Every finding on record at Elderwood at Hornell

Based on observations, interviews, and record review, the facility failed to ensure a resident was free from physical abuse for one of four residents reviewed (Resident #60). Specifically, on 06/19/2026, facility staff used physical force to direct Resident #60 back to their room and intentionally restricted the resident's movement by preventing them from freely using their arms and moving away from staff for approximately 10 to 15 minutes after becoming agitated. Rather than implementing care planned behavioral interventions, staff continued restricting the resident's movement until they calmed, resulting in multiple bruises to both hands, wrists, left forearm, left upper arm, and a skin tear above the right elbow. This resulted in actual harm to Resident #60, that was not Immediate Jeopardy.The findings include:The facility policy Abuse Prevention, Identification, Protection and Reporting, last modified on 04/30/2024, included the facility prohibits all forms of abuse, mistreatment, neglect, and exploitation. The procedure included understanding behavioral symptoms of residents that may increase the risk of abuse, mistreatment and neglect and how to respond. The facility training course Abuse Prevention, Identification, Protection and Reporting dated April 2026 included residents have the right to be free from abuse, neglect and exploitation. Abuse included willful infliction of injury, unreasonable confinement, involuntary seclusion, or intimidation resulting in physical harm, pain or mental anguish. The undated facility training course Managing Aggressive Residents in Long Term Care: Guidance for Staff instructed staff to approach residents calmly, maintain a safe distance, avoid crowding or cornering residents, use verbal de-escalation (using calm language, controlled body posture, and active listening to defuse tension) techniques, request assistance from a supervisor when behaviors escalated, and not use physical restraint except during an immediate imminent threat. The training further instructed staff to assess residents for injury following an incident and notify the provider and administration.Resident #60's diagnoses included frontotemporal neurocognitive disorder (a progressive brain disease affecting behavior, personality, and language), severe dementia (progressive loss of memory and thinking ability) with agitation (restlessness and increased physical or verbal activity), and anxiety (persistent fear or worry). The Minimum Data Set (a resident assessment tool), dated 03/25/2026, included Resident #60 had severe cognitive impairment and exhibited rejection of care and wandering behaviors that had worsened since the previous assessment.Review of the Comprehensive Care Plan, revised 06/06/2026, revealed Resident #60 was at risk for aggressive interactions towards others related to behavioral symptoms and cognitive impairment. Interventions included approaching Resident #60 using simple, calm, and non-confrontational communication; monitoring for unmet physical, emotional, and psychosocial needs; redirecting, distracting, or re-engaging the resident at the earliest signs of agitation; discontinuing the interaction if behaviors continued; ensuring the safety of the resident and others; and re-approaching the resident later when appropriate.Review of the Kardex (care plan used by staff to direct care), dated 06/15/2026, included staff were to provide Resident #60 an activity box for distraction based on the resident's previous occupation as an engineer, use simple, calm, and non-confrontational communication, redirect inappropriate behaviors at the earliest opportunity, discontinue interactions if behaviors continued, ensure the safety of Resident #60 and other residents, and re-approaching the resident later when appropriate.Review of Resident #60's weekly skin assessments completed from 03/26/2026 through 06/11/2026 documented no bruising, skin tears, or other alterations in skin integrity.Review of the undated facility investigation revealed Resident #60 became agitated on 06/19/2026 after approaching another resident. Licensed Practical Nurse #5 physically directed Resident #60 to their room. After Resident #60 left the room and became physically aggressive toward staff, Licensed Practical Nurse #5, Certified Nursing Assistant #4, and Support Aide #1 intentionally restricted Resident #60's movement for approximately five to 10 minutes. Certified Nursing Assistant #4 restricted Resident #60's arms and legs while Support Aide #1 was positioned behind Resident #60 and restricted the resident's upper body movement. Licensed Practical Nurse #5 confirmed Resident #60 could not freely stand or move their arms during the incident. The involved staff acknowledged the intervention was not acceptable. The investigation concluded the bruising identified on Resident #60's arms was consistent with injury sustained during the incident.Review of progress notes dated 06/19/2026, Registered Nurse #1 documented they responded to the unit after staff requested assistance for Resident #60's aggressive behaviors. Registered Nurse #1 contacted the on-call provider after Resident #60 had calmed. Registered Nurse #1 documented they did not directly observe the reported physical aggression, and the information was verbally reported by Licensed Practical Nurse #5.Review of a late entry (a note added to the resident's record after the required timeframe) progress note, entered on 06/20/2026 for 06/19/2026, Licensed Practical Nurse #5 documented Resident #60 approached another resident and became verbally aggressive. Staff separated the residents and physically directed Resident #60 to their room. Resident #60 exited the room, struck Certified Nursing Assistant #4, and continued swinging, kicking, and headbutting Licensed Practical Nurse #5 and Certified Nursing Assistant #4. Staff remained with Resident #60 for approximately 20 minutes until Resident #60 calmed.Review of a progress note, entered on 06/24/2026 at 11:09 AM as a late entry, the Director of Nursing documented Resident #60 had new dark purple bruising to both hands, wrists, and arms, including bruising to the left forearm consistent with the shape of a hand and thumb, additional circular bruising to the left forearm, and a skin tear above the right elbow. Resident #60 displayed no signs or symptoms of pain or discomfort. The identified areas measured as follows: Bruise to the right hand measured 3.0 centimeters by 3.0 centimeters. Bruise to the base of the right thumb measured 1.5 centimeters by 2.0 centimeters. Bruise to the left hand measured 3.0 centimeters by 2.0 centimeters. Bruises to the left forearm measured 7.5 centimeters by 3.8 centimeters, 2.0 centimeters by 1.5 centimeters, 2.0 centimeters by 1.0 centimeters, and 1.5 centimeters by 1.5 centimeters. Bruise to the left upper arm measured 2.0 by 1.6 centimeters. Skin tear above the right elbow measured 1.6 by 1.0 centimeters.Review of a provider progress note dated 06/25/2026, Physician #1 documented Resident #60 had recently been physically restrained by staff during a behavioral incident. Physical examination identified bruising to the extremities. Resident #60 had known behavioral triggers, was very sensitive to certain approaches, attempts, and personalities, and staff should remain aware of those triggers.During an interview on 06/29/2026 at 10:20 AM, Resident #60 was unable to provide reliable information due to severe cognitive impairment. During an interview on 06/29/2026 at 10:40 AM, Licensed Practical Nurse #2 stated they routinely completed Resident #60's weekly skin assessment and the resident had no bruising or skin concerns before the incident. Licensed Practical Nurse #2 stated Resident #60 did not bruise easily.During an observation on 06/29/2026 at 3:40 PM, Resident #60 was seated in the common area. Dark purple bruising remained visible to both hands, wrists, and the left arm. The bruising pattern and measurements were consistent with the Director of Nursing's assessment completed on 06/24/2026 and photographs taken by the Assistant Director of Nursing on 06/24/2026. No significant change in the bruising was observed.During an interview on 06/30/2026 at 2:45 PM, the Administrator stated if the facility had been aware of the incident on 06/19/2026, Licensed Practical Nurse #5, Certified Nursing Assistant #4, and Support Aide #1 would have been immediately suspended pending investigation. The Administrator stated staff are never permitted to use physical force to intentionally restrict a resident's movement.During an interview on 07/01/2026 at 11:05 AM, Physician #1 stated Resident #60 had known behavioral triggers related to dementia and staff should have attempted verbal de-escalation by giving the resident space and avoiding confrontation. Physician #1 stated staff likely escalated Resident #60's behaviors by becoming verbally confrontational. Physician #1 stated the facility had no policy permitting physical restraint of residents. Physician #1 stated the bruising observed on Resident #60's arms could not be conclusively attributed to the incident but could not be excluded because the bruising pattern was consistent with the reported events.During an interview on 07/01/2026 at 2:30 PM, the Director of Nursing stated Support Aide #1 reported the incident on 06/24/2026. The Director of Nursing immediately initiated an investigation, completed a skin assessment, and suspended Licensed Practical Nurse #5, Certified Nursing Assistant #4, and Support Aide #1 pending investigation. Resident #60's injuries were photographed by the Assistant Director of Nursing on 06/24/2026. The Director of Nursing stated all three staff acknowledged intentionally restricting Resident #60's movement during the incident. The Director of Nursing stated Resident #60's weekly skin assessments completed before 06/19/2026 documented no bruising or other skin alterations. The Director of Nursing stated staff should have attempted de-escalation techniques, requested additional assistance, or contacted law enforcement if Resident #60's behaviors could not be safely managed rather than using physical force to intentionally restrict Resident #60's movement.During a telephone interview on 07/02/2026 at 10:40 AM, Certified Nursing Assistant #4 stated Resident #60 approached another resident and Licensed Practical Nurse #5 physically directed Resident #60 toward their room. Certified Nursing Assistant #4 stated Resident #60 later grabbed Certified Nursing Assistant #4's arm and struck Certified Nursing Assistant #4. Certified Nursing Assistant #4 stated Licensed Practical Nurse #5 and Certified Nursing Assistant #4 held Resident #60's hands while Support Aide #1 remained behind Resident #60, restricting the resident's movement for approximately 10 minutes before the resident calmed and staff released Resident #60. Certified Nursing Assistant #4 stated they believed the intervention was appropriate because Licensed Practical Nurse #5 directed the actions but later learned the actions were wrong.During a telephone interview on 07/02/2026 at 12:03 PM, Support Aide #1 stated Licensed Practical Nurse #5 instructed Support Aide #1 and Certified Nursing Assistant #4 to hold Resident #60 until the resident calmed. Support Aide #1 stated they stood behind Resident #60 with arms positioned beneath the resident's arms. Support Aide #1 stated staff attempted to verbally calm Resident #60 but continued restricting Resident #60's movement for approximately 10 to 15 minutes because the resident attempted to strike staff whenever they released Resident #60. Support Aide #1 stated they believed the intervention was appropriate because Licensed Practical Nurse #5 directed the actions.During telephone interviews conducted on 07/06/2026 at 10:50 AM, Licensed Practical Nurse #5 acknowledged after Resident #60 became aggressive, they used physical force to direct the resident to their room and closed the door, which they were technically not supposed to do. Licensed Practical Nurse #5 stated they and Certified Nursing Assistant #4 held Resident #60's hands while Support Aide #1 held the resident from behind. Licensed Practical Nurse #5 acknowledged Resident #60 could not freely use their arms during the incident. Licensed Practical Nurse #5 stated physically restricting Resident #60's movement was not acceptable, restraining a resident was not allowed, and the intervention would probably be considered physical abuse. Licensed Practical Nurse #5 stated the intent was to prevent injury to staff and other residents and acknowledged law enforcement was not contacted during the incident.Title 10 New York Codes, Rules and Regulations 415.3(d)(1)(vii)

Based on observations, interviews, and record review, the facility failed to ensure an alleged violation involving physical abuse was immediately reported to facility administration and to the State agency as required for one of four residents reviewed (Resident #60). Specifically, Resident #60 was physically restrained by three staff members on 06/19/2026. The allegation was not reported to facility administration until 06/24/2026, approximately five days later, when Support Aide #1 disclosed the incident during a certified nursing assistant training class. After the Director of Nursing became aware of the allegation, the facility failed to report the allegation to the New York State Department of Health within two hours.The facility policy, Abuse Prevention, Identification, Investigation, Protection and Reporting, last modified 04/30/2024, included all facility staff were required to immediately report any observed or suspected abuse, mistreatment, neglect, or exploitation to the Administrator, Director of Nursing, or designee. The Administrator or designee was required to report all alleged violations involving abuse to the State agency immediately, but no later than two hours after the allegation was made or observed.Resident #60's diagnoses included frontotemporal neurocognitive disorder (a progressive brain disease affecting behavior, personality, and language), severe dementia (progressive loss of memory and thinking ability) with agitation (restlessness and increased physical or verbal activity), and anxiety (persistent fear or worry). The Minimum Data Set (a resident assessment tool) dated 03/25/2026 revealed Resident #60 had severe cognitive impairment.Review of the undated facility investigation revealed Licensed Practical Nurse #5, Certified Nursing Assistant #4, and Support Aide #1 intentionally restricted Resident #60's movement on 06/19/2026 for approximately five to 10 minutes. The investigation concluded bruising identified on Resident #60's arms was consistent with injuries sustained during the incident. All three staff members acknowledged intentionally restricting Resident #60's movement and stated the intervention was not acceptable.Review of a progress notes dated 06/19/2026, Registered Nurse #1 documented they responded after staff requested assistance for Resident #60's aggressive behaviors and contacted the on-call provider after the resident had calmed. Registered Nurse #1 did not directly observe the physical aggression and the information was verbally reported by Licensed Practical Nurse #5. The progress note did not document staff physically restrained Resident #60 or identify an allegation of abuse.Review of a late entry (a note added to the resident's record after the required timeframe) progress note entered on 06/20/2026 for 06/19/2026, Licensed Practical Nurse #5 documented Resident #60 became verbally and physically aggressive toward staff and staff remained with the resident until the behaviors resolved. The progress note did not document staff physically restrained Resident #60 or identify an allegation of abuse.Review of progress notes dated 06/19/2026 through 06/23/2026 failed to include documented evidence the allegation of physical abuse was reported to the Administrator, Director of Nursing, or designee before 06/24/2026.Review of a progress note, entered on 06/24/2026 at 11:09 AM as a late entry, the Director of Nursing documented Resident #60 had new dark purple bruising to both hands, wrists, and arms, including bruising to the left forearm consistent with the shape of a hand and thumb, additional circular bruising to the left forearm, and a skin tear above the right elbow.During an interview on 06/29/2026 at 12:25 PM, the Director of Nursing stated Support Aide #1 reported the incident occurring on 06/19/2026 during a certified nursing assistant training class on 06/24/2026.During an observation on 06/29/2026 at 3:40 PM, Resident #60 had dark purple bruising visible to both hands, wrists, and the left arm. A skin tear remained visible above the right elbow.During an interview on 06/30/2026 at 10:30 AM, Registered Nurse #1 stated upon entering Resident #60's room on 06/19/2026, the resident was calm and everyone was safe. Registered Nurse #1 stated no one reported staff physically restrained Resident #60 or indicated abuse, neglect, or mistreatment occurred.During an interview on 06/30/2026 at 2:45 PM, the Administrator stated administration was not aware of the incident before 06/24/2026. The Administrator stated the incident was reported to the State after administration became aware and the involved staff would have been immediately suspended pending investigation if administration had known of the incident on 06/19/2026.During an interview on 07/01/2026 at 2:30 PM, the Director of Nursing stated Support Aide #1 disclosed the incident during a certified nursing assistant training class on 06/24/2026 because Support Aide #1 did not know the proper reporting procedure. The Director of Nursing stated an investigation was immediately initiated after the allegation was reported. The Director of Nursing stated the allegation was not entered into the New York State Incident Reporting System until 4:52 PM on 06/24/2026.Review of the New York State Incident Reporting System documented the Director of Nursing and Administrator became aware of the allegation of physical abuse at approximately 11:00 AM on 06/24/2026. During a telephone interview on 07/02/2026 at 10:40 AM, Certified Nursing Assistant #4 stated Licensed Practical Nurse #5 directed staff to hold Resident #60 until the resident calmed. Certified Nursing Assistant #4 stated they believed the intervention was appropriate at the time but later learned physically restraining a resident was wrong.During a telephone interview on 07/02/2026 at 12:03 PM, Support Aide #1 stated they did not know the proper reporting procedure following the incident and disclosed the event during a certified nursing assistant training class on 06/24/2026 while seeking guidance.During a telephone interview on 07/06/2026 at 10:50 AM, Licensed Practical Nurse #5 stated Registered Nurse #1 had been called to the unit for assistance and was notified of the incident. Licensed Practical Nurse #5 acknowledged physically restraining Resident #60 was not acceptable and would probably be considered physical abuse.Title 10 New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on observations, interviews, and record review, the facility failed to implement an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for two of two residents reviewed (Resident #11 and Resident #12). Specifically, Resident #11 required Enhanced Barrier Precautions (an infection prevention strategy requiring gowns and gloves during high-contact resident care activities) during wound care. Registered Nurse #1 failed to properly secure the required gown, allowed the gown to contact the wound area, and failed to change gloves and perform hand hygiene between providing care to two separate wounds. Resident #12 required Enhanced Barrier Precautions during wound care. Licensed Practical Nurse #2 and Certified Nursing Assistant #3 failed to wear required gowns while providing wound care, and Licensed Practical Nurse #2 used disposable gloves carried in a uniform pocket instead of obtaining gloves from a clean supply.The findings include:The facility policy, Transmission Based Precaution Levels, last revised 06/06/2024, documented Enhanced Barrier Precautions require staff to wear a gown and gloves during high-contact resident care activities. Residents with wounds require Enhanced Barrier Precautions and staff must wear a gown and gloves when providing wound care.1.Resident #11 had diagnoses including diabetes (a disease causing high blood sugar), chronic kidney disease (long-term loss of kidney function), and obesity (excess body fat that increases health risks). The Minimum Data Set (a resident assessment tool) dated 04/05/2026 revealed Resident #11 was cognitively intact and had unhealed pressure ulcers (injuries to the skin and underlying tissue caused by prolonged pressure).Review of Resident #11's Comprehensive Care Plan last revised 06/18/2026, revealed pressure ulcers on the coccyx (tailbone) and right gluteal cleft (groove between the buttocks) and an intervention requiring Enhanced Barrier Precautions. Review of Resident #11's Kardex (a care guide used by certified nursing assistants) on 07/03/2026 revealed Enhanced Barrier Precautions were in place. Review of a current physician order dated 03/12/2026 directed staff to implement Enhanced Barrier Precautions and wear a gown and gloves while providing high-contact care, including wound care.During an observation and interview on 07/02/2026 at 12:21 PM, Registered Nurse #1 performed wound care for Resident #11 while wearing gloves and an untied isolation gown. Throughout the treatment, the gown repeatedly slipped below the Registered Nurse's elbows and contacted the wound area. Registered Nurse #1 cleansed the pressure ulcer on the coccyx and then cleansed the pressure ulcer on the right gluteal cleft without changing gloves or performing hand hygiene between treating the separate wounds. Following the observation, Registered Nurse #1 stated the gown should have been tied to prevent contamination of the wounds and gloves should have been changed and hand hygiene performed between treating the two wounds to reduce the risk of spreading infection.2.Resident #12 had diagnoses including dementia (a progressive disease affecting memory and thinking), muscle weakness (reduced muscle strength), and pressure ulcers. The Minimum Data Set, dated [DATE] revealed Resident #12 had severe cognitive impairment and an unhealed pressure ulcer.Review of Resident #12's Comprehensive Care Plan last revised 06/22/2026, revealed the resident was at risk for infection related to wounds and enhanced-barrier precautions were in place.Review of Resident #12's current Kardex on 07/02/2026, revealed Enhanced Barrier Precautions were in place. Review of a current physician order dated 09/22/2025 directed staff to implement and maintain Enhanced Barrier Precautions related to the presence of a wound.During an observation and interviews on 07/01/2026 at 1:13 PM, Licensed Practical Nurse #2 and Certified Nursing Assistant #3 provided wound care to Resident #12's pressure ulcer on the left buttock without wearing isolation gowns. Enhanced Barrier Precautions signage was posted at the resident's door, and disposable isolation gowns were available in the resident's bedside table with the wound care supplies. Licensed Practical Nurse #2 removed disposable gloves from a uniform pocket before providing wound care instead of obtaining gloves from a clean supply. Following the observation, Licensed Practical Nurse #2 stated Resident #12 required Enhanced Barrier Precautions because of the open wound and staff should have worn an isolation gown during wound care because failing to do so could increase the spread of germs to other people. Certified Nursing Assistant #3 stated they forgot Resident #12 required Enhanced Barrier Precautions and acknowledged a gown should have been worn during care to reduce the spread of bacteria.During an interview on 07/02/2026 at 12:00 PM, the Director of Nursing, who also served as the interim Infection Preventionist, stated staff were expected to wear gowns and gloves when providing care to residents requiring Enhanced Barrier Precautions. The Director of Nursing stated disposable gloves should not be stored in staff uniform pockets for patient care.During a follow-up interview on 07/06/2026 at 10:37 AM, the Director of Nursing stated gowns should be secured at the neck and waist while providing wound care to residents requiring Enhanced Barrier Precautions. The Director of Nursing stated staff should change gloves and perform hand hygiene between treating separate wounds to reduce the spread of infection.Title 10 New York Codes, Rules and Regulations 415.19(a)(1-3)

Based on observations, interviews, and record review conducted during the Recertification Survey it was determined that for one (Resident #16) of three residents reviewed for activities of daily living, the facility did not develop and implement a plan of care for the resident that included measurable objectives and interventions to address the resident's medical and physical needs. Specifically, Resident #16 had multiple scratches and sores on their right arm that were self- inflicted and had accumulated over time. The resident's Comprehensive Care Plan did not include the skin issues, the behavior creating the issues or interventions. Additionally, the use of geri-sleeves (protective arm covers) that was on the Certified Nurse Assistant Kardex were not implemented on several observations. This is evidenced by the following: Review of the facility policy, Skin Care Program (Routine and Special) last revised on 5/8/18, documented that designated nursing staff will monitor the skin condition and ensure proper skin care of each resident on an ongoing basis. Interventions for prevention of pressure ulcers/skin breakdown will be instituted for all residents upon admission/readmission, quarterly, annually and updated as indicated. The need for individual inter-disciplinary approaches to skin care will be reported and initiated, as deemed necessary. The nursing staff will enter special skin care interventions on the Profile of Care/Kardex within twenty-four (24) hours after admission or as necessary. The Unit Manager/Designee will contact the interdisciplinary care team members as soon as possible. The information will be entered on the Inter-disciplinary Care Plan and discussed at the next Resident Care Plan meeting. Resident #16 had diagnoses including kidney disease requiring dialysis (treament for filtering the blood of toxins when the kidneys are unable to), congestive heart failure and diabetes. The Minimum Data Set Resident Assessment, dated 1/18/24, revealed the resident was cognitively intact, and had no skin conditions or behaviors at the time. During observations on 1/29/24 at 11:55 AM and on 2/1/24 at 10:27 AM, Resident #16 had sores, irritated scratches, and redness throughout their right arm. Review of Resident #16's current Comprehensive Care Plan revealed the resident was at risk for impaired skin integrity due to multiple issues but did not include any issues, goals or interventions for staff due to skin impairments related to self-inflicted scratching causing skin inury. Review of Resident #16's current Kardex (care plan used by Certified Nursing Assistant to provide daily care) revealed the use of geri-sleeves but did not include the self inflicted behaviors and skin injury. At no time during the survey process was Resident #16 observed wearing geri-sleeves (until after surveyor intervention). Physician orders dated 10/16/23 included a skin examination report every Monday day shift to the Registered Nurse and to document in the medical record if new skin condition is identified. Review of interdisciplinary progress notes for the prior month did not include any documentation related to the right arm skin injury. During an interview on 1/31/24 at 3:25 PM and again on 2/1/24 at 12:13 PM Licensed Practical Nurse Manager #1 said that Resident #16 picked and scratched at their skin due to itching caused by dialysis and that they have attempted to stop the resident, but that the resident seemed unable to do so. Licensed Practical Nurse Manager #1 said Resident #16 should be care planned for the self-inflicted sores and scratches since they had a history of picking at their skin. Licensed Practical Nurse Manager #1 said that Aquaphor (topical skin cream) was recently ordered for the resident's legs, but nothing was ordered to treat their arms. Licensed Practical Nurse Manager #1 said they had never tried geri-sleeves and that the resident did not own any long- sleeved shirts. Licensed Practical Nurse Manager #1 said they had not documented (scratches and sores) on Resident #16's arm caused by self- inflicted scratching lately but should have. During an interview on 2/01/24 at 12:06 PM, Certified Nurse Assistant #1 said they had seen Resident #16 scratch their arm, lower back and legs and has put lotion on the areas after complaints of feeling dry. During an interview on 2/02/24 at 9:54 AM, the Director of Nursing said the nurses should be contacting the provider and documenting when they see Resident #16 scratching themself. The Director of Nursing said this concern should be care planned with staff interventions outlined so that all staff are aware of how to care for the resident. 10 NYCRR 415.11(c)(1)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #69) of 1 resident reviewed the facility did not ensure that the care plan was implemented and/or revised if appropriate to reflect the resident's current condition. The issue involved the lack of care plan implementation or revisions for therapy recommended wheelchair positioning. This is evidenced by the following: Resident #69 is a [AGE] year-old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], documented that the resident had severe impairment cognitively, required extensive to total assistance with all activities of daily living and had functional limitation in range of motion on one side of the lower extremities. The Comprehensive Care Plan included to use a standard wheelchair with an 'Incrediback' (a higher back wheelchair cushion) as a backrest, an anti-thrust cushion, bilateral hip bolsters, a foot buddy, and elevating leg rests. Interventions included to utilize pillows across the lap while in the wheelchair to promote positioning and comfort. Specific directions included: 1) ensure hips are back and not rotated in chair. 2) leg rests should not be elevated and a foot buddy in place. 3) ensure that the resident's legs are down with feet resting on the bottom. If resident lifts feet to top of foot buddy assist in lowering them back down to ensure proper alignment of hips in wheelchair. Review of an Occupational Therapy (OT) evaluation dated 8/11/21, revealed that Resident #69 was evaluated due to biting behavior during cares. The OT evaluation documented that the resident continued to demonstrate functional passive range of motion and would not tolerate a formal assessment. In an observation on 10/05/21 at 1:13 p.m. Resident #69 was sitting in a standard wheelchair leaning to their right side with their legs pulled up and feet resting on the top edge of the foot buddy on the footrest. No pillow observed on lap or alongside the resident's legs. The resident's head was leaning forward onto their chest and the resident was unable to fully extend their neck. Staff were attempting to feed the resident lunch, but the resident was moving/turning their head away and appeared agitated. At no time were staff observed attempting to reposition the resident's feet or body. In an observation on 10/06/21 at 9:17 a.m. Resident #69 was in the main dining room sitting in a standard wheelchair with the antithrust and Incrediback cushion. Their legs were pulled up toward their abdomen and their feet were again resting on the top edge of the foot buddy on the footrest. The resident's head was leaning forward on their chest. In an observation on 10/07/21 at 8:25 a.m. Resident #69 was being transported into the main dining room by a Certified Nursing Assistant (CNA). The footrest was elevated straight out, with the foot buddy in place and the resident's feet were resting on the top edge of the foot buddy. A note attached to the foot buddy included Please make sure leg rests on w/c are in the down position. They should not be elevated at all. This helps keep their feet down. The resident's head was again leaning forward with chin to chest, and no pillow in their lap or the wheelchair. In an interview on 10/7/21 at 10:04 a.m., CNA#1 stated that they did not know who got Resident #69 up but that the Resident's foot pedals should not be elevated, and their feet should be positioned in the foot buddy. CNA #1 said Resident #69 places their feet on top of the foot buddy and staff are supposed to assist them with repositioning. CNA#1 stated that if an intervention isn't working or there is a change in the resident, staff should notify the nurse or therapy. CNA #1 said that they are supposed to do range of motion with Resident #69 during morning care but that the resident's legs are more difficult to move, and it is uncomfortable for the resident. In an interview on 10/7/21 at 10:55 a.m. Registered Nurse (RN) #1 stated that Resident #69 prefers to be left alone. RN#1 said that the resident does not appear to be uncomfortable in the wheelchair, but that they do limit the time Resident #69 is up in the wheelchair and that they get up only for meals because the resident seems to relax more when in bed. RN#1 said Resident #69 was monitored by all staff for changes in condition and that nursing should initiate a referral to therapy if a decline or change is observed. In an interview 0n 10/7/21 at 11:05 a.m., the RN Manager (RNM) stated that Resident #69 was regressing. The RNM said that the intervention for a pillow to be placed in the resident's lap was initiated last year after a fall but that the RNM at the time did not put it on the Kardex (CNA care plan that directs daily care) so that staff would not know to do it. The RNM said that they were not aware of the note on the resident's foot buddy with instructions not to elevate the footrests and was not aware that they should not be elevated. The RNM said that the CNAs are supposed to document any tasks in the electronic medical record (EMR) regarding the resident's compliance and any functional modifications the resident was on and if it is not consistently done after 3 times an alert is generated in the EMR which is checked daily. When checked at this time, there were no alerts. In an interview on 10/7/2021 at 11:17 a.m., the Director of Rehabilitation stated that they were aware of Resident #69's positioning needs. The Director of Rehabilitation said that if nursing notices a change in the resident's positioning or comfort, they should let therapy know through an electronic referral. [10 NYCRR 415.11(c)(2)(iii)]

Based on observations, interviews and record review conducted during a Recertification Survey, completed on 10/7/21, it was determined that for one (Resident #84) of seven residents the facility did not ensure the environment remained as free of accident hazards as possible. Specifically, Resident #84 had a history of attempting to consume nonfood items and items were observed not properly stored to prevent a reoccurrence. This finding is: The facility policy Accident/Incident Reporting and Review (Staff/Visitors/Residents), dated 6/14/19, documented that staff are to report an Accident/Incident (A/I) involving a resident to the Unit Manager who fills out an A/I report and forwards it to the Director of Nursing (DON) or designee. The A/I plan of prevention is recorded on the Care Plan. Resident #84 had diagnoses including Alzheimer's disease, anxiety, and repeated falls. The Minimum Data Assessment, dated 8/26/21, revealed the resident was severely impaired cognitively, ambulated independently without supervision and did not exhibit wandering behavior. Review of the A/I report, dated 8/16/21 at 2:45 a.m., revealed that Resident #84 was wandering the unit, grabbed a bottle of barrier cream, put some in their mouth, spit it out and then attempted to eat soap. The report included no injuries were observed at the time, the resident's mouth was washed out with water, the barrier cream and soap were removed from the resident's environment and the Nurse Practitioner (NP) was notified. The A/I documented that Resident #84 was a wanderer. The investigation, dated 8/16/21, completed by the Registered Nurse Manager (RNM) documented that the care plan was updated to reflect the resident's attempts to consume nonfood items. The current Certified Nursing Assistant (CNA) Kardex (directs daily care) included under safety that Resident #84 was a fall risk and staff were to monitor their whereabouts due to unsafe wandering. The Kardex did not include the resident's history of consuming nonfood items. The Comprehensive Care Plan (CCP), revised 8/16/21, included that the resident may consume or attempt to consume nonfood items and interventions included to offer food or beverages of choice as tolerated/desired. Interventions did not include any approaches addressing the accessibility of potentially hazardous items in the resident's environment. In a progress note dated 9/1/21 at 11:50 a.m., the Licensed Practical Nurse (LPN) #1 documented that Resident #84 continued to wander around the unit. During observations on 10/6/21 starting at 9:04 a.m., Resident #84 was sitting in the hall with an untouched breakfast tray in front of them. The resident got up and ambulated into the dining room. Observed at this time in the resident's room was a bottle of shampoo on the sink counter and lotion, skin cleanser, skin protectant, and more shampoo in a basin on the sink counter. Both doors to the resident's room (2025) and bathroom were open. In an open well lighted restroom next to the dining room an open container of powder and a spray bottle of odor eliminator were observed next to the towel dispenser. During an observation on the Resident #84's unit on 10/07/21 at 8:25 a.m., Resident #84 was observed in the common area. The following items were observed: a) In room 2024, an open bottle of shampoo was accessible on the bathroom counter. b) In room 2023 skin and hair cleanser, shaving cream and personal cleanser spray lotion were accessible on the bathroom counter. c) In room 2027 a basin contained moisturizer, body wash, shave cream, skin cleanser, and personal cleanser spray lotion were accessible on the bathroom counter. During an interview on 10/6/21 at 10:04 a.m. LPN #1 stated that resident's personal care supplies are stored in a basin in the resident's bed side stand and were accessible to residents. LPN#1 stated Resident #84 had ingested personal care supplies before. The LPN stated that Resident #84 wandered into other resident's rooms and goes through their drawers and that staff try and redirect the resident when possible. During an interview on 10/6/21 at 1:52 p.m., the DON stated that they did not really change anything in the care plan related to the environment or storage of personal items and that the A/I report did not really address this. The DON stated they had not done any rounds regarding the accessibility of personal care items. During an interview on 10/7/21 at 11:16 a.m., the RNM stated that Resident #84 was in the lounge when the Incident occurred but was not aware of where the resident obtained the barrier cream but that it should have been part of the investigation along with any assessment of the resident's mouth and any directions regarding poison control. The RNM stated that all personal items should be put away in bedside stand but that they cannot lock the drawers as resident's have the right to access the drawers. 10NYCRR 415.12(h)(2)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 10/7/21, it was determined that the facility did not properly establish and maintain infection control practices to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable and transmission-based diseases and infections. Specifically, 1) the facility did not implement appropriate transmission-based precautions (TBP) for one (Resident #39) of two residents reviewed with a communicable disease, 2) A Registered Nurse (RN) did not wear appropriate Personal Protection Equipment (PPE) while assisting with COVID-19 staff testing, and 3) the facility did not have available any tracking/trending/surveillance of infections in the facility for September 2021. This is evidenced by the following: 1. Resident # 39 was readmitted from the hospital on 9/3/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 9/9/21, revealed Resident #39 had a Multi-Drug Resistant Organism ([CONDITION(S)]-a common bacterium which have developed resistance to multiple types of antibiotics) and was identified as [CONDITION(S)]-Resistant Staphylococcus Aureus ([CONDITION(S)]) infection (also transmitted from person to person or contact with contaminated surfaces) in the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The facility policy Transmission Based Precautions Levels (Type of Infectious Conditions, Techniques and Documentation) dated 10/29/20 included that Contact Precautions (gown and gloves for hands-on care) should be initiated for residents known, or are suspected to have, a serious illness easily transmitted by direct resident contact or by contact with items in the resident's environment. Review of physician orders, dated 9/10/21, included [MEDICATION(S)] (antibiotic) 125 milligrams every 12 hours for C-Diff until 10/9/21. In a progress note, dated 9/10/21, the physician documented that Resident #39 had [CONDITION(S)] and also was to be on [MEDICATION(S)] for C-diff until 10/9/21. During observations of unit tours from 10/4/21 to 10/6/21 revealed there was no PPE cart (containing gowns and gloves) or any signage outside of Resident #39's semiprivate room to indicate the resident was on TBP. On 10/7/21 at 8:27a.m., a PPE cart was placed outside Resident # 39 door but no signage or instructions for staff regarding the appropriate PPE to wear when entering. When interviewed at this time Registered Nurse (RN) #1 stated that there is a cart outside the room now because they made the decision to place Resident #39 on contact precautions. When interviewed on 10/7/21 at 9:37 a.m., the Director of Nursing (DON) stated that Resident #39 was not on precautions because the resident's infection was treated with [MEDICATION(S)] and the hospital discharge summary included that the resident was not on isolation. In a telephone interview on 10/7/21 at 10:15 a.m., the physician stated they were aware that Resident #39 had [CONDITION(S)] and C-Diff and that nursing should follow protocols (policy) for TBP. 2. During observations on 10/07/21 at 8:20 a.m., at the facility front entrance desk RN #2 was wearing a KN95 mask and glasses. RN #2 was assisting with testing staff for COVID-19 using the rapid self-test for [CONDITION(S)]-CoV-2. The staff member being tested removed their face mask and not wearing gloves, self- swabbed their nose and handed the soiled swab to RN #2 who was also not wearing a gown or gloves. RN #2 was observed sanitizing their hands with alcohol-based hand rub (ABHR) prior to continuing with the testing process but continued to not wear a gown or gloves with each test. The Center for Disease Control (CDC) Performing Broad-Based Testing for [CONDITION(S)]-COV-2 in Congregate Correctional, Detention, and Homeless Service Settings considerations for Health Departments and Healthcare Providers Summary of Recent Changes, dated 3/29/21, PPE requirements based on staff's role in specimen collection included the following: a) Gowns, National Institute for Occupational Safety and Health (NIOSH)-approved N95 or equivalent or higher-level respirator (or mask if a respirator is not available), gloves and eye protection are needed for staff collecting specimen or working within six feet of the person being tested . b) For staff having direct contact with people being tested or with the specimen, gloves should be changed, and hands sanitized after each person tested . In an interview on 10/07/21 at 8:39 a.m., the DON stated that there is no need for the RN to wear gloves during COVID-19 testing because the employee is removing the swab from the container and swabbing their own nose. The DON stated that the RN sanitizes their hands frequently during testing but should probably wear gloves after retrieving the swabbed stick from the staff member. In an interview on 10/07/21 11:31 a.m., RN #2 stated that they do not wear gloves during COVID-19 testing because staff are swabbing their own nose. RN #2 stated that both hands are sanitized with ABHR in between each staff member but that given they are touching the used swab stick, they should wear gloves. 3. A review of the facilities infection control program (ICP) revealed there was no surveillance, tracking and trending of infections for September 2021 available. In an interview on 10/07/21 at 11:40 a.m., the DON stated that the Infection Preventionist (IP) completes the surveillance, tracking and trending of infections list by hand (hard copy) and usually places it in the ICP binder. They stated that it is not on the computer and that if it is not in the binder, the IP must have it with them. The DON stated that she does not currently have access to the September 2021 surveillance, tracking and trending infection list and that the IP was unavailable. 10NYCRR483.80(a)(1)(2)(3)(4)

Based on observation and interviews conducted during a Recertification Survey, completed on 10/7/21, it was determined that the facility did not ensure that the daily posting of nursing staff directly responsible for resident care was up to date and accurately reflected the required data at the beginning of each shift. Specifically, the information posted (where residents and families could view it) was not updated with changes in the schedule. This was evidenced by the following: During a review of the Daily Staffing Sheets (names and hours of nursing staff working each shift, including shifts 'open' or not yet filled yet) provided by the facility, dated 10/4/21- 10/6/21, and the posted nursing staffing information for residents and families to view per shift revealed the information did not match. The information documented on the posted nursing staffing report was inaccurate and did not include the changes in the actual schedule. During an interview on 10/7/21 at 9:37 a.m. the Director of Nursing stated sheets containing the actual staffing were posted on the units daily in the charting rooms (not in public view as observed by the surveyor) and these sheets reflected changes in staffing (as opposed to the posted staffing sheets for public viewing). During an interview, 10/7/21 at 10:50 a.m., the Administrator stated the daily staffing sheets (the ones in the charting room) is where they included the staff call offs and any open staffing positions per shift. 10NYCRR 415.13

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not act upon grievances of residents affecting resident care and life in the facility. Specifically, the facility did not address grievances brought up by the residents in Resident Council Meetings in a timely, thorough and effective manner or provide rationale for delay in response. This is evidenced by the following: Review of Resident Council Meeting minutes, from 9/4/18 through 2/4/19, consistently documented no new concerns; only food concerns that the Food Service Director will take care of. Re-occurring concerns included, but were not limited to, too much rice/too dry, too much chicken and it is either not cooked enough or is like rubber and hard to cut, beef too hard and cannot cut or chew, too many carrots, food is often cold, and a lack of fresh fruit. The minutes did not include documented resolutions to specific resident food related concerns or plans for follow-up. During an interview on 3/20/19 at 3:00 p.m., Resident Council Representatives (#14, #27, #31, #38, #43, #54, #57 and #83) said that the facility administration had not reported back to the Resident Council regarding concerns related to food. Resident #83 said he does not get enough too eat and portions are too small. He said that chicken is sometimes served twice in one day. Residents said that food concerns are brought up every month and they feel like no one is listening because nothing ever gets done. Observations and interviews in the Main Kitchen on 3/20/19 at 11:54 a.m. included the following: a. Cook #1 was in charge of lunch meal preparation and made a grilled turkey sandwich to sample. The sandwich was the primary lunch entrée. He took a bite and said it was bland. b. The Food Service Supervisor tasted the sandwich and said it was bland. She said it could be made better with a little cheese, like pepper jack, mayonaise, or mustard. Interviews conducted on 3/21/19 included the following: a. At 1:33 p.m., the Activities Director who coordinates and attends the Resident Council Meetings said a Corporate Registered Dietitian and facility Diet Tech had attended the (MONTH) (YEAR) Resident Council Meeting, listened to resident food concerns but neither had returned to a Resident Council Meeting to discuss follow up. She said the previous Director of Food Service had written down food concerns but had not addressed specifics at the next meeting. b. At 2:02 p.m., a Diet Tech said the residents' concerns were not addressed by the previous Director of Food Service. c. At 3:45 p.m., the Administrator said there had been no formal response to resident concerns regarding food complaints. She said a new Director of Food Service is starting 5/1/19. The Administrator said that she would ask to attend the next Resident Council Meeting, in two weeks, and would address these concerns. (10 NYCRR 415.5(c)(5)(6))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #3 and #44) of two residents reviewed for tube feedings, the facility did not provide appropriate treatment and services to prevent complications. Specifically, the volume of tube feeding delivered in a 24-hour period was not consistent with the physician order. This is evidenced by the following: 1. Resident #3 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 2/16/19, revealed the resident had severely impaired cognition, weighed 139 pounds, had a feeding tube, and received 51 percent or more of calories and 501 cubic centimeters (cc) or more of fluids via tube feeding. A Nutrition Note, dated 1/30/19, revealed the resident's current weight was 130 pounds. The resident had a weight gain but it was not significant. The tube feeding delivered 1,035 milliliters (mls) per 24-hours. The resident's weight on 3/8/19 was documented as 139.4 pounds which revealed a weight gain of nine pounds in two months. The Comprehensive Care Plan (CCP), dated 3/15/19, revealed that the resident received 100 percent of nutrition through the tube feeding related to dysphagia. Interventions included to provide enteral feed and flushes per current physician orders. The current physician orders [REDACTED]. Stop the enteral feed every 24 hours to verify 920 mls have infused. The Fluid Intake Report which documents the enteral feeds delivered in 24 hours, dated 12/20/18 to 2/18/19, revealed that for 15 of 61 opportunities the 24-hour volumes of tube feeding delivered was greater than 10 percent above or below the ordered amount. The amounts ranged from 345 mls to 1,369 mls. The Fluid Intake Report, dated 2/20/19 to 3/21/19, revealed that for 8 of 12 opportunities, the 24-hour volumes of tube feeding delivered was greater than 10 percent above or below the ordered amount. The amounts ranged from 575 mls to 1,034 mls. When interviewed on 3/20/19 at 3:30 p.m., the Registered Nurse Manager (RNM) said that the resident continued to gain weight and that was why her tube feeding had been recently changed (2/19/19) to run for eight hours versus nine. During an interview on 3/21/19 at 8:22 a.m., Licensed Practical Nurse (LPN) #1 said the evening shift starts the tube feeding for the resident. She said it continues through the night and ends in the early morning hours. She said every shift should document and verify with physician orders [REDACTED]. LPN #1 said the night nurse reviews the 24-hour intake and notifies the day shift if there are any concerns. She said if she happened to notice a blank or omission on the fluid intake report, she would notify the RNM for follow up to see what happened. She said the reason for omission should be documented. 2. Resident #44 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/15/19, revealed that the resident had severely impaired cognition, had a feeding tube, and received 51 percent or more of calories and 501 cc fluid or more per day. The CCP, dated 3/15/19, revealed that the resident received 100 percent nutrition through the tube feeding related to dysphagia. Interventions included to provide enteral feed and flushes per current physician orders [REDACTED]. The current physician orders [REDACTED]. The Fluid Intake Form, dated 12/20/18 to 3/20/19, revealed that for 30 of 93 opportunities, the 24-hour volumes of tube feeding delivered were greater than 10 percent above or below the ordered amount. The amounts ranged from 48 mls to 1,400 mls. In an observation on 3/18/19 at 3:52 p.m., the resident was in the lounge, watching television. A 1,000 ml bag of the tube feeding nutrient ([MEDICATION NAME] 2.0) was hung and the pump was running. The label on the tube feeding bag included the date and time (3/18/19 at 11:00 a.m.) and the rate of 40 mls/hour. The pump display read feed rate 40 mls/hour, 77 mls fed. There were 900 mls of tube feeding in the bag. Observations on 3/19/19 included the following: a. At 9:33 a.m., the resident was in a Geri-chair with the tube feeding running. The label on the bag of [MEDICATION NAME] 2.0 included the date and time (3/18/19 -11:00 a.m.) and the rate of 40 mls/hour. The pump display read: feed rate 40 mls/hour, 222 mls fed. There were approximately 275 mls left in the bag. b. At 3:20 p.m., the resident was in his room and the tube feeding pump was running. The label on the bag of [MEDICATION NAME] 2.0 included the date and time (3/18/19 11:00 a.m.) and the rate of 40 mls/hour. The pump display read 39 mls of tube feeding given. There were 100 mls of tube feeding in the bag. c. At 3:27 p.m., LPN #2 said that she checks the pump at the beginning of her shift to be sure the settings are correct for the tube feeding and water. LPN #2 said the feeding starts between 4:30 a.m. to 5:00 a.m. each morning and ends around 11:00 p.m. each evening. She said that day (3/19/19), she had given the resident 271 mls between 6:00 a.m. and 2:00 p.m. and that she changed the tube feeding bag. She said that the pump had been turned off for a while to give medications and the resident had a shower. LPN #2 said if the volume of tube feeding or water is not met at the end of 24 hours, the nurse must figure out who did not enter the amounts given on their shift. Interviews conducted on 3/21/19 included the following: a. At 11:15 a.m. and 1:53 p.m., the Diet Technician said neither she or the Registered Dietitian review the 24-hour intakes for tube feedings. She said nursing does that and if there is a problem, nursing should notify dietary. She said issues can be discussed at morning report, but nothing had been reported for either Resident #3 or Resident #44. She said that she would want to know if too much or too little tube feeding has been given as that could result in dehydration, weight gain, or weight loss. b. At 2:25 p.m., the RNM said that if volumes of tube feeding and flushes are different from the physician orders, then staff should document the reason for the inaccuracy and notify her and the physician. c. At 3:01 p.m., the RNM and the Director of Nursing said they would review nursing progress notes to see if any of the tube feeding variances had been documented. When interviewed on 3/22/19 at 2:00 p.m., the RNM said there were no nursing progress notes regarding tube feeding amounts being inconsistent with physician orders [REDACTED]. (10 NYCRR 415.12(g)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 1 of 26 residents reviewed for care planning, the facility did not develop a person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, Resident #87 did not have a care plan developed for smoking. This is evidenced by the following: Resident #87 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/10/19, revealed the resident was cognitively intact. The Admission History and Physical, dated 8/3/18, revealed the resident was a current smoker and stated he has smoked two to three cigarettes a day for the last [AGE] years and did not want to request a smoking cessation program. The resident signed for review and receipt of the facility, Tobacco Free Policy on 8/3/18. On 3/18/19 at 9:56 a.m., during the Entrance Conference, the Administrator said there were no smokers in the facility. During an observation on 3/19/19 at 9:30 a.m., the resident was observed outside the facility on the sidewalk, about 25 feet away from the main entrance. A transport bus was there but he did not get on the bus. The resident proceeded to light a cigarette, smoked it, then lit a second cigarette from the first cigarette. The surveyor asked staff to identify that person. The Registered Nurse Manager (RNM) identified the resident by name, and said that sometimes the resident waits outside for the bus. The current Certified Nursing Assistant (CNA) Kardex does not identify the resident as a smoker. The Comprehensive Care Plan for smoking was initiated on 3/19/19. Interviews conducted on 3/20/19 included the following: a. At 9:41 a.m., CNA #1 said she knew the resident smoked but was unsure how long he had been smoking. She said she saw him go outside the other day to smoke. CNA #2 said the resident has smoked from the day he arrived at the facility. CNA #1 and CNA #2 both said the resident purchased a new truck at the time of admission and parks it in the lot. They said he goes outside to smoke in his truck and keeps his smoking supplies with him. b. At 10:13 a.m., the resident said he has been smoking maybe one or two cigarettes a week since admission. He said he keeps his smoking supplies in his room and does not want staff touching his things. c. At 12:57 p.m., CNA #2 said the resident's daughter told her he was smoking, and she just figured other staff knew the resident was smoking. d. At 2:00 p.m., the RNM said she did not know the resident smoked until the previous day (3/19/19). She said the resident said he was going outside and that he wanted to smoke, and he was bound and determined to do so. The RNM said at that point, she initiated a Smoking Safety Assessment and a Comprehensive Care Plan for smoking. (10 NYCRR 415.11(c)(1))

Based on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 554) completed on 10/13/17, it was determined that for one of four residents reviewed for accidents, and for one of one resident reviewed for [MEDICAL TREATMENT], the facility did not provide the necessary care or services to attain or maintain the highest practical physical well-being. Specifically, the facility did not provide the necessary services and/or information to the resident and/or their legal representatives in order to make informed decisions regarding end of life care following a terminal diagnosis (Resident #46), and the facility did not consistently monitor fluid intake to ensure fluid restrictions were being followed (Resident #89). This is evidenced by the following: 1. Resident #46 was admitted to the facility on [DATE] and has recent [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/4/17, revealed that the resident had severe impairment of cognitive function, that it was very important to have family involved in discussions about care, was very important to participate in religious services, and required extensive assist from staff for all activities of daily living. The current Comprehensive Care Plan (CCP) revealed that the resident is grieving related to a [DIAGNOSES REDACTED]. Interventions include, but are not limited to, to consult pastoral care as needed, provide support with problem solving and support the resident through the stages of anticipatory grieving. Intermittent observations made on 10/10/17 at 11:00 a.m., on 10/11/17 at 10:25 a.m. and on 10/13/17 at 11:18 a.m., the resident was in bed sleeping, occasionally aroused to family or staff voices, and was observed to cry out in pain whenever repositioned by staff. Review of the medical record revealed the following: a. A Hospital Discharge Summary, dated 8/24/17, included that the resident was admitted to the hospital on [DATE] following a fall resulting in a head injury, subarachnoid hemorrhage, convulsions, and hematoma (collection of blood) of the brain and was started on two new medications. b. A Hospital Discharge Summary, dated 8/31/17, included that the resident was readmitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. c. Physician Electronic Notes, dated 9/2/17 and 10/4/17, both titled Admission History and Physicals, documented that the resident had [MEDICAL CONDITION]. Long-term care (as opposed to palliative or hospice) is electronically checked and included that the resident's prognosis is 'fair.' The vital sign sections include that the resident's weight had dropped from 244 pounds on 8/27/17 to 211 pounds on 9/14/17, but no documentation that the weight loss was addressed. The note revealed that the responsible party was informed of the resident's condition as evidenced by a check mark but no further information is documented. In an interview on 10/11/17 at 10:25 a.m. and again on 10/13/17 at 11:18 a.m., a family representative visiting at the time stated that the family was notified of the resident's [MEDICAL CONDITION] while he was hospitalized , but was not told how extensive it was and had not spoken to the physician since. The family representative said that two months ago, the resident was walking around the unit and feeding himself, and now he cannot get out of bed, is in terrible pain, much less responsive and can no longer answer for himself. The family representative was wondering if [MEDICAL CONDITION] was more extensive than they were told. When asked if they were offered hospice or any religious services, the family representative stated no, but that it would be welcomed for both the resident and family as they would like more information related to the resident's prognosis. Interviews conducted on 10/13/17 included the following: a. At 11:40 a.m., the Certified Nursing Assistant (CNA) stated that the resident has been very sick and does not get out of bed anymore, cannot walk and he cries when staff move him. b. At 9:04 a.m., the Social Worker stated that when the resident returned from the hospital with a [DIAGNOSES REDACTED]. She stated that she did have a conversation regarding changing the resident's MOLST (Medical Orders for Life Sustaining Treatment) to remove hospitalization , but family declined to change anything at the time. She said that she also discussed hospice with the family, but did not document that either and was unaware if the family had any ties to any churches. c. At 9:52 a.m., the Activities Director said that there is a volunteer pastor that was told of the resident's terminal [DIAGNOSES REDACTED]. Review of the activity log from 8/23/17 to the present revealed that the resident was invited to a Church service on one occasion on 9/10/17 but was sleeping. d. At 11:49 a.m., the Registered Nurse Manager (RNM) stated that she did speak to the resident's family about changing the resident's MOLST regarding not returning to the hospital but does not recall if they discussed the resident's terminal diagnoses. The RNM said that she thought the physician talked to the resident's family although not recently. 2. Resident #89 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/28/17, revealed that the resident was cognitively intact. Review of the facility policy, [MEDICAL TREATMENT], dated July 2000, directed to monitor intake and output and other parameters as ordered by the physician and to report/document as indicated, monitor and encourage compliance with renal diet and nutritional needs identified by dietary and ordered by the physician. The resident's current physician orders included Renal Diet, regular liquids and 1,500 milliliter (ml) fluid restriction. Review of the current Kardex, and the CCP dated 4/27/17, revealed that the resident was on a 1,500 ml fluid restriction. Approaches included no water pitcher. Review of the [MEDICAL TREATMENT] Communication Records from 9/12/17 and 9/23/17 included recommendations to limit fluid intake. Review of the Daily Fluid Report from 9/29/17 through 10/12/17 documented that on 10/4/17 the resident received 1,800 ml in 24 hours, and on 10/10/17 and 10/11/17, the resident received 1,620 ml fluids in 24 hours. During an observation on 10/12/17 at 11:47 a.m., the nurse delivered the resident's meal tray and there was one cup (236 ml) of fluid on the tray. There was no water pitcher in the room. Interviews conducted on 10/12/17 included the following: a. At 11:39 a.m., the Diet Technician (DT) stated that fluid restrictions should be included in the physician orders. She said that the amount of fluids that dietary provided for a fluid restriction would be documented in the care plan. The DT stated that she was unsure if a resident on a fluid restriction would be on intake and output. b. At 1:28 p.m., a CNA stated that fluids are monitored for every resident. The CNA stated she did not recall the resident being on a fluid restriction. She said the resident comes out of her room and gets fluids to drink. After reviewing the resident's Kardex, the CNA stated the resident was on a 1,500 ml fluid restriction. c. At 1:39 p.m., the Registered Nurse Manager (RNM) stated that fluid intakes are documented for every resident. The RNM stated that if a resident is on a fluid restriction, nursing would calculate the amount of fluids needed for medication administration and work with dietary on the amount of fluids to be included on the meal trays. The RNM said that she discussed with dietary the resident's fluid allocations for nursing and dietary but it was not documented. The RNM said that the night nurse generates and reviews a Fluid Report to identify residents that are not meeting their fluid goals. The RNM stated she was unaware that the resident was over her fluid restriction limit 10/4/17, 10/10/17 and 10/11/17. She stated that nursing should be monitoring the fluids of residents on a fluid restriction. During an interview on 10/13/17 at 9:25 a.m., the [MEDICAL TREATMENT] RN Clinical Manager stated that the resident's 1,500 ml fluid restriction was communicated to the nursing staff and dietary. She said they should work together to determine the amount fluids provided on the meal tray and the amount of fluids allocated for nursing. The [MEDICAL TREATMENT] RN said that the resident's fluids should be monitored as closely as possible. The [MEDICAL TREATMENT] RN said that the nursing staff should assist with enforcing the fluid restriction (10 NYCRR 415.12)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #35) of five residents reviewed for unnecessary medications, the facility did not provide care and services in accordance with the resident's written plan of care. Specifically, physician orders [REDACTED]. This is evidenced by the following: Resident #35 was admitted to the facility on [DATE] and has current [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/17/17, revealed that the resident had severe impairment of cognitive function and was on oxygen therapy. The current facility policy, Oxygen Therapy, Concentrator, directs for staff to change the humidifier bottle at least every seven days. The policy does not include guidelines on checking the oxygen saturations. Physician orders, dated 9/5/17, included oxygen two liters via nasal cannula at bedtime to maintain saturations above 90 percent, as needed oxygen during the day for saturations less than or equal to 90 percent, and to change the humidifier bottle every week on Friday night shifts. Observations made on 10/10/17 at 11:30 a.m. and 10/12/17 at 4:48 p.m., the resident was in bed sleeping. The resident's oxygen was on two liters via nasal cannula and the humidifier bottle was dated as last changed on 9/30/17. Review of the Medication Administration Records for September 2017 through 10/11/17 revealed that the resident's oxygen signed off as administered daily at bedtime. The humidifier bottle was signed off as last changed on 10/6/17 (night shift). Review of the Oxygen Saturation Summaries and Respiratory Assessments from 9/1/17 through 10/11/17 revealed no documented evidence that oxygen saturations were checked prior to oxygen use on 23 of 41 opportunities. There were three saturations documented for that time period at bedtime. Interviews conducted on 10/12/17 included the following: a. At 11:45 a.m., the Certified Nursing Assistant stated that the resident gets her oxygen whenever she lays down in bed in the afternoon and at bedtime. b. At 4:48 p.m., the Registered Nurse (RN) Manager stated that the resident wears her oxygen whenever she is lying down in bed. She said she expects that Respiratory Assessments are completed daily by the RN and should include oxygen saturations. She stated the equipment should be changed weekly. In an interview on 10/13/17 at 9:10 a.m., the Licensed Practical Nurse (LPN) stated that the RNs complete the daily respiratory assessments, and the LPNs complete the daily oxygen saturations and document in the computer. (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 (Resident #108) of three residents reviewed for Activities of Daily Living (ADL), the facility did not ensure that a resident's care plan was revised to reflect the resident's current care needs. The issue involved the lack of care plan revisions for refusals of care. This is evidenced by the following: Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/24/17, included that the resident had severe impairment of cognitive function, had no behaviors and required extensive assist of staff for personal hygiene. Review of the current Comprehensive Care Plan (CCP) and the Certified Nursing Assistant (CNA) Kardex revealed that the resident had a deficit in ADL function due to dementia and had upper partial dentures and natural bottom teeth. Interventions included extensive assist with hygiene, to encourage and assist with oral care every morning and bedtime. Neither the CCP or the Kardex included any information or interventions related to resident's refusals of care. Review of the most recent Dental Progress Note, dated 5/8/17, included recommendations to remove the resident's dentures at night and clean them at least once per day. Observations on 10/11/17 at 9:07 a.m. and at 1:50 p.m., and on 10/12/17 at 1:39 p.m., the resident was observed to have creamy white debris in teeth crevices. Review of the Plan of Care Response History (documentation of care as entered in the Electronic Medical Record by the CNAs) revealed that for the past month the resident refused oral care once or twice daily on 16 of 30 days. Review of the Nursing Progress Notes for the past month did not include any documentation related to refusals of oral care. Interviews conducted on 10/12/17 included the following: a. At 1:41 p.m., CNA #1 (day shift) stated that she cleans the resident's teeth when she lets staff. CNA #1 said that she did not clean the resident's teeth that morning as the resident refused. When asked if she attempted again, the CNA #1 stated yes, but that the resident continued to refuse. CNA #1 stated that the resident had her own teeth and did not wear dentures. b. At 4:43 p. m., CNA #2 (evening shift) stated that the resident does not like her teeth cleaned. CNA #2 said that sometimes the resident resists but re-approaching later will often work. In an interview on 10/13/17 at 11:42: a.m., the Registered Nurse Manager (RNM) stated that if a resident refuses care then she expects staff to ask another aide to attempt. She said if the resident continues to refuse then the CNAs should notify the nurse and let them check to see if there are any issues that need to be addressed. The RNM said the resident's care plan should be revised to reflect what to do if the resident refuses. (10 NYCRR 415.11(c)(2)(i-iii))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #72) of three residents reviewed for skin conditions, the facility did not investigate an abrasion to rule out abuse, neglect, or mistreatment. This is evidenced by the following: Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/17/17, revealed that the resident had severely impaired cognition. The Comprehensive Care Plan, dated 5/31/17, included that the resident was at risk for skin tears and bruising related to a history of skin tears due to thin translucent skin and a history of rubbing her arms. Interventions included to continue treatments per order, to encourage good nutrition and hydration to promote healthier skin, to identify potential causative factors and eliminate/resolve when possible. An Incident and Accident Report, dated 10/7/17, revealed that the resident's family member had asked that the resident's leg be evaluated. It was documented that the area looked like an abrasion to the left outer leg. There was no additional information regarding the abrasion. When interviewed on 10/13/17 at 10:00 a.m., the Unit Nurse Manager (NM) said that the investigation had not been completed and that there are no staff statements. The NM stated that the survey had started and delayed the investigation process. During an interview on 10/13/17 at 10:24 a.m., the Assistant Administrator stated that she would have expected to see a skin evaluation for the left leg abrasion documented on 10/7/17. She said once that was completed it would have triggered the Registered Nurse to assess the resident's skin. She said if there was a Supervisor in the building, the nurse should have called them down to assess the resident's skin. The Assistant Administrator stated that the investigation should have been completed by now including statements and a conclusion from staff to determine the potential cause of injury and a conclusion. (10 NYCRR 415.4(b)(1-4))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for nutrition and one of four residents reviewed for accidents, the facility did not notify the physician or family. Specifically, the medical provider was not notified of a significant weight change (Resident #42) and the resident's legal representative and medical provider were not notified timely when a resident sustained [REDACTED].#46). This is evidenced by the following: 1. Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 7/8/17, revealed that the resident was cognitively intact, weighed 160 pounds, had a weight loss of 5 percent or more in the last month, and was on a physician prescribed weight loss regimen. Review of the Admission Assessment, dated 7/1/17 and signed by a Registered Nurse (RN), documented a weight of 170.2 pounds. [MEDICAL CONDITION] was not checked. Review of the Weight Summary documented that the resident weighed 170.2 pounds on 7/1/17 and 7/3/17, 160.4 pounds on 7/8/17, and 157.2 pounds on 7/12/17. Review of the Physician's Admission History and Physical, dated 7/5/17, documented the resident had no [MEDICAL CONDITION] and weighed 170.2 pounds on 7/3/17. Review of the Nutritional Assessment, dated 7/14/17, completed by the Diet Technician and signed by the Dietician on 7/19/17, revealed that the resident was on a regular diet, eating 75 to 100 percent on average with an average fluid intake of 1,807 milliliters (ml) per day. The resident had a weight loss of 13 pounds (7.6 percent) in two weeks. The resident was on [MEDICATION NAME] (a diuretic) 20 milligrams a day due to [MEDICAL CONDITION] and it may cause weight loss due to fluid retention. Review of the Physician's Discharge Note, dated 7/19/17, revealed that the resident was to be discharged home on[DATE], had no [MEDICAL CONDITION] and weighed 158.3 pounds on 7/17/17. Interviews conducted on 10/12/17 included the following: a. At 11:35 a.m., the Dietary Technician (DT) said the nurses weigh the residents and she reviews the weights for a significant change. She stated if a resident had a loss or gain of five or more pounds a reweigh would be requested. The DT stated that she or the Dietician would review the weights and document a weight note. The DT stated that she does not notify the physician of a resident's weight loss but thought maybe the nurses notified medical. b. At 1:39 p.m., Registered Nurse Manager (RNM) #1, said if a resident had a weight loss or gain of five pounds, then the resident would be placed on weekly weights. She said the physician would make the determination if the weight loss was due to a diuretic. RNM #1 stated the physician would be notified as soon as a weight loss was identified. When interviewed on 10/13/17 at 9:32 a.m., RNM #2 stated that weekly weights were obtained for all new admissions for four weeks unless the physician orders [REDACTED].#2 said that she and the DT would review the resident's weights for weight loss. RNM #2 said the physician should have been notified of the resident's weight loss. 2. Resident #46 was admitted to the facility on [DATE] and has recent [DIAGNOSES REDACTED]. The MDS Assessment, dated 9/4/17, revealed that the resident had severe impairment of cognitive function, that it was very important to have family involved in discussions about care, and required extensive assist from staff for all activities of daily living. The current facility policy, Prevention and Reporting of Accidents/Incidents, directed that the legally appointed representative and/or responsible party will be contacted immediately of an accident/incident as applicable. It also includes to consult the resident physician when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention. Review of the Electronic Health Record revealed the following: a. A Nursing Progress Note, dated 8/23/17 at 6:50 a.m. and signed by Licensed Practical Nurse (LPN) #1, documented that the resident was found on the floor in the hallway at 3:45 a.m. There was blood on the floor and a [MEDICAL CONDITION] in a z-shaped pattern. The on-call RN Supervisor was notified via telephone, neurological checks were done by LPN #1, ice applied to the wound and the resident was lifted into the chair. The resident's vital signs were stable and he denied pain. The note does not include that family or the physician was notified. b. A facility Incident/Accident Report prepared by LPN #1, dated 8/23/17, includes LPN #1's account of the fall. The report also includes a note dated 8/23/17 and written by the RN supervisor that she was notified by phone at the time of the fall and again at 7:14 a.m. by LPN #2 that the resident was worse and staff were instructed to send him to the hospital. The report also includes that it was revised on 10/6/17 (by unknown staff member), and under 'people notified' that the physician was notified at 4:00 a.m. It does not include any family notification. c. In a Nursing Progress Note, dated 8/23/17 at 7:14 a.m., LPN #2 (day shift) documented that the nursing supervisor was notified via telephone regarding the head injury sustained on the previous shift and that the resident was sent to the emergency room and the physician was notified. d. A Hospital Discharge Summary, dated 8/24/17, revealed that the resident required a CAT (computerized axial tomography) scan which indicated a traumatic subarachnoid hemorrhage, convulsions, and a hematoma (collection of blood) of the brain and was started on two new medications. e. A Nursing Progress Note, dated 8/24/17, revealed that the resident returned to the facility with ten staples in the back of his head and was started on new medications due to blood in his brain. In an interview on 10/11/17 at 10:25 a.m. and again on 10/13/17 at 11:18 a.m., a family member visiting at the time stated that family was not notified about the fall until 7:30 a.m. after the resident was sent to the hospital. The family member stated that if they had they been notified they would have requested the resident be sent immediately to the hospital due to his head injury. In an interview on 10/12/17 at 4:09 p.m., LPN #1 stated that she did not call the physician or the family after the fall because they do not make the calls on the night shift unless the resident is transferred to the hospital. LPN #1 said that it was the responsibility of the day shift nurses to notify the family and the physician. Interviews conducted on 10/13/17 included the following: a. At 8:09 a.m., the Certified Nursing Assistant stated that when she arrived on the floor at 3:45 a.m. she saw the resident lying on the floor and that there was a lot of blood all over the floor. When she asked if the resident was being sent to the hospital ,she was told that the supervisor told them not to send him. b. At 11:49 a.m. the RNM stated that she was the supervisor on call the night of the fall and was told the laceration was not very big and that the resident was stable. She said she did not call the physician or the family as it is the responsibility of the nurse on duty at the time of the incident. The RNM said that she told the nurse to call the physician at that time, and was not aware that it was not done. She said that when the day nurse told her the resident's head was bleeding a lot and that he was not acting normal, she instructed the nurse to send the resident to the hospital. (10 NYCRR 415.3 (e)(2)(ii)(a)(b), 415.3 (c)(2)(ii)(b))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 919) completed on 3/13/17, it was determined that for one (Resident #6) of four residents reviewed for accidents, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the resident was care planned to have a bedside commode on the left side of the bed at night, was found on the floor, and subsequently diagnosed with [REDACTED]. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/3/16, revealed that the resident has modified independence with cognitive skills (some difficulty in new situations only) for daily decision making, requires supervision, and one-person physical assist for toilet use. The Comprehensive Care Plan (CCP), initiated on 9/29/16, revealed that the resident was care planned for a bedside commode in her room on the left side of her bed to minimize risk of falling and is used to self-transfer to the commode at night. The Admission/Readmission form, dated 9/30/16, included a commode at bedside at night. The progress note, completed by the Licensed Practical Nurse (LPN), dated 10/3/16 at 3:21 a.m., revealed that the resident was found in a sitting position facing the bathroom. The Incident Report, dated 10/3/16 at 3:13 a.m., revealed that the resident was found a few steps away from her bed on the floor in an upright position facing the bathroom. The right hip x-ray findings, dated 10/3/16, revealed a right femoral head fracture. During an interview on 2/28/17 at 10:30 a.m., the Director of Nursing (DON) stated that the resident was found seated on the floor up against her bed approximately two steps away from her bed. The DON said that since the resident had been discharged , she would not be able to provide the Certified Nursing Assistant (CNA) care card/kardex. She said the bedside commode was care planned for on the CCP on admission on 9/29/16 and carried over to the CNA care card/kardex at that time. Interviews conducted on 3/13/17 included the following: a. At 4:05 p.m. by telephone, the night Licensed Practical Nurse (LPN) stated that she worked the night that the resident fell . She said after she completed the Incident Report and notified the resident's family, she returned to the resident's room to check for the bedside commode. She said there was no bedside commode. The LPN added that the resident was a couple of feet away from the bed facing the door. b. At 4:15 p.m. by telephone, the night CNA stated there was no bedside commode in the resident's room at the time of the fall. The night CNA added that the resident was 3 to 4 feet away from the bed, and it looked like she was heading toward the bathroom. (10 NYCRR 415.12(h)(1-2))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 919) completed on 3/13/17, it was determined that for one (Resident #6) of four residents reviewed for accidents, the facility did not thoroughly investigate a fall. This is evidenced by the following: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Incident Report, dated 10/3/16 at 3:13 a.m., documented that on 10/3/16 the resident was found a few steps away from her bed on the floor in an upright position facing the bathroom. Statements were not provided. Interviews conducted on 2/28/17 included the following: a. At 10:30 a.m., the Director of Nursing (DON) stated that the resident was found seated on the floor approximately two steps away from her bed. The DON added that statements were not located, but the Licensed Practical Nurse (LPN) wrote a progress note documenting that the resident was sitting on the floor. b. At 11:10 a.m., the Nurse Manager (NM) stated that she investigated the incident. When asked if the commode and care plan were reviewed during investigations, the NM did not respond. The NM stated that she would look for statements. c. At 11:20 a.m. when interviewed by telephone, a family member stated that the resident was used to having a bedside commode at home, and this was arranged during admission. The family member added that when the facility notified her about the fall, she asked about the commode. She said the nurse did not know if there was a bedside commode. The family member stated she had not been informed about whether the commode was at the bedside. Interviews conducted on 3/13/17 included the following: a. At 11:25 a.m., the NM stated that she was unable to locate any staff statements related to the incident. b. At 4:05 p.m. by telephone, the night LPN stated that she worked the night the resident fell and completed a progress note but did not provide a statement. The LPN stated that the resident was a couple of feet away from her bed when she was found on the floor. The night LPN added that after completing the incident report and notifying the family, she returned to the resident's room and noted that there was no bedside commode. c. At 4:15 p.m. by telephone, the night Certified Nursing Assistant (CNA) stated that she was the first one in the room the night the resident fell . She said she thought she filled out a statement, but was unsure. She said she was asked questions by the night LPN. The night CNA added that she was not sure if she was asked about the bedside commode or if the care plan included a commode. She said there was no commode in the resident's room at the time of the fall. The facility policy, Incident Reporting, reviewed March 2015, included obtaining all staff statements as indicated on the Incident Report form, and the charge nurse will review the report and forward the report with all written statements to the Director of Nursing. (10 NYCRR 415.4(b)(3))

Based on observations, interviews, and record reviews, it was determined that for 1 (Resident #4) of 38 residents reviewed for professional standards of quality, the facility did not provide services in accordance with professional standards. Specifically, nursing staff did not administer insulin in a timely manner as ordered and did not notify the Registered Nurse (RN) charge nurse or physician of this medication error. This is evidenced by the following: Resident #4 has [DIAGNOSES REDACTED]. A review of the physician progress notes [REDACTED]. A review of the Medication Administration Record [REDACTED] A review of the July 2016 MAR indicated [REDACTED]. It is also noted that the resident is to receive sliding scale [MEDICATION NAME] insulin, with a blood glucose checked at 7:00 a.m. and 11:30 a.m. According to the MAR, dated 7/20/16, the 7 units of [MEDICATION NAME] scheduled before breakfast at 8:00 a.m., was administered late at 9:47 a.m., but less than two hours later, 4 units of [MEDICATION NAME] was given for sliding scale at 11:38 a.m. for a blood glucose of 340. The 7 units of [MEDICATION NAME] scheduled before lunch at 12:00 p.m. was administered at 11:39 a.m. On 7/20/16 at 9:44 a.m., Licensed Practical Nurse (LPN) #1 was observed administering 7 units of [MEDICATION NAME] insulin. Interviews conducted on 7/20/16 included the following: a. At 10:01 a.m., LPN #1 stated that the [MEDICATION NAME]was being given late. She stated that the resident's blood sugar had been low. She had given the resident chocolate milk and the resident had eaten breakfast at 8:30 a.m. LPN #1 stated she would normally call the doctor if medication was being given late. b. At 10:24 a.m., the physician stated that for a low blood sugar, the medication may need adjusting, indicating that a result of 70 to 80 was borderline, but 50 would be worse. He stated that he would expect the nursing staff to notify him if a resident was having mental status changes. c. At 10:33 a.m., the Registered Nurse Manager (RNM) presented documentation showing that the resident's blood sugar level was 63 at 7:00 a.m., and nursing had documented that 4 ounces of chocolate milk was given to sustain until breakfast. The RNM stated that if a medication is not on time, the nurses should notify the desk nurse, and they would call the doctor. Also, the physician's orders [REDACTED]. The RNM reported that she had been the desk nurse and had not been notified that this resident's insulin was being given late. During an interview on 7/22/16 at 11:50 a.m., the RNM stated she was aware that the staff do occasionally get behind but did not know that the insulin was almost two hours late, and the next dose was being given almost on time. Review of the undated facility policy, Blood Glucose Monitor, Use and Management Of, revealed that nursing is expected to record results and observations on the appropriate record and to notify the physician if glucose is less than 40 or greater than 400. Review of the undated facility policy, Administration of Medication, revealed that medications are to be administered in accordance with written orders by the physician, as soon as possible after preparing them. This policy does not address circumstances when nursing should hold medications. (10 NYCRR 415.11(c)(3)(i))

Based on an observation, interviews, and record review, it was determined that for one (Resident #132) of two residents reviewed for dignity, the facility staff did not promote care for each resident in a manner that maintains or enhances their dignity. Specifically, a resident was provided wound care in a common area in front of several other residents. This is evidenced by the following: Resident #132 has [DIAGNOSES REDACTED]. Review of progress notes, dated 6/22/16, revealed that the resident had a biopsy on an area on top of the head at a dermatology office that day. Physician orders [REDACTED]. On 7/20/16 at 9:59 a.m., Licensed Practical Nurse (LPN) #1 was observed performing a wound dressing for this resident in front of other residents located in a common area. LPN #1 applied hydrogen peroxide to the resident's scalp, and then an ointment before putting a [MEDICATION NAME] dressing on top of the resident's head. When interviewed immediately after, LPN #1 stated that she did not think performing the wound dressing in front of other residents was a dignity issue because it was on top of the head. At 10:33 a.m. that day, the Registered Nurse Manager stated that it is not appropriate to do a treatment in the common area, and it is the expectation that all treatments are done in a private area. (10 NYCRR 415.5(a))