Every finding on record at Conesus Lake Nursing Home, LLC

Based on observation, interviews, and record review conducted during a Recertification Survey from 04/17/2025 to 04/23/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for two (2) (Residents #12 and #25) of eight (8) residents reviewed. Specifically, Resident #12 received wound care by staff who were not wearing the appropriate personal protective equipment (PPE- equipment such as gown, gloves and/or facemask worn to minimize exposure to infectious diseases). Resident #25 received an insulin injection by a staff member who was not wearing gloves and did not perform hand hygiene before or after the injection. The findings include: The facility's Infection Control Policy dated May 2024, documented that the facility will adhere to infection control standards including the practice of proper hand washing and glove usage. Gloves should be changed between residents and hand hygiene must be completed when gloves are removed. Gowns are to be worn when there is the potential for transmission of microorganisms and enhanced barrier precautions (interventions designed to reduce transmission of multidrug-resistant organisms) are indicated for a resident that has wounds or any skin openings. 1.Resident #25 had diagnoses that included diabetes, chronic kidney disease, and dementia. The Minimum Data Set (a resident assessment tool) dated 04/13/2025 documented Resident #25 was severely impaired cognitively and required insulin injections to manage their diabetes. Review of the Comprehensive Care Plan dated 11/20/2024 revealed Resident #25 was on bleeding precautions due to taking an anticoagulant (blood thinner) medication. Review of the physician order dated 10/16/2024, revealed Novolog (insulin) 10 units to be injected subcutaneously (into fatty tissue) with meals. During an observation and interview on 04/18/2025 at 1:29 PM, Licensed Practical Nurse #1 prepared Resident #25's insulin injection pen without washing their hands and then administered the insulin injection into the resident's right arm without applying gloves. Licensed Practical Nurse #1 did not wash their hands after administering the injection before exiting the room. In an immediate interview Licensed Practical Nurse #1 said they read online that they did not have to wear gloves when giving an injection with an insulin pen. During an interview on 04/18/2025 at 2:19 PM, the Administrator (acting Infection Preventionist at the time) stated their infection control policy was clear, and that nurses should wear gloves when giving an injection regardless of if the insulin was being administered with an insulin pen or not. 2.Resident #12 had diagnoses that included diabetes, dementia, and adult failure to thrive. The Minimum Data Set, dated dated dated [DATE] documented Resident #12 had moderately impaired cognitive skills and had lesions (skin wounds) on the foot that required dressings. Review of the Comprehensive Care Plan and Care Card (care plan used by Certified Nursing Assistants for daily care) initiated on 10/28/2024 and reviewed on 02/06/2025 revealed Resident #12 was at risk for pressure ulcers. Neither care plan included that the resident had open wounds on their feet or if they required enhanced barrier precautions while receiving dressing changes. Review of current physician orders on 04/17/2025 revealed for staff to clean the left ankle wounds, apply bacitracin ointment (an ointment used to prevent infection), xeroform (a moist dressing treatment) and cover with a telfa pad (a dressing that will not stick to wounds) every day starting on 03/26/2025. There were no orders for enhanced barrier precautions. In a physician progress note dated 03/03/2025 the physician documented Resident #12 continued to have a dressing in place on the left leg (wounds). In an observation on 04/21/2024 at 9:51 AM, Registered Nurse Manager #1, wearing gloves but no gown changed the dressing to Resident #12 left ankle wound. There was no sign on Resident #12's door or in their room that indicated enhanced barrier precautions were required for direct contact care. In an interview on 04/21/2025 at 2:31 PM, Registered Nurse Manager #1 stated that enhanced barrier precautions should be used for a chronic or draining wound, but they had not worn a gown when doing wound care for Resident #12 because their wound was not draining. Review of Resident #12's revised Comprehensive Care Plan dated 04/21/2025 revealed Resident #12 had a blister on the left ankle that was not intact and the resident was on enhanced barrier precautions. In an observation on 04/22/2025 at 8:50 AM, Resident #12 had a sign on the door that indicated enhanced barrier precautions including a gown and gloves should be worn when providing high contact care activities including dressing, bathing, showering, transferring, providing hygiene, and wound care. In an observation on 04/22/2025 at 8:55 AM, Certified Nursing Assistant #1 and Certified Nursing Assistant #2 wearing gloves and no gowns assisted Resident #12 to transfer from bed using a stand lift (a mechanical lift that assists the resident to stand and transfer) to a shower chair, including touching the resident's visibly soiled incontinence brief. In an interview on 04/22/2025 at 9:05 AM, Certified Nursing Assistant #1 stated they did not notice the sign for enhanced barrier precautions for Resident #12 and should have worn a gown when transferring the resident. In an interview on 04/21/2025 at 2:55 PM, the Director of Nursing stated Resident #12's left ankle blister had opened a few months ago and the resident should have been on enhanced barrier precautions. 10 NYCRR 415.19(a) (1-3) (b)(4) 49686

Based on observations, interviews and record reviews conducted during a Recertification Survey from 04/17/2025 to 04/23/2025, for one (1) (Resident #15) of one (1) resident reviewed, the facility did not ensure the resident's physician was notified immediately when there was a need to alter treatment significantly (discontinuing an existing form of treatment due to adverse consequences). Specifically, Resident #15 had complained of nostril pain while receiving a prescribed nasal spray four times daily and refused the medication repeatedly. There was no documented evidence that the physician or medical team was notified. The finding includes: The facility policy Change in a Resident's Condition or Status, dated March 2024, included the facility shall promptly notify the resident, their Attending Physician, and representative of changes in the resident's medical condition and/or status (e.g., changes in level of care). The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been a change in the resident's medical condition requiring a change in their plan of care. Resident #15 had diagnoses that included chronic obstructive pulmonary disease, chronic respiratory failure with dependence on oxygen, and heart failure. The Minimum Data Set (a resident assessment tool) dated 03/03/2025 included the resident had moderately impaired cognition, was able to make themself understood and understood others, and did not exhibit behaviors. The Comprehensive Care Plan revised on 12/21/2024 included Resident #15 had chronic obstructive pulmonary disease and was to receive medications and oxygen per medical provider order. Review of Physician orders dated 03/18/2025 revealed deep sea 0.65% nose spray two sprays in both nostrils four times a day for dryness. Review of Resident #15's Medication Administration Record from 04/19/2025 to 04/23/2025 revealed Resident #15 had refused the nose spray on 7 of 17 opportunities. In a nursing progress note dated 04/17/2025, Registered Nurse Manager #3 documented Resident #15 had complained of pain to their left nostril, it was observed to be swollen, and Registered Nurse Manager #3 would notify the Nurse Practitioner. In a nursing progress note dated 04/22/2025, Licensed Practical Nurse #2 documented Resident #15 refused their nasal spray and was angry. There was no documented evidence that anyone had notified the physician or the medical team of Resident #15's complaints of pain and swelling to the left nostril, or repeated refusals of the medication. During medication administration observation on 04/21/2025 at 10:58 AM, Licensed Practical Nurse #2 entered Resident #15's room to administer their nose spray. The resident told Licensed Practical Nurse #2 the oxygen was hurting their nose, and it felt dry even with the nose spray and oxygen humidification. Licensed Practical Nurse #2 told the resident it was possible a sore in their nose was causing the pain, and they would speak to the doctor about discontinuing the nose spray. Licensed Practical Nurse #2 encouraged Resident #15 to accept the nose spray and proceeded to administer while the resident complained with each spray and required breaks in between. During a medication administration observation on 04/22/2025 at 11:04 AM, Licensed Practical Nurse #2 entered Resident #15's room to administer the nasal spray and the resident refused the medication. Resident #15 told Licensed Practical Nurse #2 the medication was not helping, it hurt their nose, and although the resident had been telling nurses the medication was causing them pain, they continued to offer it. Resident #15 said they refused the medication often and the soreness was getting worse. During an interview on 04/22/2025 at 4:23 PM, Resident #15 said the left side of their nose was sore to the touch. The resident said they had been telling the nurses that it hurt, and they did not want the medication. Resident #15 said they did not feel they needed the nose spray because it seemed to be causing more dryness to their nose and would have thought by now, someone would have told the doctor. During an interview on 04/23/2025 at 9:40 AM, the Director of Nursing said when the medical provider was not in-house, they communicated their concerns by phone. Review of the medical provider's communication book at the time revealed no documented evidence that the medical team had been notified of Resident #15 concerns or refusals of the medication. During a follow up interview on 04/23/2025 at 10:53 AM, the Director of Nursing said they first heard about Resident #15's complaints of nose pain on 04/17/2025 when the resident told Registered Nurse Manager #3. The Director of Nursing said they had reviewed the progress notes and could not find documented evidence that the nurses had communicated the resident's complaints of pain to the Nurse Practitioner prior to today. The Director of Nursing said nursing staff should report complaints of pain to the medical provider right away and Resident #15's complaints should have been reported on 04/17/2025 when first discovered. 10 NYCRR 415.3 (2)(ii)(c)

Based on observations, interviews, and record review conducted during a Recertification Survey from 04/17/2025 to 04/23/2025, for two (2) (Resident #33 and Resident #36) of eight (8) residents reviewed, the facility did not ensure a medication error rate of five percent or less. There were two (2) medication errors for 25 opportunities resulting in a medication error rate of eight (8) percent. Specifically, during an observation of medication administration Resident #33 and Resident #36 were administered the incorrect medication. The findings are: The facility's policy Administering Medications, revised April 2019, documented that the individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1.Resident #36 had diagnoses that included constipation, chronic pain syndrome, and abdominal pain. The Minimum Data Set (a resident assessment tool) dated 03/09/2025, documented the resident was severely impaired cognitively. Resident #36's active physician's orders as of 04/22/2025 documented senna (a laxative) 8.6 milligram-give two tablets orally once daily. During an observation of medication administration on 04/18/2025 at 9:26 AM, Registered Nurse Manager #1 administered two tablets of Senna Plus 8.6-50 milligrams (a laxative plus a stool softener) to Resident #36. 2.Resident #33 had diagnoses that included constipation, chronic pain, and adult failure to thrive. The Minimum Data Set, dated dated dated [DATE], documented the resident was severely impaired cognitively. Resident #33's active physician's orders as of 04/22/2025 documented senna 8.6 milligram tablet- give one tablet orally once daily. During an observation of medication administration on 04/18/2025 at 9:36 AM, Registered Nurse Manager #1 administered one tablet of Senna Plus 8.6-50 milligrams to Resident #33. During an interview on 04/18/2025 at 12:15 PM, Registered Nurse Manager #1 stated they did not realize they had given both Resident #33 and Resident #36 Senna Plus (versus senna). Registered Nurse Manager #1 said they usually did not pass medications as they were the unit manager. Registered Nurse Manager #1 said the senna bottle was smaller than the Senna Plus bottle and the medications were given incorrectly. During an interview on 04/22/2025 at 11:36 AM, the Director of Nursing said that although the unit manager was not usually on a medication cart, they had been trained to pass medications. The Director of Nursing said the nurse should perform the five rights before giving medications and had the nurse checked, they would not have given the wrong medication to either resident. 10 NYCRR 415.12(m)(1)

Based on interviews and record review conducted during the Recertification Survey from 04/14/2025 to 04/18/2025, for one (1) (Resident #40) of one (1) resident reviewed the facility did not provide the appropriate liability and appeal notice to a Medicare beneficiary. Specifically, Resident #40 was discharged and there was no documented evidence the facility provided the resident and/or their representative with a Notice of Medicare Noncoverage (NOMNC) letter explaining their termination of Medicare A benefits and appeal rights as required by the regulations. This is evidenced by the following: Resident #40 was admitted to the facility on [DATE] under Medicare Part A benefits and discharged from the facility with days remaining on 01/31/2025. The facility was unable to provide documented evidence that a Notice of Medicare Noncoverage letter was provided to the resident or their representative following discharge from Medicare Part A services. During an interview on 04/22/2025 at 12:19 PM, Administrator said Resident #40 voluntarily left the facility and went home, and the Notice of Medicare Non-Coverage was not provided to resident because facility staff thought the discharge was planned and the liability notice was not required. In a follow up interview at 2:52 PM, the Administrator stated Social Work usually handles beneficiary notices but was unavailable for interview. They stated the interdisciplinary team normally met to discuss transfers or discharges, and beneficiary notice distribution depends on whether a transfer or discharge is planned or unplanned, if the resident went home, stayed at the facility, went to another facility, and if benefits were depleted or not. The Administrator stated staff tend to get confused on whether transfers and discharges are planned or unplanned. 10 NYCRR 415.3(g)(2)(i-iii)

Based on observation, interview, and record review conducted during a Recertification Survey conducted 11/27/23 to 12/1/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one kitchen had unclean appliances and all units had foods either unlabeled, undated, or outdated. The findings are: Review of the undated facility policy and procedure (P&P) Food Storage documented sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Foods will be stored in an area that is dry, clean, and free from contaminants. All refrigerator and freezer units should be kept clean and in good working condition. Review of the undated P&P General Cleaning of the Kitchen documented food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. Frequency of cleaning for each task will be defined and assigned to be the responsibility of specific positions. Observations on 11/28/23 at 9:01 AM through 9:30 AM during the initial walk through of the main kitchen, dry storage room and the refrigerator/freezer units in the basement revealed the following: - approximately 20 frozen sausage patties in an opened bag, undated in the dry storeroom freezer. - approximately 10 frozen uncooked cookie dough balls in a blue opened bag, undated in the dry storeroom freezer. - open box of store brand waffles, undated in the dry storeroom freezer. - small square pan of four uncovered eggs undated and unlabeled in the dry storage room refrigerator. -covered egg salad sandwich on a disposable plate undated in the dry storage room refrigerator. - opened bag of mixed vegetables undated in the dry storage room refrigerator. - one gallon plastic bottle of Worchester [NAME] opened and dated 7/15/22 on the dry storage room shelf. - one dented can of beets on the dry storage room shelf. - one opened bag of frozen chicken patties undated in the basement freezer. - the stove in the main kitchen had dried greasy stains flowing down the front and sides. During an interview on 11/28/23 at 9:31 AM the Food Service Director (FSD) stated they were unsure when any of the opened undated, unlabeled food items found in the refrigerator and freezer units were opened and should be dated. The FSD stated the kitchen gets cleaned daily by staff and that there was a daily cleaning list to follow. Observations on 11/29/23 at 8:40 AM revealed the exterior of the refrigerator and freezer units in basement and dried storage room were greasy and dirty. An observation on 11/30/23 at 11:32 AM revealed the stove in the main kitchen had dried greasy stains flowing down the front and sides. Review or the dietary Weekly Cleaning Assignments dated 11/26/23-12/2/23 documented as follows: - The big refrigerator in the basement is cleaned on Sunday morning by the morning cook. - The freezer in the basement is cleaned on Saturday by the morning cook. - The refrigerator in the stock room (dry storage room) is cleaned on Sunday by the evening cook. - The freezer in the stock room is cleaned on Wednesday by the evening cook. - The right oven is cleaned on Monday by the evening cook. - The left oven is cleaned on Thursday by the evening cook. During an interview on 11/30/23 at 1:06 PM Dietary Aide (DA) #1 stated some parts of the kitchen get cleaned every day like the floors and sinks, that all staff have an assigned area to clean and usually get it cleaned at the end of the shift if there was time. DA #1 stated there was a weekly list on the milk machine and the cleaning assignments change weekly. During an additional interview on 11/30/23 at 2:31 PM the FSD stated the kitchen staff have a daily cleaning assignment which should be initialed on the weekly cleaning assignment sheet when completed. Some areas are cleaned more [NAME] if staff have the time. The FSD said that assignments stay the same from week to week we just change the dates on the sheet. 415.14(h)

Based on interview and record review conducted during the Recertification Survey completed on 12/1/23, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries at the termination of Medicare coverage for two (Residents #16 and 39) of two residents reviewed. Specifically, the facility did not provide a Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN, form 10055) (Resident #16 and 39) and did not provide a Notice of Medicare Noncoverage (NOMNC, form 10123) (Resident #39) to the resident and/or their responsible party (RP) until after surveyor intervention. The findings are: The CMS (Centers for Medicare & Medicaid Services) Form Instructions for the Notice of Medicare Non-Coverage CMS-10123 documented the NOMNC must be delivered at least two calendar days before Medicare covered services end. The CMS Form Instructions Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage CMS-10055 documented Medicare requires SNFs to issue the SNFABN to Original Medicare beneficiaries prior to providing care that Medicare usually covers but may not pay for in this instance because the care was not medically reasonable and necessary or considered custodial. The undated policy and procedure (P&P) Notice of Non-Coverage documented the purpose of the P&P was to ensure the correct forms are signed and/or documented appropriately per Medicare guidelines. 1.Resident #39 was admitted to the facility on [DATE] under Medicare Part A services. The NOMNC, dated 11/28/23, documented Medicare Part A services ended effective 11/21/23. The NOMNC was not provided to the resident and/or RP at least two calendar days before Medicare covered services ended. The Advance Beneficiary Notice of Non-coverage, CMS-R-131, dated 11/28/23, documented Medicare services ended effective 11/21/23. The SNF ABN (form 10055) was not provided to the resident and/or RP. Resident #39 remains in the facility receiving custodial care. 2. Resident #16 was readmitted to the facility on [DATE] under Medicare Part A Services. The ABN CMS-R-131 dated 9/27/23 documented Medicare services ended effective 9/29/23. The SNF ABN (form 10055) was not provided to the resident and/or RP. Resident #16 remains in the facility receiving custodial care. During an interview on 11/29/23 at 10:00 AM, the Administrator stated they issued the NOMNC and ABN for Resident #39 on 11/28/23, when they realized the notices had not been provided to the resident and/or RP prior to Medicare Part A services ending. Additionally, the Administrator stated CMS-R-131 was provided to both Resident #16 and 39, which was the incorrect form. 10 NYCRR 415.3(h)(2)(iii)

Based on record review and interview conducted during the Standard Recertification Survey completed on 12/29/21, it was determined that for one (Employee #3) of five employee files reviewed, 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 for an individual prior to hire. The findings are: On 12/28/21 at 1:36 p.m. the Surveyor reviewed documentation related to five recently hired employees. The files included that employee #3 was hired as the Activities Director on 9/30/21. The documentation provided did not include a nurse aide registry abuse screening for Employee #3. In an interview on 12/28/21 at 2:52 p.m. the Business Office Manager stated that Employee #3 was not screened for nurse aide registry abuse because the person who had been responsible for hiring the employee was unaware of the requirement to run the nurse aide registry abuse screening. Record review on 12/28/21 at 3:03 p.m. revealed the facility Abuse, Neglect, and Exploitation Prohibition, Training, Investigation, and Reporting Policy (section 3: Screening/Prevention - Registry) included that all staff being considered for hire must also be checked with the New York State Nurse Aide Registry for a history of findings. 10 NYCRR: 415.4(b)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #1 and #29) of three residents reviewed for abuse, the facility did not report an incident of resident-to-resident altercation to the State Survey Agency. This is evidenced by the following: Review of the facility policy and procedure, Abuse, Neglect, and Exploitation Prohibition, Training, Investigation, and Reporting, dated (MONTH) (YEAR), revealed that alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately to the facility Administrator and to other officials, including the New York State Department of Health. The facility must report the results of all investigations to the facility Administrator and to other officials, including the New York State Department of Health, within five working days of the incident. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/3/19, revealed the resident had moderately impaired cognition. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/1/19, revealed the resident had severely impaired cognition, experienced hallucinations and delusions, and had physical and verbal behavioral symptoms directed toward others. Review of an Incident and Accident Report, dated 8/3/19 8:10 p.m., included a resident-to-resident altercation. Resident #29 was being taken into her room at which time she lunged at Resident #1, grabbed her left wrist and started punching her left arm. Certified Nursing Assistants (CNAs) separated the two residents and called for the nurse to assist. The facility investigation, dated 9/5/19, included that both residents had advanced dementia, and Resident #29 was determined to be the aggressor. There were no injuries sustained as a result of the altercation, and when interviewed neither resident recalled the incident. The final determination was that the altercation was an isolated incident with no harm. During several observations over the course of the survey, both residents appeared calm, were not agitated, and had no obvious behaviors. When interviewed on 9/13/19 at 11:12 a.m., the Director of Nursing (DON) stated that she notified the Administrator when the incident occurred. After further discussion with the Administrator and Social Worker, it was determined that it was an isolated incident and there was no harm. The DON said the facility made the decision not to report the incident to the State Survey Agency. When interviewed on 9/13/19 at 11:59 a.m., the Administrator stated that all Incident and Accident Reports are discussed daily during the interdisciplinary team morning meeting. She said the DON informed her of the incident when it occurred. She said it was unusual for Resident #29 to be aggressive toward another resident, but she could be combative toward staff during cares. The Administrator said she looked at the incident as an isolated situation. She said the incident was not reported to the State Survey Agency because it was the first incident involving another resident, there was no reoccurrence, and there was no significant harm as a result. She said based on reporting guidelines, the incident should have been reported. (10 NYCRR 415.4(b)(2)(4))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of two residents reviewed for aspiration precautions, the facility did not provide adequate supervision to prevent potential accidents. Specifically, Resident #39 was on aspiration precautions and was left unsupervised with food or liquids. This is evidenced by the following: Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/28/19, revealed that the resident was cognitively intact, had no swallowing issues and no natural teeth, was on a mechanically altered diet, and was independent with eating after set up help only. The facility policy, Aspiration Precautions Protocol, dated (MONTH) (YEAR), included that a resident on aspiration precautions may not be left unsupervised with food or liquids. Note: Administrator approval and physician order [REDACTED]. Physicians orders, dated 8/21/19, included a Regular CAT (consistency as tolerated-pureed) diet, nectar thickened liquids, aspiration precautions, and the resident to wear splint or cervical collar at all times. The Speech Therapist Rehab Recommendations to Nursing, dated 8/21/19, included the resident was on a pureed diet/nectar liquids, aspiration precautions, and it was ok to use a straw. The resident should be upright for all oral intake, and instructed to encourage small bites and sips at slow rate, and frequent sips with meal. Encourage the resident to be elevated for 30 minutes after meals and do not lay flat at rest. The Baseline Care Plan and Care Card, dated 8/22/19, included that the resident can eat independently after set up, and was on aspiration precautions with instructions to encourage small bites, sips of liquid at a slow rate, and may have a straw. The Nutritional Assessment, dated 8/28/19, included the resident was on a regular CAT soft diet with nectar thickened liquids. While in the hospital the resident was on a tube feeding due to dysphagia, and currently was eating pureed and ground foods. During an observation on 9/9/19 at 8:38 a.m., the resident was sitting up in bed and had just finished breakfast in bed. When observed on 9/12/19 at 8:40 a.m., the resident was eating breakfast in bed. She did not eat her pureed waffles or sausage but drank her milkshake and ate her yogurt. When interviewed at that time, the resident said that lately the staff have been leaving her in bed for breakfast. She said that she used to eat breakfast in the dining room. She said the Certified Nursing Assistants (CNAs) do not sit with her when she eats in her room. Interviews conducted on 9/12/19 included the following: a. At 9:19 a.m. and on 9/13/19 at 9:57 a.m., the CNA said that the resident usually eats breakfast in bed and staff try to get her up for lunch. The CNA said she did the wrong thing, the resident should have got out of bed for breakfast. b. At 10:12 a.m., the Licensed Practical Nurse said that the resident was on aspiration precautions. She said the resident cannot lay down for 30 minutes after eating, and staff are supposed to be in the room with her to monitor her when eating. During an interview on 9/13/19 at 11:00 a.m., the Registered Dietician said that the resident should have meals in the dining room or under supervision. She said the Speech Therapist recommendations should be followed. When interviewed on 9/13/19 at 12:30 p.m., the Director of Nursing said that the resident should be supervised with meals. (10 NYCRR 415.12(h)(2))

Based on observations, interview, and record reviews conducted during the Recertification Survey, the facility did not post daily staffing information for licensed and unlicensed nursing staff directly responsible for resident care. Specifically, the facility staffing sheets did not include the total number and actual hours worked by staff and was not posted at the beginning of each shift. This is evidenced by the following: 1. Observations of the posted staffing information included the following: a. On 9/9/19 at 11:14 a.m., the day shift staffing was blank for the total number of staff and actual hours worked by staff. b. On 9/10/19 at 2:00 p.m., the staffing information for the day shift and evening shift on 9/10/19 was blank. The information was completed after the observation. c. On 9/11/19 at 9:02 a.m., the night shift staffing information included the actual hours worked. The day shift on 9/11/19 was blank. At 2:31 p.m., staffing information for the day shift and evening shift was blank. 2. A review of the daily staffing sheets on 9/11/19 at 3:09 p.m., for the dates 9/7/19 through 9/11/19, revealed the following: a. On 9/7/19, staffing information for the day shift was blank b. On 9/8/19, staffing information was blank for the day shift and evening shift. c. On 9/11/19, staffing information for the day shift and evening shift was blank. When interviewed on 9/12/19 at 2:02 p.m., the Director of Nursing (DON) stated that nurse staffing should be completed by the Nurse Manager or Charge Nurse as close to the start of the shift as possible. She said it was her responsibility to ensure the posted staffing was complete in their absence. When interviewed on 9/13/19 at 11:59 a.m., the Administrator stated that the process for the posted nurse staffing had been corrected following the previous Recertification Survey. She said it was the responsibility of the Nurse Manager, or the DON in her absence, to complete the nurse staffing at the beginning of each shift.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #24) of five residents reviewed for unnecessary medications, the facility did not develop and implement a plan of care for each resident that included measurable objectives and interventions to address the resident's medical, nursing, mental and psychosocial needs. The issue involved the lack of targeted behaviors and specific non-pharmacological interventions for the continued use of an antipsychotic medication. This is evidenced by the following: Resident #24 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/30/18, revealed the resident had severely impaired cognition, delusions, verbal behaviors and received an antipsychotic. The Nursing Admission Assessment, dated 7/24/17, revealed the resident had a history of [REDACTED]. The Certified Nursing Assistant (CNA) Care Plan, dated 7/24/17, did not include behaviors. The Psychoactive Medication Review, dated 1/26/18, revealed the resident had a long history of paranoia, hallucinations, and delusions that increased with any changes in her environment. Physician orders, dated 4/9/18, included [MEDICATION NAME] (an antipsychotic) 7.5 milligrams (mg) every day for [MEDICAL CONDITION]. The Psychoactive Medication Review, dated 4/13/18, revealed the resident continued to be distressed at times with hallucinations and delusions. The resident's distress had decreased since the increase of the [MEDICATION NAME] on 3/22/18. The current Comprehensive Care Plan (CCP) revealed the resident's risk for adverse effects related to [MEDICAL CONDITION] drug use, an alteration in cognition related to confusion with delusions and a self-care deficit related to anxiety. The CCP did not address targeted behaviors for the use of an antipsychotic, measurable goals and or non-pharmacological person-centered approaches. The current Social Work (SW) plan of care identified the resident's cognitive deficit, behaviors at home, and hallucinations and delusions reported by the family. During intermittent observations on 5/9/18 between 9:00 a.m. and 12:30 p.m., on 5/10/18 between 8:50 a.m. and 12:05 p.m., and on 5/11/18 at 8:21 a.m., the resident was up and down ambulating independently in her room, sitting in a chair in her room, and eating lunch in the dining room. On 5/11/18 at 10:10 a.m., the resident was in her room crying and stated they are so mean to me. She stated she was going to see someone and was told to get back in her room and the door was shut in her face. The door to the resident's room had been observed opened. When interviewed on 5/10/18 at 1:51 p.m., the CNA stated the resident had paranoid behaviors at times and did not like sharing a room. The CNA stated the resident is anxious and when she gets nervous, she yells at the staff. Interviews conducted on 5/11/18 included the following: a. At 11:09 a.m., the SW stated the CCP is developed as a team. The SW stated the resident was anxious and she was in the process of developing the resident's behavior plan. The SW stated the resident's behaviors had not been an issue till recently. She stated the CNAs work with the resident like any other resident. The SW stated change was hard for the resident and she did not like having a roommate. The SW stated she could not say what interventions had been implemented to address the resident's issue with a roommate. b. At 12:14 p.m., the Registered Nurse Manager (RNM) stated the resident was paranoid and had hallucinations. The RNM stated the resident's behaviors increased when she got a new roommate. She stated the resident would get anxious and accuse the roommate of stealing her belongings. The RNM stated the resident had a behavior plan. After reviewing the medical record, the RNM stated that the resident did not have a behavior care plan. The RNM stated the resident had a long standing psychiatric history and it should be addressed on her CCP. c. At 1:50 p.m., the Director of Nursing stated the SW initiates a specific behavior plan of care with nursing and activities involvement. She stated a copy of the behavior plan is kept in a book at the nurses' desk. (10 NYCRR 415.11(c)(1))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #15) of one resident reviewed for Range of Motion (ROM), the facility did not ensure residents received appropriate treatment and services to increase ROM and/or prevent further decrease in ROM. Specifically, the resident did not have washcloths placed in her hand and was not ambulated per plan of care. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/7/18, revealed the resident had severely impaired cognition, ambulated in the corridor with the extensive assistance of two staff members, and had no functional limitations in ROM of the upper extremities which included the hands. The Certified Nursing Assistance (CNA) Resident Care Plan, dated 9/27/16, revealed the resident ambulated, held hand, with the assistance of two staff, with wheelchair to follow and directed rolled washcloths to be placed in both hands after hand and nail care. The Care Plan was updated 2/7/17 and included Passive ROM to the upper and lower extremities daily with care. Review of the CNA Activities of Daily Living Tracking Form, dated (MONTH) (YEAR), revealed from 5/4/18 through 5/6/18, and 5/10/18, ambulation in the corridor was blank. It was documented from 5/7/18 through 5/9/18 that ambulation in the corridor did not occur. An Occupational Therapy (OT) Screen, dated 8/24/17, revealed that the resident's bilateral fingers could be opened with Passive ROM and were within full limits. An OT Evaluation, completed 5/11/18, revealed the resident was referred by nursing due to hand stiffness. The OT documented that the resident had significant stiffness of the metacarpophalangeal (MP) joint (or knuckles) on both hands. The resident had ROM of 10 degrees in digits 2-5, and the plan was to further assess the stiffness and recommend appropriate splinting/positioning and determine ROM/contractures. The resident does resist with all movement. When observed on 5/9/18 at 10:43 a.m., the resident's right hand was closed tightly and there was no device in place. During observations on 5/10/18 at 8:47 a.m. and 11:26 a.m., the resident held both hands closed tightly with finger tips to the palms of the hands. The resident's hands could be opened slightly and there were no washcloths in place. When observed on 5/11/18 at 8:24 a.m. and 11:34 a.m., the resident did not have washcloths in either hand. The resident was not observed ambulating throughout the day from 5/9/18 through 5/11/18. Interviews conducted on 5/11/18 included the following: a. At 10:19 a.m., the CNA stated the resident did not participate in cares and she performed ROM on the resident's hands with cares. The CNA said she opened the resident's fingers as far as she could. b. At 11:34 a.m., the Licensed Practical Nurse (LPN) stated the resident did not participate in cares and she did not think the resident had contractures. The LPN said the resident should have washcloths in both hands. The LPN said the resident was supposed to be ambulated, and if it was not done it should be reported to the nurse. She said no one had reported to her that the resident did not ambulate. c. At 11:45 a.m., the OT stated annual screens are completed on all residents to evaluate for contractures. He stated the resident's last screen was 8/24/17 and at that time there were no contractures. The OT completed an evaluation of the resident's hands on 5/11/18 and stated the resident had a change since the last evaluation. The OT stated he had tested the resident with resistance, finding increased bilateral MP joint stiffness. The OT stated the resident would be picked up for treatment and further assessment of ROM and splinting. d. At 12:06 p.m., the Registered Nurse Manager stated that she and the nurses do rounds, spot checking to ensure the resident's care plans are being followed. She said that staff should report if a resident does not ambulate so that a referral can be sent to therapy. (10 NYCRR 415.12(e)(1-2))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #34) of one resident reviewed for respiratory care, the facility did not provide care consistent with professional standards of practice, the Comprehensive Care Plan (CCP), and the resident's goals and preferences. Specifically, the resident was on oxygen without physician orders [REDACTED]. This is evidenced by the following: Resident #34 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/18/18, revealed the resident had severely impaired cognition and oxygen therapy was provided. The Cardiologist Progress Note, dated 3/21/18, revealed the resident's oxygen saturation level was 86 percent on room air and recommended the resident use oxygen 2 liters continuously. A Nursing Progress Note, dated 3/21/18, revealed the resident returned from a doctor's office with new orders for oxygen at 2 liters continuously. A review of the physician orders, dated 3/21/18, did not include the oxygen therapy. The physician progress notes [REDACTED]. Review of the (MONTH) (YEAR) Respiratory Medication Administration Record [REDACTED]. The oxygen was not signed off as administered 27/33 opportunities. A review of the medical record revealed Nursing Progress Notes, dated 3/23/18, 3/26/18, 3/29/18 and 4/1/18 that documented the resident had increased behaviors with oxygen saturation levels between 82 - 88 percent on room air. The current CCP does not include oxygen use and/or a correlation between low oxygen saturations and an increase in confusion and/or behaviors. During an observation on 5/10/18 at 8:01 a.m., the resident was sitting at the side of his bed and he was receiving oxygen at 4 liters per minute via nasal cannula. During an observation 5/11/18 at 8:35 a.m., the resident was sitting in his room and he was not wearing his oxygen. When interviewed at that time, the resident said that he did not mind wearing the oxygen when he was in his room and should put it on. Also at that time, the Licensed Practical Nurse stated the resident did not wear the oxygen all the time, only as needed. She stated the resident was not able to apply the oxygen himself. She said he needed staff assistance. During an interview on 5/11/18 at 10:17 a.m., a Certified Nursing Assistant (CNA) stated the resident use to wear oxygen, however, she had not seen him wear it in a long time. She stated sometimes the resident would let staff apply the oxygen but not always. The CNA stated a nurse told her when the resident has behaviors it may be because his oxygen level is low. When interviewed on 5/11/18 at 1:18 p.m., the Director of Nursing (DON) stated the resident should have physician orders [REDACTED]. The DON stated the resident's behaviors improved with the administration of the oxygen and that should be included in the CCP. (10 NYCRR 415.12(k)(6))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one residential unit reviewed for medication storage, the facility did not provide for the safe and secure storage of medications. Specifically, controlled substances were not secured by two locking mechanisms and were not periodically reconciled. This is evidenced by the following: During an observation on 5/9/18 at 12:04 p.m., the medication refrigerator was locked and had a red tag. Licensed Practical Nurse (LPN) #1 unlocked the medication refrigerator and it contained several discontinued controlled substances including, but not limited to, two boxes of [MEDICATION NAME] Patches, two bottles of [MEDICATION NAME] Solution, [MEDICATION NAME], and [MEDICATION NAME] that were stored on a shelf. Interviews conducted on 5/9/18 included the following: a. At 12:13 p.m., LPN #1 stated that the discontinued controlled substances are not normally stored in the refrigerator. She said they have been storing the controlled substances in the refrigerator secured with a red tag. She said the Director of Nursing (DON) was responsible for the removal and destruction of the discontinued controlled substances. b. At 12:14 p.m., LPN #2 stated that discontinued controlled substances are generally given to the DON. LPN #2 said that the controlled substances in the refrigerator are not being counted and are stored under one lock. LPN #2 said that the last time the refrigerator was opened was in April. She said there was a red tag placed on the outside of the refrigerator that is checked daily by two nurses to make sure it coincides with the number in the narcotic book. She said the controlled substances are stored in the refrigerator until the DON retrieves them. When interviewed on 5/11/18 at 11:17 a.m., the DON, said the only medication that should be stored in the refrigerator was the liquid [MEDICATION NAME] which is secured in a locked box within the locked refrigerator. The DON stated that discontinued narcotics should be counted every shift, until she removes the medications and locks them in the safe until the destruction date. The DON stated that she was responsible for reconciliation of the discontinued medications. (10 NYCRR 415.18)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not post daily nurse staffing information. Specifically, the facility Staffing Sheets did not include the total number and actual hours worked by staff. This is evidenced by the following: During an observation on 5/11/18 at 3:30 p.m., the daily posted Staffing Sheet, dated 5/11/18, revealed the actual hours that staff worked for the day and evening shifts was blank. A review of the daily posted Staffing Sheets, from 5/8/18 through 5/10/18, revealed that actual hours that staff worked for the day and evening shifts was blank. When interviewed on 5/14/18 at 8:22 a.m., the Director of Nursing (DON) stated the charge nurse for each shift is responsible for completing the daily posted Staffing Sheets. During an interview on 5/14/18 at 8:23 a.m., the Registered Nurse Manager stated she thought she was supposed to complete the daily staffing information. She said she would need to review with the DON what was required.

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #196 and #197) 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 #196 was admitted to the facility 1/11/18 and discharged 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 to notify them of their appeal rights under the regulations. Resident #197 was admitted to the facility 1/24/18 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 to notify them of their appeal rights under the regulations. During an interview on 5/15/18 at 11:50 a.m., the Billing Specialist stated she was unsure what letters were to be given at discharge. She stated she was unaware Medicare Non-coverage letters needed to be given when residents were discharged following therapy. (10 NYCRR 415.3(g)(2)(i))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 550) completed on 2/7/18, it was determined that for one (Resident #1) of three residents reviewed for accidents, the facility did not ensure the resident's right to be free from neglect. Specifically, the resident's plan of care, dated 5/9/17, included the use of a mechanical stand lift with the assistance of two staff for transfers. Certified Nursing Assistant (CNA) #1 did not implement the care plan and transferred the resident by herself using the mechanical stand lift without utilizing the stand lift straps to secure the resident. Subsequently, the resident's knees buckled during the transfer and the resident sustained [REDACTED]. This is evidenced by the following: The facility's undated policy, Abuse, Neglect and Mistreatment Prohibition, Investigation and Reporting, revealed that it was the policy of the facility to ensure that there are procedures and systems in place to prohibit and prevent abuse, neglect, mistreatment, crime, involuntary isolation, exploitation, serious bodily injury, injuries of unknown source and/or misappropriation of personal property. Neglect was defined as the failure to provide safe, adequate and appropriate services, treatment and/or care to resident while under the supervision of the facility. The facility's Safe Lifting and Movement of Residents Guidelines, revised 12/30/15, revealed that at least two appropriate staff members are required to assist any resident using a mechanical lift device. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/2/18, revealed that the resident was cognitively intact. The CNA resident care plan, dated 5/9/17, revealed that the resident was non-ambulatory and required a two person assist with a mechanical stand lift for transfers, effective 5/10/17. The Report of Incident or Accident, dated 12/19/17, revealed that the resident was being transferred with the stand lift by CNA #1, and the resident's legs gave out. The resident was lowered to the floor and Hoyered to bed, complaining afterwards of right knee pain. The employee warning notice, dated 12/19/17, revealed that CNA #1 transferred the resident using the sit-stand mechanical lift when the resident's legs buckled and she needed to be lowered to the floor. The warning included failure to follow the facility policy for a two person assist for all mechanical transfers and failure to secure the leg and waist straps during the transfer. The hospital history and physical and right knee x-ray results revealed a [MEDICAL CONDITION] distal femur with marked separation and displacement on 12/20/17 and open reduction internal fixation (a surgical procedure to fix bone fracture or break, open reduction means realign the bone, and internal fixation refers to steel rods, screws, or plates used to keep the bone fracture stable) on 12/21/17. When interviewed on 1/5/18 at 10:00 a.m., the Administrator stated that CNA #1 was trying to reposition the resident because the resident was uncomfortable using the mechanical stand lift. She said the resident did not have a good grip of the stand lift, her knees buckled and staff eased the resident to the floor. The Administrator said the resident was in an awkward position, CNA #1 wanted to get her in the chair safely, and that was not perceived as a fall. When interviewed on 1/5/18 at 11:55 a.m., the resident stated that on 12/19/17, CNA #1 transferred her to the recliner alone. The resident said CNA #1 always uses a one person assist when transferring her using the mechanical stand lift. The resident stated that CNA #1 did not use the straps during the transfer, and she only had the sling to hold onto because she had not gotten a hold of the hand rails on the lift. When interviewed on 1/17/18 at 2:00 p.m., CNA #1 stated that the facility policy for lifts and the resident's care plan require two assists for transfers. CNA #1 stated that on 12/19/17, at approximately 8:00 p.m., she hooked the resident up to the lift stand but did not fasten the belt around the resident's knees or waist, and does not know why she did not. CNA #1 stated that she lifted the resident with the mechanical lift, pushed the lift into the bathroom over the toilet, and left the resident hooked up to the stand lift. CNA #1 said when the resident was done, she transported the resident to the recliner the same way, again not fastening the belt around the resident's knees or around her waist, stating that the main support was the resident holding onto the handles of the lift. CNA #1 stated that she then lowered the resident into the recliner when the resident said that she was not positioned right. CNA #1 stated she lifted the resident back up using the mechanical stand lift, and the resident started sliding and dropping, going down to the floor in front of the recliner. CNA #1 stated that she has always used one assist for transferring the resident, even though the resident requires two assists, and could not explain why. CNA #1 stated that she told Licensed Practical Nurse (LPN) #1 and #2 that she transferred the resident alone to and from the bathroom. CNA #1 said she was asked by one of the LPNs if she looked at the resident's care card and told the nurse she did not. CNA #1 stated that LPN #2 told her she should have had another CNA in the room. CNA #1 said it was her fault. When interviewed on 1/17/18 at 3:00 p.m., LPN #1 stated that on 12/19/17, upon entering the resident's room, the resident's legs were bent and she was hanging while holding onto the mechanical lift handles. LPN #1 said the strap under the resident's arms was holding her up. LPN #1 stated that the resident reported she could not straighten her knees. LPN #1 stated that she did not know about or discuss the care plan violation until a few days later. When interviewed on 1/17/18 at 3:35 p.m., CNA #2 stated that on 12/19/17 during the evening shift, she heard CNA #1 call for help from the resident's room. CNA #2 stated that from the resident's doorway, she saw the resident sliding from the stand lift to the floor. CNA #2 said the resident's arms were caught under the straps but she continued to go down. CNA #2 stated that she did not see the waist or leg straps fastened and was pretty sure the legs were not fastened because it probably would have helped keep the resident's legs in place. CNA #2 stated that a two person assist was required for all mechanical lift transfers. CNA #2 said when she entered the room, CNA #1 was alone in the resident's room and the resident was in the mechanical stand lift. When interviewed on 1/19/18 at 4:00 p.m., LPN #2 stated that on 12/19/17 around 8:00 p.m., she was called to the resident's room. Upon entering the resident's room, the resident was in the mechanical stand lift hanging while holding the lift handle bars with her hands and both knees were bent. LPN #2 said that the resident said she could not straighten her legs out and her knees buckled. LPN #2 said that all mechanical lift transfers require a two person assist, and the waist and knee straps were not properly in place to prevent the resident's knees from buckling and support her waist. LPN #2 stated that they lowered and seated the resident on the floor. LPN #2 stated that LPN #1 was responsible for checking to be sure the care plan was followed. LPN #2 said she did not know CNA #1 transferred the resident alone until the end of the shift. LPN #2 said that she did not speak with CNA #1 about not securing the knee and waist straps as LPN #1 would be responsible for doing that when she investigated that evening. LPN #2 stated that she never observed CNA #1 transfer that specific resident. LPN #2 stated that the resident was admitted about eight months ago and has always been a two person assist with the mechanical stand lift for transfers. LPN #2 said that she spoke with CNA #1 at the end of the night about the need to buckle the knee and waist straps. When interviewed on 1/19/18 at 5:10 p.m., CNA #3 stated that on 12/19/17 after dinner, CNA #1 came out of the resident's room and said she needed help. CNA #3 stated that the resident was hanging onto the handles of the stand lift with the sling under her arms, and it looked like her knees buckled. CNA #3 stated that she has seen CNA #1 transfer the resident alone before using the mechanical stand lift. CNA #3 said it was not her job to tell people what to do, and she was not a boss. When interviewed on 1/17/18 at 2:50 p.m., the Director of Nursing stated that she was not aware of CNA #1's failure to use two assists for all transfers involving the resident. (10 NYCRR 415.4(b)(1)(i))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 550) completed on 2/7/18, it was determined that for one (Resident #1) of three residents reviewed for accidents, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent an accident. Specifically, the resident was care planned to be transferred with a two person assist with a mechanical stand lift. The resident was transferred with a one person assist using a mechanical stand lift without using the stand lift straps to secure the resident. Subsequently, the resident's knees buckled and the resident sustained [REDACTED]. This is evidenced by the following: The facility's policy, Safe Lifting and Movement of Residents Guidelines, revised 12/30/15, revealed that at least two appropriate staff members are required to assist any resident using a mechanical lift device. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/2/18, revealed that the resident was cognitively intact. The Certified Nursing Assistant (CNA) resident care plan, dated 5/9/17, revealed that the resident was non-ambulatory and required a two person assist with a mechanical stand lift for transfers, effective 5/10/17. The Report of Incident or Accident, dated 12/19/17, revealed that the resident was being transferred with the stand lift by CNA #1, and the resident's legs gave out. The resident was lowered to the floor and Hoyered to bed, complaining afterwards of right knee pain. The employee warning notice, dated 12/19/17, revealed that CNA #1 transferred the resident using the sit-stand mechanical lift when the resident's legs buckled and she needed to be lowered to the floor. The warning included failure to follow the facility policy for a two person assist for all mechanical transfers and failure to secure the leg and waist straps during the transfer. The hospital history and physical and right knee x-ray results revealed a [MEDICAL CONDITION] distal femur with marked separation and displacement on 12/20/17 and open reduction internal fixation (a surgical procedure to fix bone fracture or break, open reduction means realign the bone, and internal fixation refers to steel rods, screws, or plates used to keep the bone fracture stable) on 12/21/17. When interviewed on 1/5/18 at 10:00 a.m., the Administrator stated that CNA #1 was trying to reposition the resident because the resident was uncomfortable using the mechanical stand lift. She said the resident did not have a good grip of the stand lift, her knees buckled, and staff eased the resident to the floor. The Administrator said the resident was in an awkward position, CNA #1 wanted to get her in the chair safely, and that was not perceived as a fall. When interviewed on 1/5/18 at 11:55 a.m., the resident stated that on 12/19/17, CNA #1 transferred her to the recliner alone. The resident said CNA #1 always uses a one person assist when transferring her using the mechanical stand lift. The resident stated that CNA #1 did not use the straps during the transfer, and she only had the sling to hold onto because she had not gotten a hold of the hand rails on the lift. When interviewed on 1/17/18 at 2:00 p.m., CNA #1 stated that the facility policy for mechanical lifts and the resident's care plan require a two person assist for transfers. CNA #1 stated that on 12/19/17, at approximately 8:00 p.m., she hooked the resident up to the lift stand but did not fasten the belt around the resident's knees or waist, and does not know why she did not. CNA #1 stated that she lifted the resident with the mechanical lift, pushed the lift into the bathroom over the toilet, and left the resident hooked up to the stand lift. CNA #1 said when the resident was done, she transported the resident to the recliner the same way, again not fastening the belt around the resident's knees or around her waist, stating that the main support was the resident holding onto the handles of the lift. CNA #1 stated that she then lowered the resident into the recliner when the resident said that she was not positioned right. CNA #1 stated she lifted the resident back up using the mechanical stand lift, and the resident started sliding and dropping, going down to the floor in front of the recliner. CNA #1 stated that she has always used a one person assist for transferring the resident, even though the resident requires a two person assist, and could not explain why. CNA #1 stated that she told Licensed Practical Nurse (LPN) #1 and #2 that she transferred the resident alone to and from the bathroom. CNA #1 said she was asked by one of the LPNs if she looked at the resident's care card and she told the nurse she did not. CNA #1 stated that LPN #2 told her she should have had another CNA in the room. CNA #1 said she agreed with LPN #2 and that it was her fault. When interviewed on 1/17/18 at 3:00 p.m., LPN #1 stated that on 12/19/17, upon entering the resident's room, the resident's legs were bent and she was hanging while holding onto the mechanical lift handles. LPN #1 said the strap under the resident's arms was holding her up. LPN #1 stated that the resident reported she could not straighten her knees. LPN #1 stated that she did not know about or discuss the care plan violation until a few days later. When interviewed on 1/17/18 at 3:35 p.m., CNA #2 stated that on 12/19/17 during the evening shift, she heard CNA #1 call for help from the resident's room. CNA #2 stated that from the resident's doorway, she saw the resident sliding from the stand lift to the floor. CNA #2 said the resident's arms were caught under the straps but she continued to go down. CNA #2 stated that she did not see the waist or leg straps fastened and was pretty sure the legs were not fastened because it probably would have helped keep the resident's legs in place. CNA #2 stated that a two person assist was required for all mechanical lift transfers. CNA #2 said when she entered the room, CNA #1 was alone in the resident's room and the resident was in the mechanical stand lift. When interviewed on 1/19/18 at 4:00 p.m., LPN #2 stated that on 12/19/17 around 8:00 p.m., she was called to the resident's room. Upon entering the resident's room, the resident was in the mechanical stand lift hanging while holding the lift handle bars with her hands and both knees were bent. LPN #2 said that the resident said she could not straighten her legs out and her knees buckled. LPN #2 said that all mechanical lift transfers require a two person assist, and the waist and knee straps were not properly in place to prevent the resident's knees from buckling and support her waist. LPN #2 stated that they lowered and seated the resident on the floor. LPN #2 stated that LPN #1 was responsible for checking to be sure the care plan was followed. LPN #2 said she did not know CNA #1 transferred the resident alone until the end of the shift. LPN #2 said that she did not speak with CNA #1 about not securing the knee and waist straps as LPN #1 would be responsible for doing that when she investigated that evening. LPN #2 stated that she never observed CNA #1 transfer that specific resident. LPN #2 stated that the resident was admitted about eight months ago and has always been a two person assist with the mechanical stand lift for transfers. LPN #2 said that she spoke with CNA #1 at the end of the night about the need to buckle the knee and waist straps. When interviewed on 1/19/18 at 5:10 p.m., CNA #3 stated that on 12/19/17 after dinner, CNA #1 came out of the resident's room and said she needed help. CNA #3 stated that the resident was hanging onto the handles of the stand lift with the sling under her arms, and it looked like her knees buckled. CNA #3 stated that she has seen CNA #1 transfer the resident alone before using the mechanical stand lift. CNA #3 said it was not her job to tell people what to do, and she was not a boss. When interviewed on 1/17/18 at 2:50 p.m., the Director of Nursing stated that she was not aware of CNA #1's failure to use two assists for all transfers involving the resident. (10 NYCRR 415.12(h)(1))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 550) completed on 2/7/18, it was determined that for one (Resident #1) of three residents reviewed for accidents, the facility did not provide services consistent with professional standards of quality. The issue involved the lack of a Registered Nurse (RN) Assessment prior to removing a resident from the floor. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/2/18, revealed that the resident was cognitively intact. The Report of Incident or Accident, dated 12/19/17, revealed that the resident was being transferred with the stand lift by Certified Nursing Assistant (CNA) #1 and the resident's legs gave out. The resident was lowered to the floor and Hoyered (mechanical lift) to bed, complaining afterwards of right knee pain. The hospital history and physical and right knee x-ray results revealed a [MEDICAL CONDITION] distal femur with marked separation and displacement on 12/20/17, and open reduction internal fixation (a surgical procedure to fix bone fracture or break, open reduction means realign the bone, and internal fixation refers to steel rods, screws, or plates used to keep the bone fracture stable) on 12/21/17. When interviewed on 1/5/18 at 11:20 a.m., the Director of Nursing (DON) stated that the resident was removed from the floor with no RN assessment, because the resident was guided to the floor, and the LPNs did not perceive the accident as a fall. The DON said that there was a RN in the facility at the time of the fall on 12/19/17. When interviewed on 1/5/18 at 11:55 a.m., the resident stated that the nurses and other CNAs came into the room after she was on the floor. The resident stated that range of motion was not done. The resident said LPN #1 said that they needed to get her off the floor and keep her non-weightbearing until they find out if it was broken. When interviewed on 1/17/18 at 2:00 p.m., CNA #1 stated that on 12/19/17, she used the mechanical stand lift to reposition the resident in the recliner, and the resident started to go down to the floor. CNA #1 stated that she and two other CNAs lowered the resident to the floor and the resident landed on her knees. CNA #1 stated that the LPNs were called into the room and straightened out the resident's legs from underneath the resident, put a pillow under her head and Hoyered the resident into bed. CNA #1 stated that she did not see a RN in the room and did not remember if range of motion was done before moving the resident. CNA #1 stated that when the LPNs arrived in the room, they asked the resident if she was okay, and the resident responded that her knees hurt and she just wanted to get off the floor, which is what they did. When interviewed on 1/17/18 at 2:50 p.m., the DON stated that there was no written policy for a RN assessment after a fall. The DON said LPNs cannot assess and need to call a RN before removing a resident from the floor. When interviewed on 1/17/18 at 3:00 p.m., LPN #1 stated that on 12/19/17, she and LPN #2 jointly decided to lower the resident to the floor. She said they straightened her legs and adjusted her body, and Hoyer lifted the resident into bed. LPN #1 stated that she did not know if the RN was in the building. LPN #1 said a RN was not notified to complete an assessment. LPN #1 stated she was not aware that she needed to notify a RN when a resident was observed being lowered to the floor. LPN #1 stated that for falls, she would call a RN and explain her observations, because LPNs are not allowed to assess and the RN would provide instruction. LPN #1 stated that if there was a RN in the building, the RN would assess, but she did not feel it was necessary for that incident. When interviewed on 1/17/18 at 3:35 p.m., CNA #2 stated that she and two other CNAs controlled the resident's fall to the floor and guided her down. CNA #2 stated that once the resident was on the floor, seated between the mechanical stand lift legs, the LPNs arrived, asked the resident if she was okay, and said to Hoyer the resident into bed. CNA #2 stated that she did not see vital signs taken or range of motion checked when the resident was on the floor. CNA #2 stated when they are required to lower a resident to the floor, they cannot lift the resident off the floor without nurse notification and direction, usually a RN, but this was a controlled fall. When interviewed on 1/19/18 at 4:00 p.m., LPN #2 stated that on 12/19/17 around 8:00 p.m., she was called to the resident's room with LPN #1. The resident was holding onto the lift handle bars in the lift sling, hanging with both knees bent. LPN #2 stated that the resident said she could not straighten her legs out, her knees buckled, and the knee and waist straps were not secured around the resident. LPN #2 stated that they lowered the resident to the floor, and LPN #1 positioned the resident's legs/knees so they were straight once the resident was seated on the floor. LPN #2 stated that they did not call the RN who was still in the building to assess before removing the resident from the floor. LPN #2 said the resident was lowered to the floor and did not fall. LPN #2 stated that LPN #1 checked the resident by moving the resident's knees up when she was on the floor, and the resident had no significant pain. LPN #2 stated that as a LPN, she cannot assess a resident, and the LPNs are expected to make observations and report to a RN. However, they did not consider that a fall. LPN #2 stated she did not observe the full transfer or how the resident ended up hanging from the lift. When interviewed on 1/19/18 at 4:40 p.m., the RN stated that on 12/19/17, she worked until 8:00 p.m., 9:00 p.m. or 10:00 p.m. and was made aware of the resident's fall the following afternoon. The RN stated that the DON asked her if anyone called her when the resident fell , and she said, No. The RN stated that if she was the only RN in the building when a resident fell , she would expect to be notified of the fall and assess prior to the resident being removed from the floor. When interviewed on 1/19/18 at 5:10 p.m., CNA #3 stated that on 12/19/17 after dinner, CNA #1 came out of the resident's room and said she needed help. CNA #3 stated that the resident had the lift sling under her arms and was hanging onto the lift handles with her hands. CNA #3 stated that it looked like the resident's knees buckled underneath her, and CNA #3 stood behind the resident as the resident placed all her body weight against CNA #3. CNA #3 stated that LPN #1 came in and gently took the resident's legs and straightened them out, and then lifted the resident's legs up and down two or three times for each leg. CNA #3 said LPN #1 asked the resident if anything hurt, and the resident responded, No. CNA #3 stated that she suggested the Hoyer, they laid the resident down on the floor, applied the Hoyer sling under the resident by turning the resident on each side and tucking the sling under the resident, and then transferred the resident into bed. CNA #3 stated that LPN #1 rechecked the resident, and initially the resident said nothing hurt, but then the resident said she was uncomfortable. CNA #3 stated that she repositioned the resident and the resident complained of right knee and hip pain, but once re-adjusted, the resident said she was okay. (10 NYCRR 415.11(c)(3)(i))

Based on observations, interviews, and record reviews, it was determined that for two of two residential units, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior. The issue was related to damaged edges of doors near foot/leg level. This is evidenced by the following: 1. Observations on 3/6/17 between 12:36 p.m. and 1:55 p.m. revealed the lower leading edges of wooden corridor doors were jagged and splintered in Resident Rooms: #4, #6, #12, #17, #24, #25, and #28. The splintered sections were between approximately 2 inches to 12 inches above the floor level. Additionally, the rigid plastic panel affixed to the door in Resident Room #17 was sharp and jagged at approximately 3 inches above the floor level. The lower inside of the door to Resident Room #12 was severely splintered, and there was a white thread hanging off a splinter on the lower edge of the door to Resident Room #6. 2. Record review on 3/6/17 at 3:15 p.m. revealed the monthly preventative maintenance log for corridor doors did not include a check for splinters. 3. During an interview on 3/7/17 at 12:14 p.m., Certified Nursing Assistant (CNA) #1 stated, We have noticed the doors that are all beat up. We can go to the department heads and have them fill out a work order. I did not tell anyone because they are always like that. 4. Observations on 3/8/17 at 1:20 p.m. revealed the edge of the door to the bathroom in Resident Room #7 had a large gouge at the bottom with a sharp piece of wood sticking up slightly. In an interview at that time, the Director of Nursing (DON) stated, that is rough, yes, it could cause a skin tear, we'll get that fixed right away. The DON said the resident in Room #7 does self-propel in her wheelchair, but very little; just a little around her room. 5. During an observation on 3/8/17 at 1:22 p.m., a resident in Room #7 was independently ambulating with a walker. During intermittent observations between 3/6/17 and 3/8/17, both residents in Room #12 were ambulating in their room. Review of the CNA care card for both residents in Room #12 revealed the residents are independent for ambulation and transfers in their room (10 NYCRR: 415.29, 415.29(a)(1), 415.29(j)(1))