff understood the proper transfer status. This is evidenced by the following: Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/30/18, revealed the resident had severely impaired cognition and required extensive assistance for transfers. The Comprehensive Care Plan (CCP), dated 1/19/18, included a one person assist and a stand pivot transfer for all transfers. The resident's Certified Nursing Assistant (CNA) Care Card and assignment sheet, effective on 2/20/18, included under ambulation, transfer, bed mobility and weight bearing, one assist for stand pivot transfer. The CNA Care Card also included under toileting, one assist stand aid (mechanical lift) to commode and/or bathroom. The Nursing Home Resident Rehab Grid, dated 2/16/18, included under transfer status, one assist stand pivot transfer and one assist with stand aid for toileting assistance. The Incident Report, dated 2/20/18, revealed that the Nurse Manager (NM) was called to the common bathroom at 8:15 a.m. for help. When she arrived the resident was laying on the floor with her right leg resting on the toilet seat. The Incident Follow-up Report, dated 2/22/18, concluded that the CNA assisted the resident to stand from the toilet and hold the grab bar in the bathroom. The resident was unable to maintain standing and was assisted to the floor. Interviews conducted on 4/9/18 included the following: a. At 12:15 p.m., CNA #1 stated that on 2/20/18 she attempted to one assist stand pivot transfer the resident from the toilet to her wheelchair. The resident's right knee gave out and the resident was guided to the floor. CNA #1 stated that the NM checked the care plan which included stand aid to commode and stand pivot transfer from the wheelchair to bed. Upon reviewing the Care Card, CNA #1 stated that for transfer status, the resident was a one assist stand pivot transfer with slide board, and for toileting the resident was a one assist stand aid for the son and daughter-in-law, and she did not know if that was for the CNAs. CNA #1 stated that the CNAs code for transfer is a T, and, under the resident's T it says one assist stand pivot transfer. CNA #1 stated that she did not see one assist stand aid on 2/20/18 because it was under Activities of Daily Living and it should be documented under transfers. b. At 1:00 p.m., the Assistand Director of Nursing (ADON) reviewed the CNA Care Card, dated 2/20/18, and stated that the care was confusing and would be clearer if the toileting piece was with the transfer piece. The ADON stated that it does indicate toilet only - stand aid - for son and daughter-in-law, but should be stand aid for toileting. When reread, the ADON stated that the Care Card directions should be the same, and it was unclear if the stand aid was for toileting and transfers or just toileting. The ADON stated that she thinks that the stand aid was used for getting the resident on and off the toilet, and the resident transferred with a one assist stand pivot and a slide board. The ADON said that the care plan was confusing. c. At 2:00 p.m., the Director of Nursing (DON) stated that she felt that the care card was clear (one assist with stand aid for toileting). The DON said she would understand if it was not clear to someone else. d. At 2:10 p.m., upon reviewing the resident's transfer status on the 2/20/18 CNA Care Card, the NM stated that the resident should be a one assist stand pivot transfer off the toilet. The NM then stated that she did not understand the CNA Care Card as it was confusing for toileting. She said the stand aid should be documented under transfers. e. At 2:15 p.m., CNA #2 stated after viewing the resident's 2/20/18 CNA Care Card, that the resident was a one assist stand pivot with slide board. If the resident was on the toilet, the slide board was placed under her leg and the gait belt was used to move the resident across the board to the wheelchair. CNA #2 said that was how she transferred the resident, and she has had the resident almost every day since admission. When CNA #2 was directed to look under toileting on the CNA Care Card, CNA #2 said the stand aid was used first to get the resident into the chair. CNA #2 said the stand pivot with slide board was for the son and daughter-in-law only. CNA #2 stated that the care card did not seem right. She said the resident's transfer status should be documented under the transfer section on the CNA Care Card. f. At 2:30 p.m., CNA #3 stated, after reviewing the 2/20/18 CNA Care Card, that she would use one assist stand pivot with the slide board to transfer the resident off the toilet. After being referred to the toileting section on the Care Card, CNA #3 stated that the resident was a one assist with a stand aid. She said it should be documented under transfers. CNA #3 said that she probably would have missed the stand aid under toileting, but technically, the stand aid was for the CNAs and the son and daughter-in-law. g. At 3:15 p.m., the Physical Therapist stated that the resident's long term goal was to eventually be stand pivot transfer off the toilet, but the resident was not there yet, and the Occupational Therapist (OT) was focusing on toilet transfers. h. At 3:30 p.m., the OT stated that Occupational Therapy was working with the resident on stand pivot transfer to the toilet, but the care plan had not been changed yet. The OT said if the care plan changed, it would be documented on the transfer grid. The OT said the transfer grid still indicates one assist stand aid for toilet transfers. (10 NYCRR 415.11(c)(3)(i))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 6 of 28 residents reviewed for accuracy of the Minimum Data Set (MDS) Assessments, the facility did not accurately code the MDS Assessment to reflect the residents' status. The issues involved inaccurate coding for dental status (Residents #7 and #100), inaccurate coding for [MEDICAL TREATMENT] (Resident #122), inaccurate coding for a pressure ulcer (Resident #77), and the lack of a pain interview for a cognitively intact resident (Resident #70). This is evidenced by, but not limited to, the following: 1. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital Physician Discharge Note, dated 6/12/17, documented the resident's skin of the distal lower extremities had [DIAGNOSES REDACTED] (redness) with small bullous (blistering) [MEDICAL CONDITION]. The resident had been on an outing and returned with a sunburn. Review of the resident's Admission History and Physical, dated 6/13/17, revealed that a Nurse Practioner documented that the resident had suffered a severe sunburn of both lower extremities and local care for [MEDICAL CONDITION] be provided. The MDS Assessment, dated 6/20/17, revealed the resident currently had an unhealed pressure ulcer noted at the time of admission. During an interview on 10/27/17 at 12:56 p.m., Registered Nurse (RN)/MDS Coordinator #1 said she would review the physician's notes and skin sheets when completing the MDS Skin Section. RN/MDS Coordinator #1 said that based on the documentation the MDS Assessment was not coded accurately. 2. Resident #122 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The MDS Assessments, dated 5/15/17 and 7/26/17, did not include specialized services for [MEDICAL TREATMENT]. When interviewed on 10/27/17 at 11:19 a.m., the RN/MDS Coordinator #2 said the clinical leader for the unit was the one who completed the MDS Assessments and is no longer employed. She said [MEDICAL TREATMENT] was documented on the admission paper work. MDS Coordinator #2 said she did not know why [MEDICAL TREATMENT] was not coded on the MDS Assessments. 3. Resident #100 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Annual Assessment, dated 2/13/17, did not include any dental concerns. A Dental Consult, dated 5/26/17, revealed the resident's teeth were broken down and he complained all teeth hurt. The resident said he wanted them out but only by an oral surgeon. The only option would be to take him to the operating room at the hospital. The forms were submitted for an extraction evaluation. During an observation on 10/23/17 at 11:02 a.m., the resident had several broken and missing teeth. When interviewed on 10/25/17 at 10:38 a.m., the LPN MDS Coordinator said she codes the dental section of the MDS Assessment based on the Dental Consult Forms. She said she would read the current note and go back as needed to obtain all dental concerns. She said if the resident rejected care she would not perform an oral exam herself. She said if a resident had broken natural teeth or cavities during the Comprehensive MDS Assessment it should be coded. 4. Resident #70 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. During the resident interview on 10/23/17 at 11:00 a.m., the resident said that she always has pain, especially on her bottom. She said the staff give her medicine which helps. On the MDS Assessment, dated 7/25/17, Section C revealed that the resident scored a 15/15 on the Brief Interview Mental Status which means the resident could answer all the questions accurately and is cognitively intact. On Section J Health Conditions (J0200), should the staff assessment for pain be conducted?, the code entered was zero meaning do not interview as the resident is rarely/never understood. When interviewed on 10/26/17 at 12:00 p.m., the RN said that the facility should have conducted a pain interview/assessment. (10 NYCRR 415.11(b))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents # 54 and #47) of four residents reviewed for choices, the facility did not provide services in accordance with the written plan of care. The issue involved a lack of showers per care plan. This is evidenced by the following: 1. Resident #54 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and required the assist of one staff for bathing. The current Evening Certified Nursing Assistant (CNA) Care Card/Assignment Sheet revealed the resident was care planned for a shower on Sunday and Wednesday evenings. Review of the Progress Notes from 8/21/17 through 10/26/17 revealed one note, dated 8/23/17, that documented the resident refused her shower. The Evening Assignment Sheets, dated 10/1/17, 10/4/17, 10/8/17,10/22/17 and 10/25/17, revealed documentation on 10/25/17 that the resident refused a shower. The Routine Bath/Shower/Bed Bath and Body Skin Check Form instructed staff to complete the form upon completion of bath, shower, or bed bath. The resident's October 2017 forms revealed the form was completed two (10/10/17 and 10/18/17) out of eight opportunities. The form, dated 10/18/17, documented the resident refused a shower and received a complete body wash. When interviewed on 10/24/17 at 11:28 a.m., the family representative stated the resident received one shower a week and they preferred twice a week. The family representative stated the resident's past preference was two to three showers per week. Interviews conducted on 10/26/17 included the following: a. At 10:10 a.m., CNA #1 stated the resident received two showers a week on Sunday and Wednesday. She said that the information was documented on the Assignment Sheet. The CNA stated after a shower/bath is completed then a Bath/Shower Form is filled out to document that a shower was completed. b. At 1:39 p.m., a Registered Nurse Manger (RNM) stated showers are documented as completed by filling out a Bath/Shower Form for the resident. The RNM stated when a resident refuses a bath or shower, it should be documented in the Progress Notes. She stated if there is no documentation then there is no proof the shower was provided. c. At 2:20 p.m., CNA #2 stated a completed Bath/Shower Form means the resident received a bath or shower. He said if a Bath/Shower Form was not completed the shower was not done. d. At 2:48 p.m., the Director of Nursing (DON) stated the Bath/Shower Form is completed after the resident's bath/shower was given. The DON stated that when a resident refuses a shower or bath, it should be documented in the Progress Notes and passed on in report so the shower can be rescheduled. e. At 3:51 p.m., a Licensed Practical Nurse (LPN) stated that staff should report if a resident refuses a shower, then she would document that information in the Progress Notes. 2. Resident #47 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A MDS Assessment, dated 8/7/17, revealed the resident was cognitively intact. The current Care Card documented that the resident was care planned for showers on Tuesdays and Fridays. Review of the medical record and the Shower Book for September 2017 and October 2017 revealed that the resident was not showered. When interviewed on 10/23/17 at 1:08 p.m., the resident said that he would like to shower more often. The resident said he would like a shower at least once a week but two would be better. He said he used to take showers at home. Interviews conducted on 10/26/17 included the following: a. At 10:45 a.m., CNA #3 said the resident does not get a shower because his legs are wrapped and he cannot get them wet. At that time, the LPN stated that the wound clinic informed the staff that he cannot get a shower because his dressing must stay dry and intact. b. At 11:15 a.m., the Registered Nurse Manager (RNM) said there are no restrictions from the wound clinic regarding showers. She said that staff would just cover the resident's legs with bags and give him a shower. The RNM said she told staff that the resident could be showered. The RNM was unable to find documentation that the resident was showered. (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 (dementia unit) of five residential units reviewed for medication storage, the facility did not provide safe and secure storage of medications. Specifically, medications were left unattended at Resident #12's bedside. This is evidenced by the following: Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/17/17, revealed the resident was severely cognitively impaired. Review of the facility policy, Medication Record and Administration, dated April 2017, directed do not leave medications at the bedside. During an observation on 10/24/17 at 10:59 a.m., the resident was in bed positioned on her right side facing away from the door. A white paper soufflé cup was observed on the bedside table and contained two red gel capsules, a large white pill and five other pills (one brown, one yellowish and two white in color). When interviewed at that time, the Licensed Practical Nurse (LPN) stated the resident was sitting up on the side of the bed to take the medications when he was in the room. The LPN said he should not have left the room until the resident swallowed the medications. The LPN stated the medications in the cup included Isosorbide (nitrate used to prevent angina) and Risperdal (antipsychotic). The LPN said the medications should not have been left at the bedside. During an interview on 10/26/17 at 1:53 p.m., a Registered Nurse Manager stated she would expect the nurses to remain with the resident until the medications are swallowed. She stated medications should not be left at the bedside unless a resident has an order to self-medicate. She said none of the residents on the dementia unit self-medicate. (10 NYCRR 415.18(e)(1-4))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #10 and #22) of three residents reviewed for resident rights, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries to notify them of their appeal rights under the regulations. Specifically, the facility did not provide the beneficiary with a Medicare Non-Coverage letter prior to discharge home. This is evidenced by the following: Resident #10 was admitted to the facility for rehabilitation on 4/26/17 and discharged home on[DATE] with Medicare Part A coverage days remaining. There was no evidence that a Medicare Non-coverage letter was provided with the appropriate liability and appeals notice prior to discharge in order to notify them of their appeals rights under the regulations. Resident #21 was admitted to the facility for rehabilitation on 6/8/17 and discharged home on[DATE] with Medicare Part A coverage days remaining. There was no evidence that a Medicare Non-coverage letter was provided with the appropriate liability and appeals notice prior to discharge in order to notify them of their appeals rights under the regulations. During an interview on10/24/17 at 3:36 p.m., the Minimum Data Set Assessment Coordinator said she was not aware that residents were supposed to receive the Medicare Non-Coverage letter when they were discharged home and had Medicare covered days remaining. (10 NYCRR 415.3(g)(2)(i))