Every finding on record at Elderwood at Lockport

Based on interviews and record reviews conducted during survey, the facility failed to ensure that the residents' environment remained as free of accidents as possible, and that each resident receives adequate supervision and assistance devices to prevent accidents for one (1) (Resident #1) of three (3) residents reviewed for accidents. Specifically, on 12/24/2025, the facility failed to use two (2)-person bed mobility assistance, from lying to sitting on the edge of the bed, resulting in Resident #1 falling to the floor, sustaining a left hip fracture requiring an open reduction internal fixation (ORIF-surgical procedure to realign and secure broken bones with metal fasteners). This resulted in actual harm to Resident #1 that is not Immediate Jeopardy. The findings are: The policy titled Comprehensive Care Plan, dated 06/18/2025, documented the nursing home will develop and implement a comprehensive, person-centered care plan for each resident that addresses the resident's medical, nursing, mental, and psychosocial needs and will be reviewed and revised regularly to ensure optimal care. Components of the care plan included the services to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being. The policy titled Kardex (care guide), dated 10/11/2021, documented a Kardex will be developed and available for all residents to act as a quick reference to particular needs of each individual. The Kardex will be referenced prior to rendering care to ensure that care is provided appropriately. The Certified Nursing Assistant (CNA) Job Description, dated 07/2022, documented Certified Nursing Assistants assist with ensuring the health and well-being of the residents by providing direct nursing and personal care support. The Certified Nursing Assistant is responsible for assisting residents with all aspects of daily living activities (basic self-care tasks necessary for everyday functioning which include personal hygiene, dressing, eating, toileting, and mobility/transferring) ensuring that the highest degree of quality resident care is maintained at all times. Essential job functions included assisting residents with the following Activities of Daily Living (ADLs), according to their plan of care, individual needs and care preferences: bathing, grooming, dressing, toileting, eating, exercising, positioning, transferring, ambulation, and transportation. Resident #1 had diagnoses including cerebral infarction (stroke) with left hemiplegia (paralysis)/hemiplegia (weakness), aphasia (absence or difficulty with speech), and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 10/16/2025, documented the resident had moderate cognitive impairment and was dependent (helper does ALL of the effort, resident does none of the effort to complete the activity or the assistance of two (2) or more helpers are required for the resident to complete the activity) for lying to sitting on side of bed.The Comprehensive Care Plan initiated on 12/08/2023 documented Resident #1 had a deficit in activity of daily living function related to cerebral vascular accident (stroke). Interventions included bed mobility (lying to sitting on side of bed) substantial or maximal assistance/two (2) plus person physical assist. The Progress Note completed by Registered Nurse #1 dated 12/24/2025 at 9:08 AM documented Resident #1 had fallen out of bed. Resident reported pain in both hips and was noted to be drawing left leg up to chest due to pain. Three (3) staff members assisted the resident back to bed via mechanical lift (device used to raise or lower people). Medical Doctor was notified and an order received to send the resident to the hospital for evaluation. The Progress Note completed by Registered Nurse #1 dated 12/24/2025 at 11:09 AM documented the hospital emergency department updated the facility with x-ray results of left intertrochanteric (hip) fracture. The facility Complaint/Incident Investigation Report 2700648 (5-day report sent by the facility), received 12/27/2025, documented Certified Nursing Assistant #1 provided care to Resident #1 prior to the fall, sat the resident on the side of the bed, left the room to get assistance and a mechanical lift to transfer Resident #1 out of bed. Care plan review revealed Resident #1 required assistance from two (2) staff members for sitting on side of bed. The care plan was violated when Certified Nursing Assistant #1 did not get a second person to assist Resident #1 from lying to sitting on side of bed. Certified Nursing Assistant #1 was given a final disciplinary action for improper conduct and violation of work expectations. Further education was provided on importance of reading and following resident care plans prior to providing care. The hospital Discharge summary dated [DATE] documented Resident #1 sustained a left hip fracture and underwent an open reduction internal fixation of the fracture on 12/26/2025. During a telephone interview on 03/12/26 at 9:36 AM, Certified Nursing Assistant #1 stated on 12/23/2025, they assisted Resident #1 to a sitting position on the side of the bed, without assistance from any other staff members, left Resident #1 sitting on the edge of the bed while they left the room to get a mechanical lift and a staff member to assist with the transfer of Resident #1 from the bed to a chair. When they returned to the room, Resident #1 was on the floor. Certified Nursing Assistant #1 stated they immediately notified the nurse. Certified Nursing Assistant #1 stated they did not review Resident #1's Kardex prior to providing care for Resident #1 because they had taken care of Resident #1 a few weeks prior. During an interview on 03/12/2026 at 10:53 AM, Registered Nurse #1 stated Certified Nursing Assistant #1 reported to them on 12/24/2025 that Resident #1 had fallen. Resident #1 was on the floor next to the bed, the Registered Nurse performed an assessment of the resident and was concerned regarding Resident #1's level of pain and complaints of headache. Certified Nursing Assistant #1 had told Registered Nurse #1 they had left the resident on the side of the bed and left the room to get a mechanical lift. Additionally, Resident #1 required maximal assistance of two (2) staff members to move from lying to sitting on side of bed secondary to poor trunk control unable to support self in an upright position unassisted. During an interview on 03/12/2026 at 11:00 AM, the Director of Nursing stated Certified Nursing Assistant #1 violated the care plan by not providing maximal assistance of two (2) staff members and leaving Resident #1 sitting on the side of the bed unassisted. Additionally, they stated staff are expected to review the resident Kardex prior to providing resident care. During a telephone interview on 03/12/2026 at 2:12 PM, the Nurse Practitioner stated Resident #1 had a history of cerebral vascular accident and required two (2)-person assistance with sitting on the edge of the bed because they were unable to sit alone unsupported. Additionally, they expected facility staff to follow resident care plans when providing care to prevent accidents. During a telephone interview on 03/13/2026 at 8:31 AM, the Medical Director stated they expected facility staff to follow resident care plans and Resident #1 sustained an injury when staff did not follow the care plan. During a telephone interview on 03/13/2026 at 10:36 AM, the Administrator stated all staff are expected to follow the resident care plan when providing care. 10 New York Code Rules Regulations (NYCRR) 415.12(h)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 5/2/25, the facility did not ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for one (1) (Resident #6) of two (2) residents reviewed. Specifically, Resident #6 had a moderate amount of unwanted facial hair on their upper lip, chin, and neck. The finding is: The policy titled A.M. Care, dated 4/10/2018, documented AM (morning)care will be provided for all residents in preparation for breakfast and the daily routine. Part of AM care included assisting with grooming needs: shave or clip facial hair. The policy titled Shaving a Female Resident, dated 5/8/2018, documented a nursing assistant will shave the face of a female resident, as needed, to remove extraneous facial hair. The nursing assistant is to report to immediate supervisor that the procedure was completed, any pertinent observations, and document appropriately. The policy documented to report if resident refused to be shaved. Resident #6 had diagnoses including anxiety, cognitive communication deficit (difficulty communicating their thoughts), and the need for assistance with personal care. The Minimum Data Set (a resident assessment tool) dated 2/21/25, documented they were severely cognitively impaired, sometimes understood and sometimes understands. They had no rejections of care, required partial/moderate assistance with personal hygiene, and substantial/maximum assistance for bathing/showering. The comprehensive care plan, dated 12/3/24, documented Resident #6 required one-person physical assistance for showers and received their shower on Thursdays in the afternoon. They were on anticoagulant therapy, and staff were to utilize an electric razor for shaving safety. The Kardex (a guide used by staff to provide care) dated 5/1/25, documented Resident #6 was a partial/moderate assist (one-person physical assist) for showers, weekly on Thursdays. The Certified Nurse Aide task documentation from 4/1/25-5/1/25 documented Resident #6 was assisted with personal hygiene at least once daily, with no refusals. Showers were documented weekly. The Treatment Administration Record from 4/1/25-4/30/25 documented weekly skin assessments from the nurse. Review of the nursing progress notes dated 4/1/25-5/1/25 revealed there was no documented evidence that Resident #6 was offered or refused shaving. During an observation on 4/29/25 at 8:53 AM, Resident #6 was in their wheelchair in the main dining room, at a table with two other residents. They had visible facial hair, approximately one centimeter long on their upper lip, chin and neck. During an interview on 4/29/25 at 10:07 AM, Resident #6's family member stated they had noticed the facial hair in the past. They stated Resident #6 did not like it and they would want it shaved. Resident #6's family member stated the resident was unable to take care of it themselves. During observations on 4/30/25 at 11:07 AM in the dining room, and 5/1/25 at 7:40 AM in the common area on West, Resident #6 was in their wheelchair. They had visible facial hair, approximately one centimeter long on their upper lip, chin and neck. During an interview on 5/1/25 at 9:45 AM, Registered Nurse #1, Unit Manager stated Certified Nurse Aides should shave residents on their shower days, but they should offer to shave them whenever they notice visible facial hair. If a resident refused to be shaved it should be documented. They had not been told that Resident #6 refused to be shaved. During an interview on 5/1/25 at 9:55 AM, Registered Nurse #2 stated Certified Nurse Aides should shave the residents on their shower day, or whenever they notice there is unwanted facial hair. They had not been informed Resident #6 refused to be shaved. They did not know when Resident #6 was last shaved. During an interview on 5/1/25 at 10:02 AM, Certified Nurse Aide #1 stated Resident #6 got up before 7:00 AM on 5/1/25. They stated they provided AM care, including washing face and hands, under arms, brushing hair, and incontinent care. Certified Nurse Aide #1 stated they did not notice Resident #6 had visible facial hair. They stated residents were usually offered shaving on their shower day, but they should offer to shave them if they notice visible hair. They stated it was important to shave unwanted facial hair for dignity. Certified Nurse Aide #1 stated they did not know when the last time Resident #6 was offered to be shaved because they didn't work on their unit very often. During an interview on 5/2/25 at 8:53 AM, Certified Nurse Aide #2 stated there was no set schedule for shaving residents' facial hair. Staff should offer to shave them at least on their shower day, or whenever they notice it. They did not know when the last time Resident #6 was shaved. During an interview on 5/2/25 at 9:43 AM, the Director of Nursing stated Certified Nurse Aides were responsible for shaving the residents' facial hair. They stated the residents should be offered to be shaved on their shower days, and any time staff notice they have visible facial hair. The Director of Nursing stated it was very important for unwanted facial hair to be removed for the resident's dignity and self-esteem. 10NYCRR 415.12 (a)(3)

Based on interview, observation, and record review conducted during a Standard survey completed on 5/2/25, the facility did not ensure that they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) (Resident #54) of four (4) residents observed for infection prevention and control during care. Specifically, staff did not wear personal protective equipment including gowns while providing incontinent care for Resident #54 who had ESBLs (extended spectrum beta-lactamase-an infection caused by antibiotic resistant bacterial enzymes) in their urine. The finding is: The policy titled Transmission Based Precaution Levels (Type of Infection Condition, Techniques, and Documentation) Skilled Nursing Facility dated 6/6/2024 documented that enhanced barrier precautions involved gown and glove use during high contact resident care activities (including changing incontinence briefs) for residents known to be colonized or infected with a multi drug resistant organism as well as those at an increased risk of multi drug resistant organism acquisition. Resident #54 was admitted to the facility with diagnoses of type 2 diabetes, chronic kidney failure, and muscle weakness. Review of the Minimum Data Set (a resident assessment tool) dated 3/14/2025 documented that Resident #54 was severely cognitively impaired and was dependent on staff for toileting. The enhanced barrier precautions list, provided by the Assistant Director of Nursing/Infection Preventionist, dated April 2025 documented that Resident #54 was on enhanced barrier precautions for having ESBLs in their urine. The comprehensive care plan dated 4/11/2025 documented that Resident #54 was totally dependent on two staff members for toileting. The kardex (used by staff to guide care) dated 5/1/2025 documented that Resident #54 was always incontinent of urine and to check their brief after meals. Laboratory reports for Resident #54 from 2/16/2025 to 4/21/2025 documented the following: 2/16/2025 - colony count greater than 100,000 CFU (colony forming unit)/ml (milliliter) of Escherichia coli (ESBL) bacteria in their urine. 4/21/2025 -colony count greater than 100,000 CFU/ml of Escherichia coli (ESBL) bacteria in their urine. During an observation of Resident #54's room on 4/30/2025 at 11:00 AM, revealed a blue diamond on the name plate outside the resident's door. Observation in Resident #54's room revealed a poster with enhanced barrier precautions and what personal protective equipment staff were to wear during care for residents. There was a container attached to the wall next to the door that contained yellow gowns to wear when care was performed. During an observation of incontinent care on 4/30/2025 at 11:00 AM, Certified Nurse Assistant #3 and Certified Nurse Assistant #4 donned gloves to change Resident #54's wet incontinence brief. They did not wear gowns while Resident #54's brief was changed. During an interview on 4/30/2025 at 11:17 AM, Certified Nurse Assistant #4 observed the blue diamond on the resident's name plate and stated that meant the resident was on enhanced barrier precautions. Certified Nurse Assistant #4 stated that they should have worn a gown when they performed incontinent care for Resident #54. During an interview on 4/30/2025 at 11:18 AM with Certified Nurse Assistant #3, they stated that Resident #54 was on enhanced barrier precautions, and they should have worn a gown when they performed incontinent care. Certified Nurse Assistant #3 stated that there could be cross contamination between residents if a disposable gown was not worn. During an interview on 4/30/2025 at 11:20 AM with Registered Nurse Unit Manager #3, they stated they expected staff to wear the appropriate personal protective equipment when they performed incontinent care. Registered Nurse Unit Manager #3 they stated that Resident #54 had a history of ESBL in their urine and that was why Resident #54 was on enhanced barrier precautions. Registered Nurse Unit Manager #3 stated that gowns should have been worn by staff because they risked getting bacteria on their clothes and they could spread the bacteria to other residents. During an interview on 5/1/2025 at 12:55 PM with Assistant Director of Nursing/Infection Preventionist, they stated that any resident with open areas, catheters, or ESBLs in their urine, staff were required to wear gowns and gloves during care. They stated that the blue diamond on the resident's name plate indicated that the resident was on enhanced barrier precautions. They stated that they had posters on the back of the resident's room doors that let staff know what type of personal protective equipment to wear when care was performed. They stated that there was a bin on the wall that contained gowns for staff to wear when they performed care, and they expected staff to wear them. They stated that staff were to wear gowns and gloves so that they did not spread bacteria to other residents. During an interview on 5/1/2025 at 1:07 PM with the Director of Nursing, they stated that they expected staff to wear appropriate personal protection equipment when they performed care on a resident with a history of urinary tract infections. During an interview on 5/2/2025 at 9:00 AM, Physician #1 stated they expected staff to wear a gown and gloves when they performed incontinent care especially for a resident with ESBL in their urine. 10NYCRR 415.19(a)(2)

Based on observation, interview, and record review conducted during Complaint investigations (#NY00309961, #NY00316113) during the Standard survey completed on 6/6/23, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three (East, West, North Units) of three resident care units. Specifically, the facility did not have adequate nursing staff based on the facility's established minimum number of staff for each unit and each shift. There was lack of answering resident call lights timely and providing toileting/incontinence care as planned. Resident's beds were not made, and residents didn't receive their medication on the East Unit the evening of 6/4/23. Additionally, the Facility Assessment did not include the minimal staffing numbers needed in order to care for their resident population. Resident #'s 3, 4, 8, 9, 12, 15, 16, 17, 20, 22, 32, 35, 37, 42, 44, 45, 46, 55, 56, 57, 58, 66, 74, 79, 81, 86, 89, 93 and 101 were involved. Resident Room #'s 24C, 25B, 26A, 27A and 28B were involved. The findings are: Refer to F677-Activities of Daily Living, scope and severity (S/S) =D 1a. Review of the Facility assessment dated [DATE] documented the facility's average daily census was 105 residents. The facility assessment documented staffing needs were based on total resident population, resident acuity, and facility layout. Refer to the attached master staffing plan. There was no master staffing plan attached to the facility assessment. Review of the Master Staffing Plan 2023 provided by the Administrator on 6/1/23 at 11:24 AM, revealed on the LTC (long term care) units (East/West Unit) day shift had two Registered Nurse (RN)/Licensed Practical Nurse (LPN) team leaders and 4/5 nurse assistants 7 days per week. Evening shift had two RN/LPN team leaders and 3/4 nurse assistants 7 days per week. The Administrator stated this was the master plan that should have been attached to the Facility Assessment. Review of the Facility Assessment Direct Care Nursing Staffing Plan dated 6/5/23, provided by the Director of Nursing (DON) on 6/5/23 at 4:20 PM, revealed minimum nursing staff numbers, for an anticipated average census of 103, as follows: day shift nurses 4.5, Certified Nurse Aides (CNAs) 8. Evening shift nurses 4.5, CNAs 8. Night shift nurses 3, CNAs 3. Review of the Daily Staffing Sheets from 5/20/23 to 6/4/23 documented the facility did not meet their minimum number of CNAs on: 5/20/23 evening shift - 6.5 (down 1.5) 5/21/23 day shift - 6 (down 2) 5/21/23 evening shift - 6.75 (down 1.25) 5/22/23 evening shift - 6.75 (down 1.25) 5/25/23 evening shift - 7.5 (down .5) 5/27/23 day shift -7 (down 1) 5/28/23 day shift - 7 (down 1) 5/28/23 evening shift - 6.5 (down 1.5) 5/29/23 evening shift -6 (down 2) 5/31/23 evening shift- 6.5 (down 1.5) 6/4/23 day shift - 7 (down 1) 6/4/23 evening shift - 6 (down 2) 6/5/23 day shift - 5 (3 Unit Managers were listed as help CNA) During an interview on 6/5/23 at 8:39 AM, the Staffing and Labor Operations Specialist stated they used the adequate staffing grid provided by the Administrator for their staffing numbers, and it was based on the facility census. At 3:34 PM, the Staffing Specialist stated they used the adequate staffing column as their minimum staffing numbers. During an interview on 6/5/23 at 3:38 PM, the Regional Nurse Consultant stated the adequate staffing grid was not what was used for their minimum staffing numbers, and they would provide it. During an interview on 6/5/23 at 3:42 PM, the Staffing and Labor Operations Specialist stated they had many vacant positions in the facility that included for day shift 2 full time and 7 part time CNAs, evening shift 6 full time and 8 part time CNAs. They stated the facility used agency staff and they had one full time contract CNA which gets a fixed schedule and works every other weekend. The rest was made up of agency per diem CNAs who worked as their schedules allowed. The Staffing and Labor Operations Specialist stated it was hit or miss whether staff would be enticed by offered weekend bonuses. The Staffing and Labor Operations Specialist stated they worked with the DON and stated the Daily Staffing Sheets were the most accurate documentation of their facility staffing. During an interview on 6/5/23 at 4:20 PM, with the Regional Nurse Consultant present, the DON stated when the facility falls below the minimum staffing levels, they (the DON) go into the facility to assist. The DON stated they were at the facility Saturday (6/3) and Sunday (6/4) evenings to help pass dinner trays, answer call lights, and speak with family members to help. The Assistant Director of Nursing (ADON) also worked. The DON stated they were at the facility until after dinner but couldn't give a specific time. The DON stated today (6/5) they had many call ins (3 CNAs, 2 nurses, and 1 unit clerk), so the unit managers worked as CNAs. Sometimes the managers do have to take an assignment, however this morning would have been hard because of doctor rounds. During an interview on 6/6/23 at 10:25 AM, the DON stated the minimal staffing numbers (Facility Assessment Direct Care Nursing Staffing Plan) was dated 6/5/23 but had been in place since Spring of 2022. The DON stated according to the Daily Staffing Sheets dated 5/20/23, 5/21/23, 5/22/23, 5/25/23, 5/29/23, 5/31/23, and 6/4/23 the facility did not meet their minimum number of 8 CNAs and was aware they didn't meet the minimums. The DON stated on 6/5/23 they had 5 actual CNAs working, the 3 RN Unit Managers worked as CNAs. The DON stated the RN Unit Manager on the North Unit helped with the morning medication pass, then worked as a CNA. The DON stated they themselves, the Regional Nurse Consultant, and activity staff were on the units helping. 1b. Review of Resident Council Minutes revealed the following: - 3/23/23 meeting notes documented the residents voiced concerns that there are not enough staff on the units on the weekends. - 4/20/23 meeting notes documented, Old Business- Residents reported that there aren't enough staff in the building on the weekend. It was also documented in the minutes the issue was not resolved to their satisfaction, and the minutes were reviewed and signed by the Administrator. - 5/18/23 meeting notes documented, Old Business- revealed the minutes did not address the resident's previously voiced concern of their dissatisfaction regarding their staffing concerns. During a Resident Council meeting held on 6/1/23 at 10:07 AM with 11 residents participating, they stated at times their call lights were not answered for up to an hour while waiting for their needs to be met such as toileting; returning to bed and receiving their meals. The Residents stated there was poor staffing during the week on days and evening shift, and especially short staffing on the weekends during the day and evening shifts. 1c. Interviews with Residents and Family Members: During an interview on 5/31/23 at 11:01 AM, Resident #66 stated the facility was hideously understaffed. It was difficult for them because they would call for a bed pan, the staff wouldn't come, so they don't get the bedpan. Wait times vary for call light response, but sometimes they've waited up to an hour. During an interview on 5/31/23 at 12:39 PM, an anonymous family member stated nothing was on time; medications, meals, and answering of call lights. During an interview on 5/31/23 at 12:54 PM, Resident #101 stated the facility was always short staffed and most of the time there was one aide on the evening shift. The resident stated that weekends were the worst, they had to wait a long time to go to bed, sometimes until 11:30 PM at night. During an interview on 5/31/23 at 1:12 PM, Resident #35 stated there was not enough staff in the building and they could wait 30 to 45 minutes for staff to respond to their call bell when they wanted their pain medication. During an interview on 5/31/23 at 3:39 PM, Resident #4 stated there was not enough staff in the building. They would have to wait 15 minutes and sometimes up to an hour for their call light to be answered. If they can't hold it they end up urinating in their brief and then they feel terrible. During an interview on 6/1/23 at 3:06 PM, CNA #4 (East Unit) stated they usually only work with 2 CNAs on the evening shift, and it has been that way for the past year. They can't get everything done, showers, stocking rooms with gloves/soap. CNA #4 stated the residents get upset with them, sometimes they can't put everyone to bed by the end of their shift. During an interview on 6/2/23 at 11:14 AM, LPN #5 (East Unit) stated staffing in the facility was very poor and unfair to the residents, and staff can't get to the residents in a timely manner. LPN #5 stated the East Unit usually only had 2 to 3 aides on the day shift, and they were frequently asked to stay/work over 2-3 times a week. LPN #5 stated the staffing was even worse on the weekends, usually only 1-2 aides on a unit and short nurses. During an interview on 6/2/23 at 1:58 PM, CNA #5 stated the North Unit was often short staffed. Most of the time they have two aides on the unit, it's hard to get all the work done, and they usually don't take a break. There have been times, they were the only aide on the unit. CNA #5 stated sometimes management comes in to help when they were very short staffed. During an interview on 6/5/23 at 11:42 AM, an anonymous family member stated they had spoken to the DON concerning the staff shortage, call lights being on for 40 minutes, and weekends noted with only one CNA and one nurse on the unit. 2a. During an observation and interviews on 6/2/23 at 9:53 AM of the East Unit, Resident #66's call light was on, the resident looked upset and stated they were soiled. They stated the had the call light on for a half hour to ask for a bedpan, but nobody came, so they had a bowel movement in their brief. Observation at 9:54 AM of the nurse call system located at the nurse's station, showed the resident's call light had been on for 18 minutes. At 9:55 AM, LPN #5 stated CNAs and nurses were supposed to answer the call lights within 5 minutes. During an interview on 6/2/23 at 10:24 AM, CNA #1 stated they only had 3 CNAs on the unit that day and it was hard to get everything done for the residents. During an interview on 6/2/23 at 11:09 AM, the Registered Nurse (RN) Unit Manager (UM) #1 stated on the East unit, they currently had 42 residents. The RN UM #1 stated call lights should be answered in 10 minutes but would like them checked sooner. RN UM #1 stated 18 minutes was not acceptable but unfortunately it was happening, the staff and themselves can only be in one place at one time. They had 15 residents who needed physical assistance with meals and 15-16 residents who transferred with a mechanical lift. 2b. Observations and interviews on the East Unit on 6/2/23 revealed the following: -At 2:02 PM, beds were unmade with disposable incontinent pads and linens present on beds in rooms 24C, 25B, 26A, 27A and 28B. -At 2:04 PM, CNA #2 stated they can't finish their assignment and feel it was impossible due to having too many residents. CNA #2 stated the CNAs were responsible for cleaning and making the residents beds if there was no support staff available. -At 2:11 PM, LPN #5 stated the residents' beds should have been made by the day shift staff because it makes their rooms feel more like home -At 3:25 PM, Resident #18 stated it bothered them that their bed wasn't made. Don't like it messed up all day long and then have to go to bed in it. Resident #18 stated beds were quite often not made, and it doesn't feel homelike. Additionally, Resident #18 stated they think they were short staffed. -At 3:28 PM, the RN #1 UM stated their expectation stated the CNAs were supposed to tidy up and make residents beds to keep a clean, neat environment, and for quality of life. The priority is to keep residents safe, feed and attend to them as quickly and efficiently as possible. -At 3:42 PM, Resident #22 stated they liked their bed made because it made their room look nice. 2c. Observations and interviews on the East Unit on 6/5/23 revealed the following: -At 8:46 AM, the nurse call system at the nurse's station showed Resident #20's call light was on for 81 minutes, Resident #89 call light was on for 29 minutes, and Resident #8 call light was on for 24 minutes. There were many residents still in bed that have breakfast trays in front of them. Reviews of the 2 aide assignment sheet dated 6/5/23, located at the nurse's station, documented CNA #2 and CNA #3 had 21 residents each on their assignments. -At 8:50 AM, RN UM #1 stated they were working as a CNA that day and pushed a mechanical lift down the hallway. -At 8:55 AM, activity staff were on the unit and answered Resident room [ROOM NUMBER] call light and Resident Rooms #'s 18 and 15 were still on. -At 8:58 AM, CNA #2 stated they had two aides working that morning, that's why Resident #20 call light had been going off for so long, and the time on the call light system at the desk was correct. CNA #2 stated they were still trying to get people up for breakfast, and that Resident #20 wasn't on their assignment then went to the linen cart. -At 9:04 AM, Resident #55 was in bed and eating breakfast. The resident stated they preferred to be up for breakfast, they didn't know why they were still in bed, and to ask the person in charge. -At 9:06 AM, the DON was in with Resident #20, repositioning the resident in their bed. -At 9:11 AM, Resident #20 was lying in their bed and stated they wanted to go to the bathroom, and it had been hours and hours and they still haven't gone. The resident stated it was terrible today, they haven't gotten their breakfast yet and they are usually up for breakfast. At 9:13 AM, RN #5 (med nurse) went in to assist the resident. -At 9:43 AM, Resident #20 was brought to the dining room and their breakfast tray was provided to them. During an interview on 6/5/23 at 1:31 PM, CNA #3 stated they didn't have enough staff to get everything done for the residents. CNA #3 stated they didn't know Resident #20 call light was on for 81 minutes, and they had answered that resident's call light one time, told them they were trying to get everyone up and had to wait a few minutes. CNA #3 stated they tried to do the best they could. During an interview on 6/5/23 at 4:20 PM, with the Regional Nurse Consultant present, the DON stated there was no set time call lights should be answered but would like to say 10 minutes or less for the initial look in, and they ask that call lights stay on until the resident's needs are met to their satisfaction. During an interview on 6/6/23 at 1:50 PM, RN UM #1 stated Resident #55 usually gets up for breakfast, and they weren't up on 6/5/23 because they had 2 CNAs and themselves working. On days like that, they prioritize getting the residents up who need supervision or physical assistance with their meals. Then as time allows, they go back to get the rest of the residents out of bed who it was more of a preference for versus a safety issue. 2d. During a continuous observation on the East Unit on 6/5/23 from 9:22 AM to 10:21 AM revealed at 9:22 AM Resident #22 was sitting in the lounge and requested out loud their need to use the bathroom. The nurse (RN #5) was present in lounge assisting another resident with eating responded there were only 2 aides, and they couldn't leave to take them to the bathroom. At 9:45 AM, Resident #22 stated they'd like to go to the bathroom, but there wasn't any help and didn't know how long they had been waiting. At 10:14 AM, Resident #22 was observed and heard asking staff entering the lounge area if there were any aides to take them to the bathroom. At 10:17 AM, Resident #22 was heard calling out specific staff names and said, Can anybody help? At 10:19 AM, Resident #22 stated to the Activities Director (AD) Is there anybody yet? the AD responded, somebody is coming, and Resident #22 stated I hope so. At 10:21 AM, Resident #22 was heard saying Still haven't gone to the bathroom. This place is a disgrace. As a staff member removed Resident #22 from the lounge and wheeled them to their room. During an interview on 6/5/23 at 10:28 AM, the AD stated they will usually let a nurse or aide know if a resident requested to go to the bathroom. The AD stated this was important for dignity and would want their needs met. 2e. Review of the Medication Administration Records dated 6/1/23 to 6/30/23 for Resident #s 3, 4, 8, 9, 15, 16, 17, 20, 32, 35, 37, 42, 44, 45, 46, 56, 57, 58, 74, 79, 81, 86, 89, and 93 (East Unit) revealed medications scheduled to be given on 6/4/23 at 7:00 PM to 10:00 PM were not initialed as administered. During an interview on 6/5/23 at 9:00 AM, Resident #17 stated they did not receive their medications on Sunday (6/4), evening shift. Resident #17 stated they told the nurse, and the nurse never came back. During a telephone interview on 6/6/23 at 8:34 AM, LPN #2 stated they were the only nurse on the East unit after 6:00 PM on 6/4/23. LPN #2 stated that usually a supervisor would come to the unit and help them with a medication pass if they were alone, but on 6/4/23 no supervisor came to help. LPN #2 stated they found out later the supervisors were passing medications on other units. LPN #2 stated the medications they didn't click on they didn't give and that they signed for the medications they gave. LPN #2 stated the supervisors knew they needed help and were behind. LPN #2 stated they did what they could do and had never passed medications to the entire unit during the evening shift by themselves. Additionally, LPN #2 stated there were only two CNAs on unit as well, so they had to stop passing their medications to assist them. During a telephone interview on 6/6/23 at 9:20 AM, the Assistant Director of Nursing (ADON) stated the past weekend (on 6/4/23) they worked the evening shift as a CNA on the North Unit because there was no aide. The ADON stated if a nurse couldn't get their medications done, a supervisor should have been told, then a supervisor would go over to help them. The ADON stated but if a supervisor was already on a cart, they didn't know how that was supposed to get done. The ADON stated they were all multitasking on Sunday. Three attempts were made without sucess to contact LPN #8 Supervisor that worked 6/4/23 during the 7:00 PM-7:00 AM shift. During an interview on 6/6/23 at 2:25 PM (with the Regional Nurse Consultant present), the DON stated they strive to have two LPN medication nurses on each unit. On 6/4/23 the East Unit dropped down to one nurse at 7:00 PM. The Regional Nurse Consultant stated they identified 35 residents who had blanks on their MARs on 6/4/23. They stated there was a liberalized medication pass times and if LPN #2 would have notified a supervisor that they had trouble passing the medications, they would have adjusted to get done what wasn't done. The DON stated they thought there were enough nurses to get the work done and they met their minimum number of nurses. During a telephone interview on 6/6/23 at 3:38 PM, LPN #7 Supervisor stated they worked as the facility supervisor on Sunday 6/4/23 from 7:00 AM to 7:00 PM and passed medications on the [NAME] unit as well. LPN #7 stated it was difficult to complete their assignment but was able to get it done. LPN #7 stated they had to assist with aide work such as transfers, showers and anything that needed to be done. LPN #7 stated LPN #2 did not discuss their inability to complete their assignment with them on 6/4/23. LPN #7 stated they would expect a nurse to inform the supervisor if they needed assistance with their assignment. During an interview on 6/6/23 at 9:20 AM, the Assistant Director of Nursing (ADON) stated staffing had been terrible at the facility since they started working at the facility several months ago. The ADON stated they have worked the evening shift, passed medications, worked as a CNA, and supervised the building. They helped where they were needed. The ADON stated the past weekend (on 6/4/23) they worked the evening shift as a CNA on the North Unit because there was no aide. During an interview on 6/6/23 at 2:20 PM, the DON stated they didn't meet their minimum staffing numbers on those days (5/20/23, 5/21/23, 5/22/23, 5/25/23, 5/29/23, 5/31/23, and 6/4/23) and the Administrator was aware. The DON stated they do discuss staffing at resident council and if there are any individual concerns, they review it. The DON stated they try to accommodate resident's individual needs, but someone has to wait for staff to get in there and they apologize. During an interview on 6/6/23 at 2:49 PM, the Administrator stated staffing had been a challenge since they started at the facility two months ago and that they do their best to meet the facility assessment numbers (The Master Staffing Plan 2023). The Administrator stated they weren't aware of the separate minimum staffing numbers (Facility Assessment Direct Care Nursing Staffing Plan) the DON had provided. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observation, record review, and interviews conducted during a Standard survey completed on 6/6/23, the facility did not ensure each resident was treated with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #66) of two residents reviewed. Specifically, the facility did not ensure Resident #1 was treated with respect and dignity by a Certified Nurse Aide (CNA) while providing morning care. The finding is: The policy and procedure (P&P) titled Dignity dated 8/1/19, documented each resident has the right to be treated with dignity and respect. All activities and interactions with residents by any staff must focus on assisting the resident in maintaining his or her self-esteem and self-worth. 1. Resident #66 had diagnoses including chronic respiratory failure, diabetes, and depression. The Minimum Data Set (MDS-a resident assessment tool) dated 5/10/23 documented Resident #66 was cognitively intact and required extensive assist with bed mobility and toileting. Review of the comprehensive care plan revised 5/23/23 revealed Resident #66 had an ADL (activities of daily living) deficit and required total assistance for toileting hygiene and was frequently incontinent of bowel. During an observation of morning care on 6/2/23 at 10:00 AM, CNA #1 brought linens into Resident #66's room, went into the bathroom, and let the water run, donned (put on) gloves and the resident stated you'll need more washcloths than that. At 10:01 AM, CNA #1 removed their gloves and stated they'd get some wipes and then stated, I really want to go home, then left the room. Resident #1 stated this was CNA #1's typical attitude and they always acted this way. The resident stated they did not feel the statement was dignified. At 10:03 AM, CNA #1 returned to the room and got the resident's personal clothes out of the closet, put the resident's head of bed down, went to the bathroom and stated, no gloves and you see why I want to go home. During an interview on 6/2/23 at 10:24 AM, CNA #1 stated they normally didn't speak that way in front of a resident and they were having an off day. During an interview on 6/2/23 at 11:18 AM, the Registered Nurse (RN) Unit Manager (UM) #1 stated staff should not be saying that they want to go home in front of a resident because it was inappropriate, rude and could make the resident feel like they did something wrong. The RN UM #1 stated it was a dignity issue. During an interview on 6/6/23 at 11:05 AM, the Director of Nursing (DON) stated the statement made by CNA #1 sounded like they were being rude and that wasn't what they expected regarding customer service toward residents. 10 NYCRR 415.5(a)

Based on observation, interview, and record review conducted during a Complaint investigation (NY00316113) during a Standard survey completed on 6/6/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for three (Residents #39, #74 and #101) of six residents reviewed for ADL's. Specifically, Residents #39 and #74 did not receive assistance with toileting needs as per their plans of care and Resident #101 did not receive assistance with their preferred number of showers per week as per their plan of care. The findings are: The policy and procedure (P&P) titled Perineal Incontinent Care documented perineal care will be provided with AM & HS (bedtime) care and when residents are incontinent or cannot provide such care for themselves. Nursing Assistants will provide incontinent care for residents. Perineal care will be given to cleanse the genital area, to prevent infections and to eliminate odors. The P&P titled ADL Assistance and Supervision dated 1/4/2018 documented, the Unit Manager/designee will ensure that a plan of care for receiving ADLS assistance and/or supervision is incorporated into the daily nursing care of each resident. The Team Leader provides a daily report to the Nursing Assistants regarding the ADL assistance/ supervision status of each assigned resident as needed. The Team Leader monitors the ADL assistance/ supervision provided for residents throughout the shift and gives appropriate guidance and assistance to Nursing Assistants. The P&P titled Bath, Tub/Shower dated 8/7/21 documented a tub bath or shower will be given to provide comfort and relaxation. A tub bath or shower will be given once a week and/or as deemed necessary to all residents or per resident preference. 1. Resident #39 had diagnoses that included dementia with agitation, peripheral vascular disease (PVD- poor circulation of lower extremities), and major depressive disorder. The Minimum Data Set (MDS - a resident assessment tool) dated 3/23/23 documented Resident # 39 had severe cognitive impairment and did not exhibit rejection of care. The resident required total assistance of two persons for toilet use (includes cleanses self after elimination, changes pad, adjusts clothes). Resident #39's undated comprehensive care plan (CCP) identified as current by the Director of Nursing (DON), documented Resident #39 had decreased ADL function and was always incontinent of bowel and bladder. Interventions included the use of incontinence products (brief), provide prompt incontinent care and check, and change every 2 to 4 hours and required total dependence of one person for incontinence care. Resident #39's undated Kardex (a guide used by staff to provide care) identified as current by the DON, documented the resident was always incontinent of bowel and bladder. Instructions included to check and change every 2 to 4 hours, incontinent product (brief) and requires total dependence of one person. Review of Resident #39's Progress Notes dated 5/13/23 through 6/6/23 revealed there was no documented evidence the resident refused incontinence care. During a continuous observation on 6/2/23 at 8:57 AM through 1:38 PM, Resident #39 was seated in a Broda chair (specialized wheelchair) in the [NAME] Unit Lounge and was not checked for incontinence. At 1:38 PM Resident #39 was transported from the lounge to activity off the Unit. During an interview on 6/2/23 at 1:41 PM, Certified Nursing Assistant (CNA) #3 stated they were assisted CNA #10 on 6/2/23 with morning care and transferring Resident #39 out of bed before breakfast approximately 8:30 AM. CNA #3 stated they had not checked or provided incontinent care to Resident #39 after 8:30 AM and did not know if CNA #10 had checked and provided care to Resident #39 before leaving the facility at 1:00 PM. CNA #3 stated Resident #39 was unable to communicate if they were incontinent and should be checked and changed every 2 - 4 hours according to the plan of care for dignity and prevent skin breakdown. During an interview on 6/2/23 at 1:57 PM CNA #7 stated they had not assisted CNA #10 with Resident #39, had not provided any care, or checked the resident for incontinence on 6/2/23. CNA #10 stated they did not know if CNA #10 had checked and provided care to Resident #39 before leaving the facility at 1:00 PM. CNA #7 stated Resident #39 was unable to communicate if they were incontinent and should be checked and changed every 2 to 4 hours according to the plan of care for dignity, prevent urinary tract infections and skin breakdown. During an interview on 6/2/23 at 3:04 PM, CNA #8 stated they had removed Resident #39 from an activity at 2:30 PM to check the resident for incontinence. The resident was incontinent of both bladder and bowel, required incontinence care and did not know how long the resident was sitting in their urine and feces. CNA #8 stated if Resident #39 was last provided care prior to breakfast at approximately 8:30 AM then they should have been checked for incontinence no later than 12:30 PM because the resident was unable to communicate if they were incontinent. Resident #39 was care planned to be checked and changed every 2 to 4 hours for dignity and prevent skin breakdown. During an interview on 6/2/23 at 3:19 PM, Registered Nurse (RN) #3 stated Resident #39 was care planned to be checked and changed every 2 to 4 hours, was totally dependent on staff for incontinence care to maintain dignity, good hygiene, and skin integrity; and was unable to communicate if they were incontinent. RN # 3 stated if Resident #39 last received care at approximately 8:30 AM then CNA #10 should have ensured the resident was checked for incontinence by 12:30 PM. During an interview on 6/5/23 at 1:00 PM CNA #10 stated they were responsible for providing care to Resident #39 on 6/2/23 until 1 PM when they had left the facility. CNA #10 stated Resident #39 was provided incontinent care before breakfast at approximate 8:30 AM and should have been checked and changed every 2 to 4 hours according to their plan of care but was not because they didn't have time. CNA #10 stated the resident should have checked by 12:30 PM for incontinence and provided care as needed before they had left the facility. During an interview on 6/6/23 at 10:43 AM, RN Unit Manager (UM) #4 stated Resident #39 was totally dependent on staff to maintain hygiene including incontinence care and was to be checked and changed every 2 to 4 hours according to the plan of care. RN UM #4 stated they would have expected CNA #10 to communicate to the remaining CNA and nurses they were unable to check and change the resident per their plan of care prior to leaving the facility. RN UM #4 stated the CNAs should be following the plan of care and the staff nurses were responsible to ensure the plan of care was followed and incontinent care is provided timely. RN UM #4 stated they were ultimately responsible to ensure the staff were following the plan of care for all residents. 2. Resident #74 had diagnoses that included Alzheimer's Disease, dementia with severe agitation and anxiety, and cognitive communication deficit. The MDS dated [DATE] documented Resident #74 was rarely/never understood and understands. The resident required extensive assistance of two persons for toileting and was always incontinent. Resident #74's comprehensive care plan (CCP) last revised 10/6/22, documented Resident #74 was always incontinent of bowel and bladder. Interventions included to offer toileting after meals (initiated: 12/21/22); incontinent care every 2-4 hours and as needed (initiated: 6/6/23) and to provide prompt incontinent care (initiated 10/6/22). The CCP revised on 12/8/22 documented Resident #74 required total dependence for hygiene; two-person extensive physical assist for transfers and toileting. The Follow Up Question Report dated 5/31/2023 - 6/6/2023 did not document toilet use for Resident #74 during day shift hours 6:00 AM to 2:00 PM. Review of the Kardex for Resident #74's with an as of date of 6/6/23 revealed it was reflective of the CCP regarding the resident's toileting needs. Review of Resident #74's Progress Notes dated 5/22/23 through 6/6/23 revealed there was no documented evidence the resident refused incontinence care. During intermittent observations on 6/2/23 at 8:43 AM through 11:48 AM, Resident #74 was seated in scoop wheelchair in the East Unit Lounge in front of a table. 8:43 AM- the resident was fidgety, moving, and repositioning legs frequently. 8:57 AM- the resident was still fidgety and making crying noises. 9:22 AM- the resident was placing their legs over the arm rest on scoop chair, mumbling and making crying noises 10:19 AM- the resident was sleeping with their head in downward position with their [NAME] to their chest. During continuous observations on 6/2/23 at 11:48 AM through 2:00 PM, Resident #74 remained seated in scoop wheelchair in the East Unit Lounge in front of a table and was not checked for incontinence. During an observation on 6/02/23 at 1:06 PM, while on East Unit, CNA #11 was heard saying out loud while walking down hallway in front of lounge where residents were seated, there is no way we are going to be able to change all these residents and put them into bed. During an interview on 6/2/23 at 1:50 PM, Resident #74 responded yes when asked if they were wet and needed to be changed. During an interview on 6/2/23 at 2:04 PM, CNA #2 stated they were assigned to Resident #74 and that they had not toileted Resident #74 since getting them up around 6:30 AM. CNA #2 stated they had no idea about Resident #74's incontinent care frequency but should be checking them every 2 hours. CNA #2 stated they were unable to check Resident #74 because they had so many residents, and Resident #74 required two- assist. CNA #2 stated they did not report to anyone that they needed help and could not meet #74's care needs timely. During an interview on 6/2/23 at 2:11 PM, Licensed Practical Nurse Team Leader (LPN) #5 stated Resident #74 was unable to voice their needs and would get worked up if they needed something. LPN # 5 stated the unit dropped down to 2 CNAs before lunch and was not informed that Resident #74 hadn't been toileted and should have been. LPN #5 stated some residents were unable to tell staff when they need to be changed and this places them at risk for urinary tract infections (UTIs), skin issues, and safety risk-falls. During an interview on 6/2/23 at 3:28 PM, RN UM #1 stated their expectation was that residents were toileted every 2-4 hours to prevent skin breakdown, falls, UTI's and for comfort. RN #1 stated there wasn't enough time and hands with having only 3 aides on the unit. RN #1 stated there were 42 residents on the East Unit and when staffed with 3 aide's residents may not be toileted or provided incontinent care as often as they should be. The priority was to keep them safe, feed and attend to them as quickly and efficiently as possible. Additionally, RN UM #1 stated Resident #74 should have been checked and had they been informed, they could have helped. During an interview on 6/6/23 at 2:51 PM, the DON stated Resident #74 was incontinent, totally dependent on staff and had a care plan for providing incontinent care every 2 - 4 hours. The DON stated CNA #2 should have informed the team leader and/or the Unit Manager that they were unable to provide care as planned for Resident #74, so the care could be provided. 3. Resident #101 had diagnoses that included fracture of left lower leg, depression, and anxiety. The MDS dated [DATE] documented Resident #101 was understood, understands and was cognitively intact. The CCP initiated on 4/21/23 documented under Customary Routine Resident #101 preferred a shower two times a week, every Thursday and Sunday. The Kardex documented Resident #101 was to receive a shower on the 7AM to 3PM shift every Thursday and Sunday. The undated North Unit Shower List documented Resident #101 was to receive a shower on the 7 AM to 3 PM shift every Thursday and Sunday. The Bathing Schedule Task Report date 5/11/23 through 6/2/23 documented Resident #101 only received a shower on 5/26/23. Review of the Progress Notes dated 5/11/23 through 6/5/23 revealed there was no documented evidence Resident #101 received a bath/ shower or refused showers. During an interview on 6/02/23 at 12:33 PM, Resident #101 stated they did not get shower yesterday (6/1, Thursday) and was suppose too. During an interview on 6/06/23 at 9:51 AM, Resident #101 stated they did not get a shower on Sunday (6/4) and has only had a couple showers since admission about a month ago. They did get a shower today when they asked the aide for one because they had a doctor's appointment today. Resident #101 also stated they don't feel they should have to ask for their showers if they are scheduled. During an interview on 06/06/23 at 10:10 AM, CNA #5 stated they worked on Sunday with another aide CNA #12 and did not provide care for the resident and was unsure if Resident #101 received a shower. During the survey attempts were made to contact CNA #12 without success. During an interview on 6/6/23 at 10:32 AM, LPN #3 stated the residents should get their shower or bath on assigned days, if the resident refuses the aide should tell the nurse and the nurse should encourage the resident. If the resident still refuses it should be document in in the electronic medical record (EMR). During an interview on 6/6/23 at 12:29 PM, LPN #4 stated they usually work full time on the North Unit and were familiar with Resident #101. Sometimes the resident will refuse their shower because they like to sleep in and I'll go talk to the resident and encourage them, but they do not document if the resident refuses in the EMR. LPN #4 was unsure if the resident was re-offered a shower on 6/1/23 and 6/4/23. During an interview on 6/6/23 at 1:40 PM, RN UM #2 stated they were responsible for assigning resident shower days. The aides should report to the nurses if the resident refuses and it should be documented and offered the next shift or the next day. Residents should get their showers on their assigned days. During an interview on 6/6/23 at 2:18 PM, the DON stated they would expect the resident to get showers per their preference and plan of care, if it's not done for whatever reason the CNA should tell the nurse and the nurse should document a reason in the EMR. 10 NYCRR 415.12 (A)(iii)

Based on observation, interview, and record review conducted during the Standard survey completed on 6/6/23, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for two (Residents #35 and 66) of four residents reviewed for infection control practices during personal care. Specifically, staff did not perform adequate hand hygiene while providing fecal incontinence care (Resident #66) and pressure sore treatment (Resident #35). Additionally, when emptying a urinary drainage collection bag, staff did not use a barrier on the floor or alcohol to wipe the collection bag drain tube (Resident #35). The findings are: The policy and procedure (P&P) titled Handwashing Technique dated 3/19/20, documented staff were instructed to use the proper handwashing techniques under the following circumstances: after contact with contaminated linen, object, or article; before handling any item that was to be maintained in a clean state such as linens, dishes, etc. The P&P titled Dressing, Clean, Wound, Incision dated 8/6/19 documented staff were to remove soiled dressing, discard gloves and perform hand hygiene, apply nonsterile gloves, and cleanse the wound as ordered, apply topical medication as ordered, and place appropriate dressings over the wound. The P&P titled Catheter: Emptying/Changing of Urinary Drainage Bag dated 9/18/20, documented residents with indwelling catheters will have regular catheter care including emptying of drainage bag for purposes of preventing urinary tract infections. Steps of the procedure included placing a barrier pad on the floor and placing the graduated cylinder (used to measure volume of liquid) on top of the pad and under the collection bag tubing, disconnect the catheter tubing from the collection bag, allow all urine to drain into the graduated cylinder, cleanse end of catheter tubing with an alcohol wipe and reconnect the tubing to the collection bag. 1. Resident #35 had diagnoses including stage 4 pressure ulcer (full thickness tissue loss with exposed bones, tendons, or muscles) of the sacrum (area above the tailbone on right and left buttocks) and left buttock, diabetes, and depression. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 4/8/23 documented Resident #35 was cognitively intact, had an indwelling urinary catheter, and had two stage 4 pressure ulcers. Review of the comprehensive care plan (CCP) dated 1/30/23 documented Resident #35 had an indwelling urinary catheter that was used for wound management, staff were to empty the urine and record the output every shift and had a urinary tract infection (UTI). The CCP documented the resident had stage 4 pressure ulcers on their sacrum and ischial tuberosity (the curved bone that makes up the bottom of the pelvis). Interventions included to assess for signs of infection (drainage, redness, odor). Review of the Order Summary Report dated 6/5/23, revealed an active order dated 1/30/23 for a urinary catheter 16 Fr (French- gauge system used to measure the size of the catheter).There were orders dated 4/7/23 to irrigate the sacral wound with Dakin's solution (used to kill germs and prevent germ growth in wounds), pack wound with calcium alginate (highly absorptive dressing), then cover with a dry clean dressing (DCD); and to irrigate the left ischial tuberosity with Dakin's solution daily, pack with iodoform (aseptic gauze packing strip, pat dry, and cover with a DCD. During an observation of wound care on 6/2/23 at 1:20 PM, Licensed Practical Nurse (LPN) #1 placed treatment items on the resident's overbed table, and applied gloves. Certified Nurse Aide (CNA) #11 performed catheter care, then LPN #1 and CNA #11 turned Resident #35 onto their left side. The resident was incontinent of stool. LPN #1 used washcloths to provide bowel incontinence care, dried the area and applied barrier cream to the resident's upper posterior thighs and lower buttocks. Without changing their gloves and performing hand hygiene, LPN #1 removed the dressing on the resident's sacrum, irrigated the sacrum and ischial pressure ulcers with Dakin's solution, packed each ulcer, and covered with a DCD. LPN #1 removed their gloves and donned (put on) new gloves without performing hand hygiene, obtained the graduated cylinder from the resident's bathroom and placed it directly on the floor under the urinary collection bag. LPN #1 removed the catheter drain tube, opened the clamp and emptied urine from the collection bag into the graduated cylinder. LPN #1 re-clamped and refastened the drain tube to the collection bag without cleaning the end of the tubing with an alcohol wipe. LPN #1 emptied the urine into the toilet and placed the graduate back onto the shelf. LPN #1 then removed their right glove, picked up soiled linen that had been on the floor and exited the room without performing hand hygiene. During an interview on 6/2/23 at 1:55 PM, LPN #1 stated they didn't change their gloves after providing bowel incontinence care, and before they completed the resident's pressure ulcer treatments. LPN #1 stated they didn't expect Resident #35 to have had a bowel movement and didn't have another pair of gloves. The LPN #1 stated they should have changed their gloves so they wouldn't cross contaminate the ulcers. LPN #1 stated they emptied the urinary collection bag without using a barrier on the floor and an alcohol pad to clean the tubing. The LPN #1 stated they had never used an alcohol pad when emptying an indwelling catheter and didn't know if it was the facility policy. LPN #1 stated Resident #35 had a UTI about a month ago and seemed to get them a lot. During an interview on 6/6/23 at 11:37 AM, Registered Nurse (RN) Unit Manager (UM) #1 stated they expected that LPN #1 changed their gloves and performed hand hygiene after providing incontinent care and again after removing the old dressings to the resident's pressure sores. The RN UM #1 stated this was for infection control purposes, they could have cross contaminated the wounds and that this Resident #35 had one wound infection since January. RN UM #1 stated the proper procedure for emptying the urinary collection bag was to put a barrier on the floor, place the graduated cylinder on it and the collection bag tubing should have been cleaned with alcohol wipes before and after emptying the urine from the bag. The RN UM #1 stated this was for infection prevention and Resident #35 had a history of UTIs and had one recently in May. During an interview on 6/6/23 at 2:13 PM, the Director of Nursing/Infection Preventionist (DON/IP) stated they would have expected the LPN #1 to remove their gloves and wash their hands after providing bowel incontinence care and before they performed the clean portion of the treatment to prevent contamination and exposure to infectious organisms. The DON/IP stated the UM and themselves were supposed to ensure nurses were providing care correctly. The DON/IP stated the LPN #1 should have put a barrier on the floor and used an alcohol pad before reconnecting the drainage tube to the collection bag to prevent infection. 2. Resident #66 had diagnoses including chronic respiratory failure, diabetes, and depression. The MDS dated [DATE] documented Resident #66 was cognitively intact and required extensive assist by staff with bed mobility and toileting. Review of the comprehensive care plan revised 5/23/23 revealed the resident had an ADL (activities of daily living) deficit and required total assistance for toileting hygiene by staff and was frequently incontinent of bowel. During an observation of morning care on 6/2/23 at 10:08 AM, CNA #1 donned gloves and washed the resident's underarms, applied deodorant, and put the resident's dress on. The CNA #1 then unfastened the incontinence brief and cleaned the resident's genitals and bilateral groins. Resident #66 then turned onto their right side and the incontinence brief was soiled with a large amount of stool. CNA #1 removed the soiled brief and used multiple wet wipes to clean stool from the resident's buttocks and sacrum. The CNA #1 touched the resident's buttocks with both hands to ensure the resident's rectal area was clean, then applied barrier cream to the buttocks and sacrum. CNA #1 applied a clean brief, had resident turn onto left side to smooth out the brief and fastened it. CNA #1 then pulled the resident's dress down, put a pillow under the resident's right leg, covered the resident with a sheet, retrieved a hair clip from the resident's bedside stand and handed it to the resident, closed the privacy curtain without changing their gloves and washing their hands. During an interview on 6/2/23 at 10:24 AM, CNA #1 stated for sanitary purposes they should have changed their gloves and washed their hands after cleaning stool from the resident. During an interview on 6/2/23 at 11:18 AM, the RN UM #1 stated CNA #1 should have changed their gloves and washed their hands after providing bowel incontinence care and applying barrier cream so that they did not spread bacteria throughout the room and back onto the resident who was now clean. During an interview on 6/6/23 at 11:05 AM, the DON/IP stated staff should change their gloves when soiled and would have expected CNA #1 to remove their dirty gloves, wash their hands and apply clean gloves to finish the tasks for Resident #66. 10 NYCRR 415.19(a)(1)(b)(4)

Based on observation, interview, and record review conducted during the Standard survey completed on 6/6/23, the facility did not post, on a daily basis, the following information: resident census. Specifically, the posted staffing reports did not include the facility census number as required. The finding is: The policy and procedure (P&P) titled Posting of Daily Resident Care Staffing (BIPA) dated 4/12/18 documented SNF (skilled nursing facility) staffing will be posted daily at the beginning of each shift. Other posted data included resident census. During observation on 5/31/23 at 9:05 AM, the DOH Staffing Report was posted in the lobby near the door to the administration offices. The posted report documented a census of 0 which did not reflect the current facility census. Review of the Midnight Census Report dated 5/30/23, documented the current resident census was 103. Review of the DOH Staffing Report dated 5/6/23-6/4/23 revealed the census was documented as 0. During an interview on 6/6/23 at 12:20 PM, the Director of Nursing (DON) stated that the DOH Staffing Reports were generated from their payroll system, and it didn't populate the census correctly onto the staffing sheet. The DON stated, usually the midnight supervisor posted the sheets. During an interview on 6/6/23 at 2:34 PM, the DON stated they looked at the posted staffing information to ensure that it was there but didn't realize there wasn't a census number on it. 10 NYCRR 415.13

Based on observation, interview, and record review conducted during a COVID-19 Focused Infection Control Survey conducted 11/22/21, the facility did not maintain an infection prevention and control program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, Licensed Practical Nurse (LPN) #1 did not use appropriate Personal Protective Equipment (PPE), a N95 mask, during a specimen collection for COVID-19 for one (Resident #1) of one resident observed. The finding is: The Centers for Medicare and Medicaid Services (CMS) QSO-20-38-NH revised 9/10/21, Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, documented: During specimen collection, facilities must maintain proper infection control and use recommended PPE, which includes an N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown, when collecting specimens. During an observation on 11/22/21 at 8:18 AM on the East Unit, Resident #1's room had a yellow precaution sign was posted on wall out- side their door. The sign stated, be sure to use gloves, gown, eye protection, and an N95 mask. LPN #1 was observed performing a COVID-19 rapid swab specimen on Resident #1 while wearing a wearing a gown, gloves, eye goggles and a procedure (surgical) mask. The Assistant Director of Nursing (ADON)/Infection Preventionist (IP), was assisting LPN #1 with testing remained outside of Resident #1's room and was wearing a gown, eye protection, gloves, N95 mask and a procedural mask over the N95 mask. During an interview on 11/22/21 at 9:18 AM, the ADON/IP, stated they were performing COVID-19 rapid swab testing on residents of the East Unit who were identified as being exposed to COVID-19. The ADON/IP stated they conducted contact tracing and 17 of the 43 residents on the unit were identified as being exposed and required testing. Resident #1 was identified as being exposed. During an interview on 11/22/21 at 9:20 AM, LPN #1 stated the following PPE was required for COVID-19 testing: a gown, gloves, eye wear and a mask. LPN #1 stated an N95 mask was required if a resident was positive for COVID-19. LPN #1 stated they were trained on-line in September 2021 through their agency and it was advised to wear a N95 mask for COVID-19 positive individuals. During an interview on 11/22/21 at 9:23 AM, the ADON/IP stated the following PPE was required when swabbing (testing) for COVID-19: a gown, gloves, goggles, N95 mask and a procedure mask over the N95 mask. The ADON/IP stated the staff educator was responsible to ensure proficiency of staff performing COVID-19 testing. The ADON/IP stated LPN#1 was not wearing an N95 mask during the specimen collection for Resident #1. During an interview on 11/22/21 at 9:26 AM, Registered Nurse (RN), Unit Manager #2 stated the following PPE was required in rooms identified as yellow (exposed) precautions: gloves, gown, eye wear, N95 and a surgical mask over the N95 mask. Resident #1 was identified as exposed to COVID-19. During an interview on 11/22/21 at 9:34 AM, with the Direction of Nursing (DON)/IP and the Administrator, the DON/IP stated themselves (DON/IP), ADON/IP, managers, the Administrator, LPNs and Nursing Supervisors perform COVID-19 testing. The DON/IP stated training and competency for COVID-19 testing was done by themselves and the educator. The Administrator stated that competency was based on verbal, visual and written education. The DON/IP further stated that all staff that perform COVID-19 testing (specimen collection) have completed a competency. When a COVID-19 testing need was identified, the DON/IP stated they (the Administrator and DON/IP) assign testing to staff who have previously completed competency and performed testing in the past. During an interview on 11/22/21 at 10:54 AM, the ADON/IP stated the were responsible for resident COVID-19 testing today (11/22/21) and Resident #1 was the first resident that was swabbed by LPN #1. During an interview on 11/22/21 at 12:38 PM, the DON/IP stated that LPN #1 has had verbal instruction, demonstration of all the steps and redemonstration to be deemed competent to perform COVID-19 testing. The DON/IP stated themselves and the Administrator were responsible for testing compliance standards and monitoring of staff. The DON/IP stated that staff demonstrate competencies upon hire, annually and as needed if there were identified concerns. DON/IP stated an N95 mask was required for COVID-19 testing. A document titled COVID-19 rapid [MEDICATION(S)] testing competency skills evaluation dated 11/22/21, provided by the DON/IP at 12: 38 PM, had no documented instruction or demonstration as part of the testing competency. DON/IP stated the competency form was incomplete. During an interview on 11/22/21 at 12:55 PM, DON/IP stated they were unable to provide a competency skills evaluation form for LPN #1 prior to 11/22/2021 and stated the content of the agency infection control training was unknown. 415.19(a)(1)

Based on observation, interview, and record review conducted during a Standard Survey completed on 7/30/21 the facility did not follow the prepared menus. One of one prepared lunch meal did not provide the residents receiving mechanically altered diets the same food item that was posted on the menus for that day. Specifically, on 7/28/21 puree and ground consistencies received ground pork with gravy instead of the Polish sausage which was listed on the posted menu. This affected the following residents (Resident #4, 5, 7, 21, 29, 40, 51, 60, 61, 69, 71, 86, 349, 352, and 353). The finding is: Review of the policy and procedure titled Diet Types and Menu Requirements date last modified 10/30/2018 revealed daily menus and menu cycles used at this facility will be planned to meet the nutritional and personal needs of residents. The approved menus in the preparation of meals with substitutions only made when food items are not available from vendors or there is a situation occurring requiring use of the emergency/ disaster menu. Review of the posted Fall/Winter Week1 Menu dated 7/25/21 revealed for Wednesday at lunch Polish sausage was listed as part of the main entree. Review of the Extension Sheets Week 1, Wednesday day 4 Fall/Winter dated 7/28/21 revealed at lunch Polish sausage was listed for both Mechanical Soft (ground consistency) and Puree diets. During an observation on 7/28/21 at 9:54 AM the cook placed pre-cooked ground pork and gravy in the Robo Coupe (equipment used to puree food) and pureed them together to a pudding like consistency to be used for residents on puree consistency. During an interview on 7/28/21 at 10:00 AM the cook stated, we use ground pork with gravy versus the Polish sausage for the puree and ground consistencies. I do not know why we do not use Polish sausage like the regular consistency, it has always been done that way. During an interview on 7/28/21 at 10:15 AM the Food Service Director stated, we do not use the Polish sausage for the puree or ground consistencies because it is too watery when we blend it and the skin leaves chunks. Ground pork and gravy was the closest to Polish sausage. During the lunch meal tray line observation on 7/28/21 between 11:30 AM and 12:15 PM Residents (#7, 29, 61, 71, and 86) were provided puree ground pork and Residents (#4, 5, 21, 40, 51, 60, 69, 349, 352, and 353) received ground pork on their meal plates. There was no Polish sausage provided. During a further interview on 7/28/21 at 1:16 PM the Food Service Director, stated the posted menu has Polish sausage listed on it for today (7/28/21) at lunch. We did give the puree and ground consistencies ground pork with gravy, not polish sausage. Maybe, I will have to look for a different Polish sausage product that will work. I understand that the mechanically altered diets should be receiving the same food items as what the regular consistencies receive, which is posted on the menu. During an interview on 7/30/21 at 11:59 AM the Registered Dietitian stated the posted menus should be followed. The puree and ground consistencies should have received Polish sausage. 415.14(c)(1-3)

Based on observation, record review, and interview conducted during the Standard survey completed on 7/30/21, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #s 43 and 60) of three residents reviewed for indwelling urinary catheters (Foley, tube inserted into the bladder used to drain urine). Specifically, proper infection control practices were not maintained. Residents #43 and #60's Foley catheter drainage bag (bag for collecting urine from the urinary drainage tube) and tubing were observed directly on the floor without a barrier. The findings are: The facility policy and procedure (P&P) titled, Catheter, Daily Care (Indwelling) dated 4/11/18, documented that staff were to ensure the drainage bag was attached to the bed frame or wheelchair and the drainage bag or tubing cannot touch the floor. 1. Resident #60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 6/6/21 documented the resident usually understands, was usually understood, and was cognitively intact. Additionally, the MDS documented the resident had a Urinary Tract Infection (UTI) in the past 30 days and utilized an indwelling catheter. The Comprehensive Care Plan (CCP) dated 5/19/21 documented Resident #60 had an indwelling urinary catheter and the intervention to utilize a urinary leg bag (holds urine that drains from catheter and fits under clothing) when out of bed. Review of the Order Summary Report dated 7/29/21 revealed Resident #60 had a 16 F (French-size of catheter 5 mL (milliliter) balloon (used to anchor the catheter in the bladder) indwelling urinary catheter started on 5/19/21; and UTI protocol (an extra 240 mL of fluid offered each shift for residents with a UTI) was started on 7/26/21 for seven days. Intermitent observations of Resident #60 during survey from 7/26/21 through 7/29/21 revealed the following: - 7/26/21 at 9:29 AM, Resident #60 was sitting in their wheelchair in their bedroom with approximately four inches of the indwelling catheter tubing in direct contact with the floor. Additionally, the bottom of Resident #60's sneakers were in direct contact with the indwelling catheter tubing. - 7/28/21 at 8:16 AM, Resident #60 was sitting in their wheelchair in their bedroom with approximately eight inches of the indwelling catheter tubing in direct contact with the floor. Additionally, the bottom of Resident #60's sneakers were in direct contact with the indwelling catheter tubing. - 7/28/21 at 9:09 AM, Resident #60 was self-propelling their wheelchair back-and-forth in their bedroom with approximately eight inches of the indwelling catheter tubing in direct contact with the floor. Additionally, the bottom of Resident #60's sneakers were in direct contact with the indwelling catheter tubing. - 7/28/21 at 10:02 AM, Resident #60 was sitting in their wheelchair in the main dining room, participating in an activity program with approximately eight inches of the indwelling catheter tubing in direct contact with the dining room floor. Additionally, the bottom of Resident #60's sneakers were in direct contact with the indwelling catheter tubing, and sediment (stringy white flecks) was observed in the indwelling catheter tubing. - 7/28/21 at 11:51 AM, Resident #60 was self-propelling their wheelchair from the main dining room to a common area on the unit (approximately 120 feet), with approximately 3 inches of tubing dragging directly on the floor. - 7/29/21 at 7:40 AM, Resident #60 was self-propelling their wheelchair back-and-forth in their bedroom with approximately eight inches of the indwelling catheter tubing in direct contact with the floor. - 7/29/21 at 9:12 AM, Resident #60 self-propelling their wheelchair from their bedroom to the common area on the unit (approximately 75 feet) with approximately four inches of the indwelling catheter tubing dragging directly on the floor, and the urine in the indwelling catheter tubing appeared turbid (unclear, murky appearance). During an interview on 7/29/21 at 10:16 AM, Licensed Practical Nurse (LPN) #2 stated the floor was a contaminated surface, and if the urinary drainage bag directly touches the floor it would be considered an infection control issue. During an observation/interview on 7/29/21 at 10:38 AM, Registered Nurse (RN) Unit Manager (UM) #2 stated Resident #60's indwelling catheter tubing was quite long and directly touching the floor which has a lot of germs and could possibly increase the risk of infection. During an interview on 7/29/21 at 10:45 AM, the Director of Nursing (DON) stated that no tubing or bag should drag on the floor, the floor is dirty, and the tubing could collect germs from the floor which could be transferred to the bladder via the tubing, increasing the risk for infection. During an interview on 7/30/21 at 8:24 AM, Resident #60's Physician stated indwelling catheter bags and tubing should not come into direct contact with floor as that increases the risk for infection. 2. Resident #43 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident had an indwelling urinary catheter and was cognitively intact. Review of the Order Summary Report dated 7/30/21 revealed Resident #43 had a 16 F 10 mL balloon indwelling urinary catheter started on 5/28/21. During an observation on 7/26/21 at 11:16 AM, Resident #43's urine drainage bag was observed laying on floor without a barrier between the bag and the floor. The drainage bag was dated 7/8/21. Further observation on 7/29/21 at 8:16 AM revealed the resident was lying in bed, the urine drainage bag was on the floor next to the resident's bed, there was no barrier between the bag and the floor. The drainage bag was dated 7/8/21. During an interview on 7/29/21 at 12:16 PM, CNA #3 stated the urinary collection bag was not usually on the floor and it should be hooked on the bed. CNA #3 stated right now, they have a clean barrier under it because it's on the floor, but it should be on the bed. CNA #3 was observed to pick the drainage bag up off the floor and hook the drainage bag to the bedframe. During an interview on 7/30/21 at 8:46 AM, CNA #1 stated they usually hook the catheter bag on the bed, but if a bag was on the floor, they use a barrier between the floor and the bag because the floor was dirty, and they don't want to contaminate the bag. CNA #1 stated they remembered the drainage bag being on the floor the day before (7/29/21). During an interview on 7/29/21 at 2:30 PM, LPN #1 stated the expectation would be for the CNA to tell the nurse if a urine drainage bag was on the floor without a barrier so the nurse could replace the bag. During an interview on 7/30/21 at 9:20 AM, the RN UM #1 stated if a urine drainage bag was directly on the floor, the CNA should tell the nurse, so the nurse can clean the bag off if it was on a contaminated surface. The floor was considered contaminated. The RN UM #1 stated the drainage bag could either be attached to the bedframe with the hook or it could be on the floor with a barrier. During an interview on 7/30/21 at 10:02 AM with the Director of Nursing/Infection Preventionist (DON/IP) and the Regional RN Consultant present, the Regional RN Consultant stated usually urine drainage bags were hooked to the bedframe at the bottom of the bed. If it was a low bed, staff would put a barrier between the floor and the bag because it would touch if the bed was in a low position. The Regional RN Consultant stated staff could wipe the drainage bag down with a [MEDICATION(S)] wipe or some type of antibacterial wipe if it was found on the floor. The DON/IP stated an alcohol wipe would be acceptable, but it was not the preferred method to clean the drainage bag and that the floor was considered a contaminated surface. During an interview on 7/30/21 at 12:33 PM, the Administrator stated a resident with an indwelling urinary catheter should have their drainage bag affixed to the bed. 415.19(a)(1)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 753) completed on 10/28/19, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #1) of three residents reviewed for accidents/supervison did not receive adequate supervision to prevent accidents. Specifically, a resident receiving one to one supervision was left unattended in a common area resulting in a fall and sustained a [MEDICAL CONDITION]. This resulted in actual harm to Resident #1 The finding is: During an interview on 10/28/19 at 9:35 AM, the DON stated that they do not have a policy on providing 1:1 observation for resident safety. 1. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a resident assessment tool) dated 6/9/19 documented the resident required extensive assist of two people for bed mobility, transfers, walking in and out of room, and dressing. The resident's Comprehensive Care Plan dated 6/5/19 documented, Focus-safety: at risk for falls related to history of falls, impaired gait, incontinence and medication usage. Interventions: provide safe environment and to wear non-skid socks. The Kardex (used by staff to provide care) dated 6/11/19 documented, Mobility-ambulation and transfer extensive one assist with wheeled walker; Safety-keep call light within reach, encourage use and non-skid socks. Review of Nurse's Notes documented the following: -6/8/19 at 9:54 PM by the Nursing Supervisor Registered Nurse (RN) #1, Resident was crawling on the hallway floor. Resident is alert with no apparent injuries, 2-assist back to bed. RN assessment, neuro checks and ROM (range of motion) all extremities within normal limits. Floor mats added to beside. Family and MD (medical doctor) notified. -6/8/19 at 10:30 PM, by the Licensed Practical Nurse (LPN) #3, Resident crawled out of bed twice this shift, second time obtaining a skin tear to elbow. Resident had been very agitated and combative throughout the shift. -6/9/19 at 2:23 AM by the Charge Nurse LPN #2, Resident confused to time and place expressing preparations to leave and go home. Able to redirect resident back to bed, shortly after resident back out of bed and in bathroom. One staff assist to wheelchair and brought to Nurse's Station for close 1:1 observation, snacks offered, T.V. on and resident able to sit still, neuro checks continue within normal limits. -6/9/19 at 5:48 AM by the Charge Nurse LPN #2, Responding to noise in the feeding lounge, resident noted laying on his back-right hand under head, right lower extremity slightly bent, left upper and lower extremities out stretched. Resident states, my head hurts because I hit my head. Neuro checks within normal limits, no bleeding or bruising noted. Three staff assist with Medi lift (mechanical lift) to wheelchair. RN to update MD. -6/9/19 at 6:30 AM by the Nursing Supervisor RN #1, Called to the unit for resident self-ambulating from wheelchair in lounge area found on floor on his left side. Resident moving all extremities making attempts to get himself up. Upon transfer to the wheelchair resident complained of pain in left leg. Upon further assessment resident unable to externally rotate (leg) and complaining of pain. Neuro checks initiated, vital signs stable, call placed to MD. Order to send resident to the emergency room for an evaluation. -6/9/19 at 3:36 PM documented the resident was admitted to the hospital. -6/10/19 at 10:46 AM by the Nursing Supervisor RN #1, Call received from the hospital. Resident anticipated for surgical repair of left [MEDICAL CONDITION] this AM. Review of an untitled Accident/Incident (A&I) report dated 6/9/19 at 6:15 AM by Nursing Supervisor RN #1 documented the resident ambulated without assist, had an un-witnessed fall with a suspected [MEDICAL CONDITION] hip. During a telephone interview on 10/10/19 at 2:53 PM, CNA #3 who was assigned 1:1 to Resident #1 on 6/9/19 during the night shift revealed she had no recollection of the incident and stated, I don't work there anymore. During an interview on 10/11/19 at 5:25 AM, CNA #4 stated CNA #3 was assigned 1:1 to Resident #1 on 6/9/19 during the night shift. CNA #3 was sitting right next to the resident while she was care tracking (charting in the medical record). The resident was sitting next to CNA #3 in a wheelchair in the feeding lounge. CNA #4 stated CNA #3 did not tell me she was going to the bathroom. During that time Resident #1 stood up and fell . CNA #4 stated, 1:1 means there is more attention put on to the resident, so the resident won't fall or get up. It's used to keep the resident safe. I would've notified the nurse or the other aide if I was leaving the resident unattended when providing a resident with 1:1. During a follow-up interview on 10/28/19 at 5:45 AM, CNA #4 stated that on 6/9/19 she and CNA #3 took turns providing Resident #1,1:1 observation at 20 minute intervals on and off for about 2 hours that night. At first we attempted to put the resident in a Geri chair but he didn't tolerate that and continued to try to climb out of it, so we put him in a wheelchair. Prior to the fall CNA #3 took him in to the feeding lounge and kept him by her side. She left him to go to the lady's room without telling me. That's when I heard the noise and looked up and saw the resident on the floor. During an interview on 10/10/19 at 1:26 PM, the Assistant Unit Manager LPN #1 stated that it is a nurse's judgement to assign a resident 1:1. If a resident is deemed safe, behaviors decreased, cognitive changed for the better, then a 1:1 is removed by the nurse. I'd expect that a CNA finds coverage if they have to step away or go on break. The CNA should give report to whoever is covering for them or taking over the assignment. The nurse should be informed if coverage is not available. During a telephone interview on 10/10/19 at 2:28 PM, the Charge Nurse LPN #2 stated that on 6/9/19 during the night shift Resident #1 kept standing up, so we (RN Supervisor #1) made him a 1:1 which means the resident must be in your line of vision so you can intervene and stop a fall. During an interview on 10/11/19 at 5:00 AM, Charge Nurse LPN #2 stated, I made Resident #1 a 1:1 myself which is a nursing judgement call because of his unsafe behaviors of confusion, threatening to leave the facility and continuing to try to self ambulate. There were two CNA's working on the unit that night, but I can't recall which one was assigned 1:1 to Resident #1. During an interview on 10/10/19 at 3:28 PM, Nursing Supervisor #2 stated, that if a resident is experiencing unsafe behaviors the nursing supervisor can make the resident a 1:1. The assigned CNA should always stay with the resident while the resident is awake. If the resident is asleep, the CNA can leave the resident unattended briefly. I'd expect that the CNA would give report to another staff member if they're going to leave the resident unattended, that would be my preference. That would be clinical common sense. During an interview on 10/11/19 at 5:34 AM, Nursing Supervisor #2 stated that nurses can place a resident on 1:1 if the resident is having unsafe behaviors. If a resident was placed on 1:1 during the night shift it would not need to be written in the Care Plan, staff would be told verbally, until the interdisciplinary team (IDT) team meets that morning and makes the decision as a group to maintain or remove the 1:1 status. During an interview on 10/10/19 at 12:39 PM, the Director of Nursing (DON) stated if a resident is made a 1:1, the expectation is the CNA or LPN assigned stays with that resident or the resident is placed in a common area where they can be observed. Implementing and discontinuing 1:1 would be a nurse's judgment. During a follow-up interview at 1:38 PM, the DON stated, Resident #1 was safe to be left alone in the lounge because his eyes were closed, and he was resting which meant the 1:1 was no longer needed because he was determined to be safe by the CN[NAME] During an interview on 10/10/19 at 3:50 PM, the Administrator stated, I wasn't aware of Resident #1 because of the short time he was here. The expectation is to make a resident 1:1 according to the resident's needs. It must be judiciously applied, with what are the needs of that particular resident, and then be reevaluated every shift with what we are hoping for. From what I'm told he was sleeping when the CNA left the resident unattended. I think there wasn't any violation of the care plan. All his safety needs were met according to his care plan. 415.12(h)(1)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 753) completed on 10/28/19, the facility did not have evidence that all alleged violations are thoroughly investigated for one (Resident #1) of three residents reviewed for accident investigation. Specifically, the investigation lacked documented witness statements from all staff members involved. The finding is: The facility policy and procedure titled Accidents/ Incident Reporting and Review dated 4/17/19 revealed it is the policy of this facility to include staff member's version of the occurrence on the Witness Account of the Accident-Incident Form if indicated. 1. Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a resident assessment tool) dated 6/9/19 documented the resident required extensive assist of two people for bed mobility, transfers, walking in and out of room, and dressing. Review of Facility Investigation dated 6/9/19 documented that staff reported they had just toileted Resident #1. The aide was sitting with him and she got up herself and turned and he had fallen. During a telephone interview on 10/10/19 at 2:53 PM, Certifed Nurse Assistant (CNA) #3 who was assigned 1:1 to Resident #1 on 6/9/19 during the night shift revealed she had no recollection of the incident and stated, I don't work there anymore. During an interview on 10/11/19 at 5:25 AM, CNA #4 stated CNA #3 was assigned 1:1 to Resident #1 on 6/9/19 during the night shift. CNA #3 was sitting right next to the resident while she was care tracking (charting in the medical record). The resident was sitting next to CNA #3 in a wheelchair in the feeding lounge. CNA #4 stated CNA #3 did not tell me she was going to the bathroom. During that time Resident #1 stood up and fell . CNA #4 stated, 1:1 means there is more attention put on to the resident, so the resident won't fall or get up. It's used to keep the resident safe. I would've notified the nurse or the other aide if I was leaving the resident unattended when providing a resident with 1:1. During a follow-up interview on 10/28/19 at 5:45 AM, CNA #4 stated that on 6/9/19 she and CNA #3 took turns providing Resident #1,1:1 observation at 20 minute intervals on and off for about 2 hours that night. At first we attempted to put the resident in a Geri chair but he didn't tolerate that and continued to try to climb out of it, so we put him in a wheelchair. Prior to the fall CNA #3 took him in to the feeding lounge and kept him by her side. She left him to go to the lady's room without telling me. That's when I heard the noise and looked up and saw the resident on the floor. Further review of the Facility Investigation dated 6/9/19 revealed there were no statements obtained for CNA's #3 & 4. During an interview on 10/11/19 at 9:36 AM, the Regional RN Consultant revealed she had completed the investigation report and determined the care plan was followed and stated, We don't have witness statements from the aides (CNA's #3 & 4). We didn't get them, and that was a mistake. 415.4(b)(3)

Based on observation and interview during the Standard survey completed on 6/3/19, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Specifically, shower plumbing devices and hoses did not have vacuum breakers installed to prevent backflow in three (East, West, North) of three resident units. The findings are: 1a. Observation in the East Unit Shower Room on 5/28/19 at 8:50 AM revealed the hand-spray wands in two of two shower stalls were not equipped with vacuum breakers. The length of the hoses allowed the hand-spray wands to be submerged in water on the shower floor if the water did not drain properly. 1b. Observation in the West Unit Shower Room on 5/28/19 at 9:10 AM revealed the hand-spray wands in two of two shower stalls were not equipped with vacuum breakers. The length of the hoses allowed the hand-spray wands to be submerged in water on the shower floor if the water did not drain properly. 1c. Observation in the North Unit Shower Room on 5/28/19 at 9:55 AM revealed the hand-spray wand in one of one shower stall was not equipped with a vacuum breaker. The length of the hose allowed the hand-spray wand to be submerged in water on the shower floor if the water did not drain properly. 1d. Observation in the bathroom in Resident room [ROOM NUMBER] on the East Unit on 5/31/19 at 8:55 AM revealed the hand-spray wand in one of one shower stall was not equipped with a vacuum breaker. The length of the hose allowed the hand-spray wand to be submerged in water on the shower floor if the water did not drain properly. During an interview on 5/31/19 at 2:50 PM, the Director of Maintenance stated he was not aware of the requirement for backflow prevention on the shower wands, and to his knowledge, there were no backflow preventers installed on the shower wands. 415.29(f)(4)

Based on interview and record review during the Standard survey completed on 2/12/18, the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Seven (1-Registered Professional Nurse and 6-Licensed Practical Nurses) of seven agency employees, that worked in the facility during the last four months and were subject to the New York State Nurse Aide Registry, had not been reviewed for the New York State Nurse Aide Registry prior to their employment. The findings are: 1a.) Interview with the Administrator, Director of Nursing, and the Regional Director of Operations on 2/8/18 at approximately 11:25 AM revealed the facility was using three agencies to provide the facility with agency Registered Professional Nurses and agency Licensed Practical Nurses. Interview with the Director of Nursing on 2/8/18 at approximately 12:18 PM revealed: - The facility was not conducting New York State Nurse Aide Registry checks on agency employees prior to their employment at the facility. - The facility was relying on the agencies to conduct New York State Nurse Aide Registry checks on the agency employees prior to their employment at the facility. - The agencies were not conducting New York State Nurse Aide Registry checks on the agency employees prior to their employment at the facility. Interview with the Human Resources Coordinator (Authorized Person) on 2/8/18 at approximately 12:34 PM revealed: - She did not conduct any background checks or deal with any paperwork for the agency staff that worked at the facility. - She only conducted background checks and did the paperwork for the facility's staff. - She had nothing to do with any of the agency staff that worked at the facility. Review of the hire dates and Regular Monthly Schedules provided for agency employees on 2/8/18 revealed the facility had not conducted a New York State Nurse Aide Registry check on the following agency employees, prior to their employment at the facility. - Employee #1A (agency Registered Professional Nurse) Was hired to work at the facility on 1/12/18. A New York State Nurse Aide Registry check was conducted for the employee on 2/7/18. The agency employee worked at the facility for three days between 1/23/18 and 1/25/18 on one of the facility's three units. - Employee #2A (agency Licensed Practical Nurse) Was hired to work at the facility on 1/24/18. A New York State Nurse Aide Registry check was conducted for the employee on 2/7/18. The agency employee worked at the facility for three days between 2/5/18 and 2/7/18 on one of the facility's three units. - Employee #3A (agency Licensed Practical Nurse) Was hired to work at the facility on 1/10/18. A New York State Nurse Aide Registry check was conducted for the employee on 2/7/18. The agency employee worked at the facility for seven days between 1/24/18 and 2/5/18 on two of the facility's three units. - Employee #4A (agency Licensed Practical Nurse) Was hired to work at the facility on 11/1/17. A New York State Nurse Aide Registry check was conducted for the employee on 2/7/18. The agency employee worked at the facility for one day on 11/1/17 on one of the facility's three units. - Employee #5A (agency Licensed Practical Nurse) Was hired to work at the facility on 1/3/18. A New York State Nurse Aide Registry check was conducted for the employee on 2/8/18. The agency employee worked at the facility for one day on 2/4/18 on one of the facility's three units. - Employee #6A (agency Licensed Practical Nurse) Was hired to work at the facility on 1/3/18. A New York State Nurse Aide Registry check was conducted for the employee on 2/8/18. The agency employee worked at the facility for five days between 1/8/18 and 2/7/18 on two of the facility's three units. - Employee #7A (agency Licensed Practical Nurse) Was hired to work at the facility on 1/11/18. A New York State Nurse Aide Registry check was conducted for the employee on 2/8/18. The agency employee worked at the facility for two days between 1/14/18 and 1/15/18 on one of the facility's three units. Review of a Criminal History Record Checks policy dated 4/2016 provided by the facility as its policy for back ground checks for perspective employees in non-licensed positions on 2/8/18 revealed it contained no information pertaining to New York State Nurse Aide Registry checks. Review of a Records and Process for Hiring a Staff Member policy dated 9/2017 provided by the facility as its policy for back ground checks for perspective employees on 2/8/18 revealed: -Nurse Registry checks must be completed by the facility for all agency staff. -No agency staff will be permitted to work until all required information is obtained. 415.4(b)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/12/18 the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinical contraindicated, in an effort, to discontinue these drugs. One (Resident #49) of three residents reviewed for antipsychotic medication use was on [MEDICATION NAME] [MEDICATION]) since 9/28/16 with no GDR attempt. In addition, there was no documentation for continued use of the medication and non-pharmacological interventions being used. The finding is: Review of a facility policy entitled Gradual Dose Reductions of [MEDICAL CONDITION] Medications dated 9/25/15 revealed residents who use [MEDICAL CONDITION] medications will receive gradual dose reductions and behavioral interventions, unless clinically indicated, in an effort, to discontinue the use of these medications. Clinically contraindicated means that a resident need not undergo a gradual dose reduction or behavioral interventions if the resident's physician provides justification why the continued use of the drug and the dose is clinically appropriate. Such justification must include: a diagnosis (which must include the description of symptoms); a discussion of differential psychiatric and medical diagnosis; a description of the justification for the choice of a particular treatment, or treatments; and a discussion of why the present dose is necessary to manage the symptoms of the resident; the need for no further GDRs will be reviewed by MD (physician) on at least an annual basis and physician will consider tapering of dose if the resident's clinical condition has improved or stabilized, underlying causes of the original target symptoms have resolved, and nonpharmacological interventions, including behavioral interventions have been effective, or resident's condition had not responded to treatment or has declined despite treatment. 1. Resident #49 was admitted into the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/8/18 revealed that the resident is severely cognitively impaired and is rarely/never understood or rarely/never understands. Section E revealed there were no potential indicators of [MEDICAL CONDITION], no behavioral symptoms, no behaviors exhibited during care and no wandering exhibited. In addition, this was indicated on the MDS from 9/9/17 and 6/10/17. Review of Section N revealed the resident received an antipsychotic medication. Antipsychotic medication review is marked that antipsychotics were received on a routine basis only and no GDR has been attempted. Physician documented GDR as clinically contraindicated on 6/9/17. Review of Comprehensive Care Plan dated 9/21/17 revealed the resident was on [MEDICATION NAME] for SDAT (senile dementia Alzheimer's type) with [MEDICAL CONDITION]. Goals included the resident will have behaviors controlled with decreasing calling out, chewing on clothing and disruptive behavior will decrease. Approaches included: Refer to standards Psych (psychological) Consults prn (as needed). Episodic Care Plan dated 1/9/18 revealed decrease chewing noted. Meeting/ review for 1/9/18 revealed no recent reports chewing on clothing noted. Review of an undated Closet Care Plan reveals under Additional Information: if chewing on clothing, dress resident in facility gown; one backwards and one on the front. Review of the physician's orders [REDACTED]. 5/11/16 - N.O. (new order) [MEDICATION NAME] 0.5 mg (milligrams) one by mouth (po) Q8H (every eight hours) for SDAT with behaviors, [MEDICAL CONDITION]. 9/20/16 - Decrease [MEDICATION NAME] 0.5 mg one po Q12H for SDAT with behaviors and [MEDICAL CONDITION]. 9/28/16 - Increase [MEDICATION NAME] 0.5 mg one po Q8H for SDAT with behaviors and [MEDICAL CONDITION]. 10/18/16 - Resident on [MEDICATION NAME] 0.5 mg Q8H with no further dose reduction. Notes: Resident on [MEDICATION NAME] 0.5 mg Q8 for SDAT with behaviors and [MEDICAL CONDITION]. Recent GDR was attempted and unsuccessful where resident had increase in distressful calling out and chewing on clothing. No further GDR as I feel this may impair her function or cause psychiatric instability. 6/9/17 - Resident on [MEDICATION NAME] 0.5 mg Q8H with no further dose reduction. Notes: Resident on [MEDICATION NAME] 0.5 mg Q8 for SDAT with behaviors and [MEDICAL CONDITION]. Recent GDR was attempted and unsuccessful where resident had increase in distressful calling out and chewing on clothing. No further GDR as I feel this may impair her function or cause psychiatric instability. Review of Medication Administration Records (MAR) for the months of September 28, 2016 through February 2018 revealed the resident received [MEDICATION NAME] 0.5 mg Q8H every day. Intermittent observations made from 2/8/18 and 2/9/18 revealed the resident in her bed sleeping as she was ill. There were no behaviors observed. Review of the Physician Visits dated as follows revealed the following: 6/9/16 - (60-Day Visit) - new [DIAGNOSES REDACTED]. [MEDICAL CONDITION] medication usage - [MEDICATION NAME] 0.5 mg Q8H SDAT with behaviors and [MEDICAL CONDITION]. Cognitive: anxiety; agitation, non-verbal. 9/21/16 - (60-Day Visit) - [MEDICAL CONDITION] medication usage- [MEDICATION NAME] 0.5 mg Q12H. Cognitive: non-verbal 11/16/16 - (Annual Visit) - [MEDICATION NAME] 0.5mg Q8H. Cognitive: agitation, non-verbal. 1/12/17 - (60-Day Visit) - [MEDICAL CONDITION] medication usage- [MEDICATION NAME] 0.5 mg Q12H. Cognitive: agitation, non-verbal. Physician Visits from 3/8/17 through 1/24/18 revealed resident was receiving [MEDICATION NAME] 0.5 mg Q8H for SDAT with behaviors and [MEDICAL CONDITION]. Review of the Psych NP (Psychiatric Nurse Practitioner) consults revealed the following: 5/10/16 - Treatment Team report: Staff notes continued if not worst calling out, chanting and biting/ ripping clothing. Diagnosis (DX): [MEDICAL CONDITION]; Dementia with behaviors. Recommendations: start [MEDICATION NAME] 0.5 mg TID (three times daily). 9/13/16 - Treatment Team Report: Occasional calling out or verbal outburst but chewing on clothing much improved (did recently occur 9/18). DX: Dementia with behaviors. Recommendations: decrease [MEDICATION NAME] to 0.5 mg BID (two times daily). 10/18/16 - Treatment Team Report: Seen 9/13/16. We decreased [MEDICATION NAME] to 0.5 mg BID. Staff noted increase in verbal behaviors and chewing clothing when GDR took place. Dose reinstated 9/28/16 with improvement seen. 1/31/17 - Treatment Team Report: Continue [MEDICATION NAME] 0.5 mg Q8H. Staff was reporting some increase in chewing clothing and calling out. Recommendations: continue [MEDICATION NAME] 0.5 mg Q8H for behaviors. 2/7/17 - Treatment Team Report: Continue [MEDICATION NAME] 0.5 mg Q8H. Staff was reporting some increase in chewing clothing and calling out. Recommendations: continue [MEDICATION NAME] 0.5 mg Q8H for behaviors. 5/2/17 - Treatment Team Report: On [MEDICATION NAME] 0.5 mg Q8H. No mood/ behavior issues noted since 4/3/17 - Recommendations: continue [MEDICATION NAME] 0.5 mg Q8H for behaviors. Follow- up per treatment team. Review of the Nursing Notes from 9/28/16 through 2/12/18 revealed the following notes regarding behaviors and non-pharma logical interventions if provided: 10/3/16 - 2:47 PM, Resident seems aggravated this shift. 10/4/16 - 2:57, Resident was sleeping through most of shift. When woken for medications, she was very agitated. 12/25/16 - 8:21 AM, Resident observed by writer and staff eating her shirt. Resident had chewed off part of her shirt, a piece of shirt found in her mouth. Much 1:1 and redirection provided. 1/2/17 - 8:12 AM, Resident calling out and noted to be chewing on her clothing. 1:1 with resident with little effect. 1/17/17 - 9:58 AM, Dark foul urine noted. Resident to be chewing on clothing. 1/18/17 - Self-inflicted scratches to left hip. Resident had some repetitive phrases and chewing on clothing. Redirected with some resistance. 2/17/17 - Resident noted to be chewing on gown/ blanket. 2/21/17 - During first rounds CNA (certified nurse aide) found resident's tooth stuck in her shoulder. 2/22/17 through 2/12/18 revealed there were no notations of any behaviors exhibited by Resident #49. Review of Quarterly Restraint/ [MEDICAL CONDITION] Medication Evaluation & Review revealed the following: 11/10/16 - Medication: [MEDICATION NAME] 0.5 mg Q8H for SDAT with behaviors & [MEDICAL CONDITION]. Nursing summary: [MEDICATION NAME] for behaviors with [MEDICAL CONDITION], calling episodes continue to occur however decreased in nature. Resident continues to have episodes of chewing on her clothing but also has decreased in nature with the increase in [MEDICATION NAME]. Diversional activities of music, activities, 1:1, moving to another environment have minimal effect. Resident followed by Psych NP. 2/9/17 - Medication: [MEDICATION NAME] 0.5 mg Q8H for SDAT with behaviors & [MEDICAL CONDITION]. Resident continues with some repetitive speech. Resident is alert with confusion. Occasional episodes of yelling out and occasional episodes of chewing on clothes. Episodes are stable since [MEDICATION NAME] was increased to Q8H. No changes from Psych NP visit 2/7/17. 5/11/17 - Medication: [MEDICATION NAME] 0.5 mg Q8H for dementia with behavioral disturbance. Resident is alert with confusion. Occasional episodes of calling out continue despite needs being met. Usually episodes are short in duration. 8/10/17 - Medication: [MEDICATION NAME] 0.5 mg Q8H for dementia with behavioral disturbance. Resident remains alert with confusion. Needs anticipated by staff. Repetitive speech at times. Resident cooperative with care, at times attempts to push staff away with attempts to feed or give meds. Overall stable. 11/8/17 - Medication: [MEDICATION NAME] 0.5 mg Q8H for [MEDICAL CONDITION] with unspecified dementia with behavioral disturbance. Oriented to first name. Needs are anticipated and met by staff. No noted adverse effects. There were no documented repetitive behaviors (chewing on clothes), no verbal/ physical outbursts. Review of a Documentation Survey Report v2 for Behavior Monitoring from August 2017 through November 2017 revealed the following: August 2017: 11 x marked for yelling/ screaming September 2017: eight x marked for yelling/ screaming October 2017: five x marked for yelling/ screaming November 2017: one x marked for yelling/ screaming During an interview on 2/12/18 at 8:26 AM, the Physician stated that if a resident has failed a GDR once why try again because it isn't a benefit to the patient. The Physician stated Resident #49 was being seen by the Psychiatric Nurse Practitioner (Psych NP) and that he follows what is recommended by them. The Physician stated, why would I have a consultation done, if I am not going to listen to the recommendations. I continued the medication because the resident was continuing to have agitation. During an interview on 2/12/18 at 8:59 AM, Registered Nurse (RN) Unit Manager (UM) (RN #1) stated, I would expect the nursing staff to document anytime the resident has a behavior. The staff would document it in the nursing progress notes in the computer. The only other place behaviors would be documented is on the Quarterly Restraint/ [MEDICAL CONDITION] Medication Evaluation and Review. I really do not know why there is no behavior charting on her maybe because she hasn't had any. Non- pharmacological interventions that we do with residents on [MEDICAL CONDITION] medications include 1:1, checking to make sure resident does not have something else medically wrong with them like a UTI (urinary tract infection) or infection, making sure the resident isn't in any pain, provide incontinent care/ toileting, turning and positioning, offer a snack or beverage or have Activities take them to a program to try to redirect them. During an interview on 2/12/18 at 10:25 AM, the Director of Nursing (DON) stated, we chart by exception here, meaning if there are behaviors they should chart them. We attempt GDR every so often and we go through the Psych NP and the Physician for their recommendations. The Social Worker (SW) follows the residents on antipsychotic medications and comes up with a list of residents we meet about and discuss as a team. I believe Resident #49 wasn't having any behaviors and that why nothing is documented. The Physician documented not to GDR so it a GDR wasn't done. During an interview on 2/12/18 at 10:34 AM the Social Worker (SW) stated, I track all the anti-psychotic medications very closely here. We have quarterly reviews and weekly restraint meetings. This resident was placed on [MEDICATION NAME] on 5/11/16 and we did a GDR once in September 2016. The resident failed it and then the Physician wrote a note about it. The Physician did review it again in June 2017 and wrote a note not to do another GDR for the [MEDICATION NAME] again because she failed it on the first attempt. The resident is also seen by the Psych Nurse Practitioner (NP) and has not made any recommendation to try a GDR again for the [MEDICATION NAME]. The Psych NP was following the resident for some time and trying numerous medications for her behaviors before placing her on the [MEDICATION NAME]. We haven't tried another GDR because the resident wasn't having any behaviors. Why would we stop something that is working? During a telephone interview on 2/12/18 at 12:01 PM, the Consultant Pharmacist stated that he would not normally make recommendations for a GDR for antipsychotic medications because this facility did not want me at the meetings or make recommendations and that they would handle all of that. The facility would decide at their Quarterly meetings or at their weekly restraint meetings whether a GDR should be done. The Pharmacist stated he wouldn't want to make a recommendation because it may contradict what they decided at the meetings. The Pharmacist stated, I rarely attended the meeting because that would be way too many meetings, but I would sign off on the weekly restraint meeting reports that the facility would give to me to sign. The Pharmacist stated, I should probably be a part of the meetings and decisions but that is not what that facility wanted me to do. I do make recommendations at other facilities, but not this one. On 2/12/18 at 12:06 PM Surveyor requested from the SW the report sheets for the weekly restraint meetings for the past year. The Surveyor never received this information. 415.12(1)(2)(ii)

Based on observation, interview, and record review completed during the Standard survey completed on 2/12/18 the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. One (Resident #100) of four residents observed for pressure ulcers had issues. Specifically, the lack of skin monitoring and pressure reducing interventions when an immobilizer was initiated to the resident's right lower leg. The resident developed a pressure ulcer to her right lower extremity (RLE). The finding is: Review of the undated policy entitled Nursing Services Splint/Brace Care revealed appropriately trained staff will provide assistance as needed by either: providing a scheduled program of applying and removing a splint or brace, monitoring the resident's skin and circulation under the device, and repositioning the limb as needed. 1. Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 1/16/18 revealed the resident is cognitively intact and has an unstageable pressure ulcer. Review of an Order Summary Report dated 12/1/17 through 2/28/18 revealed an order dated 12/10/17 for an immobilizer to the right lower extremity at all times, check CMS (color, motion sensitivity) every shift; for fractured right patella (knee bone). May remove immobilizer for dressing and showers. An order dated 12/19/17 revealed an ABD pad (abdominal pad-thick dressing) to posterior right thigh under immobilizer for comfort, check and change daily and as needed. Review of a Comprehensive Care Plan reviewed 12/18/17 revealed the resident had actual skin breakdown and is at risk for skin breakdown, had a stage 1 (intact skin with non-blanchable redness) pressure area on her right buttock, approaches included to see the MAR/TAR (medication administration record/treatment administration record), CCP (closet care plan-used by staff to provide care). Review of the closet care plan dated 12/11/17 revealed special equipment included an immobilizer on at all times. Review of the Treatment Administration Record (TAR) dated 12/1/17 through 12/31/17 and 1/1/18 through 1/31/18 revealed the following: - immobilizer to rt (right) lower extremity aat (at all times), check CMS every shift. May remove for dressing and showers. This was initialed by staff as completed from 12/10/17 to 1/18/18, when the immobilizer was discontinued. - ABD pad to posterior right thigh under immobilizer for comfort, check and change daily and as needed on night shift. This was initialed by staff as completed from 12/19/17 to 1/17/18. Review of a Licensed Practical Nurse (LPN) Progress Note dated 1/13/18 revealed at 2:00 PM a [MEDICAL TREATMENT] nurse called the facility and stated the resident has an area of concern to right ankle area at the bottom of the immobilizer; stated there was a small amount of drainage to pillow where her right lower extremity (RLE) was resting. Resident had no pain in the area. Review of a Registered Nurse (RN) Progress Note dated 1/13/18 revealed [MEDICAL TREATMENT] nurse called today stating they noted a large amount of bloody drainage from the right posterior (back) calf. Upon resident return, noted a large unstageable area measuring 5 x 5 centimeters (cm)in size with yellow slough present in wound base. MD (medical doctor) notified, and a new order was received. Review of a Skin assessment dated [DATE] revealed a facility acquired unstageable pressure ulcer (full thickness tissue loss where base of ulcer is covered by slough-yellow, tan, grey, green or brown tissue and or eschar (black, dead tissue), measuring five centimeters (cm) in length (l) by five cm in width (w) with no depth on the right lower leg (rear). There was a moderate amount of serosanguineous drainage (blood and serum drainage) and the wound bed was yellow in color. The treatment plan was to cleanse with normal saline and apply [MEDICATION NAME] (topical antibacterial wound ointment that contains honey), cover with gauze pad and ABD pad and wrap with kling (flexible, absorbent gauze bandage used to wrap wounds) daily and prn (as needed). Observation of the pressure ulcer treatment on 2/9/18 at 7:40 AM revealed the resident had an unstageable pressure ulcer on her posterior (back) right lower leg, approximately five cm long by six cm wide, that had a moderate amount of serosanguineous drainage on the old dressing and yellow slough (dead tissue) in the wound bed. The resident had no complaints of pain during the dressing change. During an interview on 2/9/18 at 10:15 AM, the RN Unit Manager stated the resident had a patella fracture, went to the ortho, wasn't a candidate for surgery and was in an immobilizer for sixish weeks. When asked how were they monitoring the resident for the immobilizer, the RN stated, the usual things, watching for CMS, (color, motion, sensitivity), the integrity of the skin, pulses during care. When asked if the facility had a policy for how often the immobilizer would be removed the RN stated, their policy would be to remove every shift and have the nurses look at the skin, inspect the skin, during am care and hs (bedtime) care. When asked what they did when the resident complained of the immobilizer rubbing on her leg, the RN stated, we started padding it with an ABD pad, and every nurse every shift was to check the padding was in place. I would imagine that would be the same time they were doing the skin check. The RN stated they did look at the resident's skin when the treatment for [REDACTED]. When asked when the pressure ulcer was noted the RN stated, it was noted on 1/13. During an interview on 2/9/18 at 11:45 AM, the LPN #2 stated the resident had an issue at the thigh area, they would log roll the resident to her side and the LPN would remove the ABD pad, made sure the area wasn't getting any worse, it was red and tender but blanchable. It appeared the immobilizer was rubbing against her too often. They would do this every night and it took a total of three days before the red area went away but they kept the ABD pad there so it wouldn't come back. When asked if she ever removed the immobilizer the LPN stated no, there was enough room, could fit two fingers in there so I didn't have to undo it to see the red area, I could shine a flashlight in and see the area, I'd be scared to (remove the immobilizer). The LPN further stated she would check her CMS by ask the resident to close her eyes, pinch one toe, pinch other toe and ask her which toe I was pinching, check cap refill in nail bed, tell her to wiggle her toes, I never took off the immobilizer. During an interview on 2/9/18 at 2:10 PM, LPN #1 stated she usually worked on Tuesdays when the resident would have skin checks done. The LPN further stated this resident typically would refuse her shower and get a bed bath, we would once over her from head to toe, the immobilizer would be undone and then would lift the leg up, look underneath, and put it back on. When asked how immobilizer care was done the LPN stated the immobilizer would get out of position would have to adjust it and the resident would complain it was uncomfortable. When asked if she removed it, the LPN stated they would have to take it off to adjust it back for her when she said it was uncomfortable, then they put the ABD pad in place and that seemed to work. When asked if she did this every time the LPN said only when the resident complained it was uncomfortable for her. When asked if she noticed anything wrong with the resident's skin during skin checks the LPN stated no when asked if she removed the immobilizer the days she worked prior to the 13th of January the LPN stated I don't remember. During an interview on 2/9/18 at 3:03 PM, LPN #3 stated she would make sure the immobilizer was in place and comfortable and there was one point where we were putting padding underneath the bottom side of the immobilizer but that was done on mornings and it was in place by the time I got here and I didn't have to change it. When asked how she checked circulation in the leg the LPN stated would check for pulse, see if feeling sensation, check pedal pulse, wiggle her toes when asked if she ever looked at her knee the LPN stated I usually didn't undo the immobilizer, I never undid it and further stated she didn't notice anything wrong with the resident's skin. During an additional interview on 2/12/18 at 9:45 AM, the RN Unit Manager stated she would expect nurses to be monitoring and looking under the brace for skin integrity on a shiftly basis and the immobilizer should have been removed for hygiene and showers. The RN further stated the nurses should have been checking the skin integrity of the whole area, not just toes and hygiene should be happening more than on shower day and CNAs should take it off as care planned for hygiene needs, not to evaluate the skin but to report anything unusual. The LPNs should be evaluating on an ongoing basis, I don't understand that they weren't. The RN reviewed the TAR and said the unit nurse would have been signing for the ABD pad placement and at least shiftly, immobilizer to RLE at all times, check for color, motion, sensitivity every shift may remove for dressing and showers. It does say may remove it, it does not say must remove it but I don't know how you can evaluate the skin without removing it, it says extremity, does not say the toes. Clearly we need to educate on what an extremity equals. The RN further stated she thinks the TAR was documentation that there was no issue and the weekly skin observation tools done with showers showed there were no issues. During an interview on 2/12/18 at 10:42 AM, the Physical Therapist (PT) stated therapy staff did not remove the resident's immobilizer when she was in therapy. The immobilizer should have been removed with dressing and hygiene daily. The PT would have expected the immobilizer to be removed at least daily and would assume daily skin checks by nursing. During an interview on 2/12/18 at 11:20 AM, Certified Nurse Aide (CNA #1) stated that she never removed the immobilizer, they would provide peri care, toilet her but she never removed it. When asked if she ever saw any nurse's remove it the CNA stated no, not that I'm aware of. During an interview on 2/12/18 at 2:25 PM, CNA #3 stated they would remove the immobilizer on shower days, to wash her up. The CNA stated she didn't notice anything wrong with her skin and the immobilizer would slip down at times when she started moving around more and we would have to adjust it. During interview on 2/12/18 at 11:32 AM, the Director of Nursing (DON) stated she expects the nurses to remove the immobilizer completely to complete skin inspections. 415.12(c)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/12/18, the facility did not ensure that a resident, with an indwelling catheter Foley - a tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTI's) to the extent possible. Specifically, one (Resident #29) of one resident, observed for infection control practices related to an indwelling urinary catheter had issues that involved improper handling and storage of a urinary collection bag. The finding is: 1. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set- a resident assessment tool) dated 10/2/17 revealed the resident is cognitively intact and has an indwelling urinary catheter. Review of a Medication Review Report dated 2/12/18 revealed an order dated 9/20/17 to change the catheter as needed with a 16 FR (French - measurement scale used to describe dimension of medical device tubing) 30 ml (milliliter) balloon. Review of the Progress Note dated 10/30/17 revealed physician was updated on urine C&S (culture and sensitivity-urine test) results and that resident was currently [MEDICATION NAME](antibiotic) for pneumonia but urine bacteria is resistant to the cipro. New antibiotic orders were obtained. Review of a Specimen Inquiry dated 11/4/17 revealed a urine culture was positive for pseudomonas aeruginosa (bacteria that can cause disease) and yeast. Review of the closet care plan (guide used by staff to provide care) dated 2/8/18 revealed instructions for a Foley (indwelling urinary catheter) with leg bag when out of bed (OOB), cap unused Foley bag to maintain sterility. Intermittent observations revealed the following: - 2/6/18 at approximately 9:00 AM a urinary collection bag was observed hanging on the rail in the resident's shared bathroom, not covered and the end (where the collection bag tubing connects to the urinary catheter tubing) was not capped. - 2/7/18 at approximately 10:00 AM a catheter urinary collection bag was observed hanging on the rail in the resident's shared bathroom, not covered and the end was not capped. -2/8/18 at 12:41 PM and 3:27 PM a urinary collection bag was observed hanging on rail in bathroom, not covered and the end was not capped. During observation of care on 2/9/18 at 9:30 AM, Certified Nurse Aide (CNA #2) provided catheter care then disconnected the urinary collection bag from the urinary catheter and reconnected a leg drainage bag. The CNA then went into the resident's bathroom, placed the collection bag into a large plastic bag and tied the bag around a railing in the bathroom. The collection bag contained a moderate amount of yellow urine, was not emptied at this time, and the end was not capped. After completing the resident's care, the CNA entered the bathroom, donned (put on) gloves and removed the urinary collection bag from the plastic bag and used alcohol swab to clean the end where the collection bag tubing connects to the urinary catheter tubing and used a second alcohol swab to clean the end of the tubing where you empty the collection bag. The CNA emptied the urine into a cylinder and stated 350 ccs (cubic centimeters). The CNA then used alcohol swabs and cleaned each end of the collection bag tubing as described above. The CNA did not cap the end of the tubing. The CNA then placed the collection bag into the same large plastic bag and tied it around the railing in the bathroom. The CNA then disposed of the urine appropriately. During an interview on 2/9/18 at 10:06 AM, CNA #2 stated they (Foley bags) are supposed to be covered because resident's might get embarrassed. When asked how the collection bags are supposed to be stored when not in use, the CNA stated, covered up so no dust or germs get in. During an interview on 2/9/18 at 10:15 AM, the Registered Nurse Unit Manager (RN #1) stated CNAs are supposed to put it in a clean bag, closed, contained in the resident's bathroom, they are supposed to alcohol and cap, it should be capped before put in the bag so it's fully contained and clean. Review of the facility policies entitled Catheterization-urinary indwelling or straight and Giving urinary catheter care dated 6/17 and 3/10 respectively, revealed there was no facility policy for handling or storage of a urinary collection bag when not in use. 415.12(d)(1)

Based on interview and record review conducted during the Standard survey completed on 2/12/18 the facility did not ensure that the Pharmacist report any irregularities to the attending Physician and the facility's Medical Director and Director of Nursing, and these reports must be acted upon. One (Resident #49) of five residents reviewed for Drug Regimen Reviews was on [MEDICATION NAME] [MEDICATION]) since 9/28/16 with no recommendations for a GDR (gradual dose reduction) from the Pharmacist. The finding is: Review of a policy entitled Medication Regimen Review (Monthly Report) dated 1/07 revealed in performing medication regimen reviews, the Consultant Pharmacist incorporates federally mandated standards of care, in addition to other applicable professional standards. Review of an undated policy entitled Continuous Quality Improvement (CQI) of the Medication Use Process revealed the Consultant Pharmacist is responsible for monitoring the quality of the entire medication use process, including the provision of pharmacy services and the outcomes of consultant pharmacy services. 1. Resident #49 was admitted into the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 12/8/18 revealed that the resident is severely cognitively impaired and is rarely/never understood or rarely/never understands. Section E revealed there were no potential indicators of [MEDICAL CONDITION], no behavioral symptoms, no behaviors exhibited during care and no wandering exhibited. In addition, this was indicated on the MDS from 9/9/17 and 6/10/17. Review of Section N revealed the resident received an antipsychotic medication. Antipsychotic medication review is marked that antipsychotics were received on a routine basis only and no GDR has been attempted. Physician documented GDR as clinically contraindicated on 6/9/17. Review of Comprehensive Care Plan dated 9/21/17 revealed the resident was on [MEDICATION NAME] for SDAT (senile dementia Alzheimer's type) with [MEDICAL CONDITION]. Goals included the resident will have behaviors controlled with decreasing calling out, chewing on clothing and disruptive behavior will decrease. Approaches included: Refer to standards Psych (psychological) Consults prn (as needed). Episodic Care Plan dated 1/9/18 revealed decrease chewing noted. Meeting/ review for 1/9/18 revealed no recent reports chewing on clothing noted. Review of the physician's orders [REDACTED]. Review of Medication Administration Records (MAR) for the months of September 28, 2016 through February 2018 revealed the resident received [MEDICATION NAME] 0.5 mg Q8H daily. Review of the Consultant Pharmacist Medication Regimen Reviews from February 2017 through January 2018 revealed the resident had no irregularities noted and there were no recommendations made by the pharmacist. During an interview on 2/12/18 at 11:44 AM, the Director of Nursing (DON) stated the Pharmacist comes in once a month and reviews the medications for every resident, including new admissions. The Pharmacist does a monthly medication review. The Pharmacist does make recommendations and has made them regarding antipsychotic medications. I would expect the Pharmacist to make recommendations. During a telephone interview on 2/12/18 at 12:01 PM, the Consultant Pharmacist stated that he would not normally make recommendations for a GDR for antipsychotic medications because this facility did not want me at the meetings or to make recommendations. That they would handle all of that. The facility would decide at their Quarterly meetings or at their weekly restraint meetings whether a GDR should be done. The Pharmacist stated he wouldn't want to make a recommendation because it may contradict what they decided at the meetings. The Pharmacist stated, I rarely attended the meeting because that would be way too many meetings, but I would sign off on the weekly restraint meeting reports that the facility would give to me to sign. The Pharmacist stated, I should probably be a part of the meetings and decisions but that is not what that facility wanted me to do. I do make recommendations at other facilities, but not this one. 415.18(c)(1)

Based on interview and record review conducted during a Standard survey completed on 2/12/18, the facility did not ensure that each resident's drug regimen was free of unnecessary drugs. An unnecessary drug is any drug when used in excessive dose, for excessive duration, without adequate monitoring or in the presence of adverse reactions. One (Resident # 16) of five residents reviewed for unnecessary drugs had issues. Specifically, a resident receiving insulin (used to decrease glucose (blood sugar) levels in the blood) lacked the proper monitoring of the resident's glucose levels. The finding is: Review of a document provided by the facility entitled Clinical Changes to be Reported to MD dated 4/3/15 revealed a blood sugar of less than 70 or greater than 350 should be called to the MD (Medical Doctor). 1. Resident #16 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS - a resident assessment tool) dated 11/10/17 revealed the resident has moderate cognitive impairment, is sometimes understood and sometimes understands. Review of an Order Review History Report dated 11/1/17 through 11/30/17 revealed and order dated 11/3/17 for [MEDICATION NAME] solution (long acting insulin) to inject 60 units subcutaneously (beneath the skin) at bedtime for diabetes and an order for [REDACTED]. Review of a progress note Orders- Administration Note dated 11/17/17 at 11:57 AM by a Licensed Practical Nurse (LPN) revealed the order for [MEDICATION NAME] R and the sliding scale coverage was discontinued per the MD (medical doctor). Review of an Order Recap Report dated 10/1/17 through 12/31/17 revealed a new order was obtained on 11/20/17 to monitor finger sticks (finger prick to monitor blood sugars) BID (twice daily), twice a month starting the first of the month every month and had a start date of 12/1/17. Review of a Medication Administration Record [REDACTED]. There were no finger sticks documented or [MEDICATION NAME] R administered 11/17/17 through 11/30/17 on the MAR. Continued review of the November 2017 MAR indicated [REDACTED]. Review of an Order Review History Report dated 12/1/17 through 12/31/17 revealed an order dated 12/4/17 to monitor finger sticks BID (twice daily) twice monthly. Review of a MAR indicated [REDACTED]. On 12/1/17 at 6:00 PM the resident had a blood sugar level of 358 (normal 70 - 100). Review of the Weights and Vitals Summary report revealed that on 12/25/17 at 3:54 PM a blood sugar level (glucose) of 391 was documented. Review of the progress notes dated 12/1/17 through 12/31/17 revealed there was no documented evidence that the Physician was notified of the 12/1/17 blood sugar level of 358 or of the 12/25/17 blood sugar level of 391. Review of the Order Recap Report dated 1/1/18 through 2/9/18 revealed an order dated 1/18/18 to increase the [MEDICATION NAME] Solution to 70 units subcutaneously daily at bedtime. Review of the Order Recap Report dated 1/1/18 through 2/9/18 and the Medication Administration Record [REDACTED]. Additionally, on 1/15/18 when the scheduled accu- check (finger stick) was completed revealed a blood sugar level of 462. Review of an Order Recap Report dated 1/1/18 through 2/9/18 and Medication Administration Report (MAR) dated 1/1/18 through 1/31/18 revealed a one-time dose of Humalog insulin 16 Units subcutaneously was ordered and administered on 1/15/18 at 4:38 PM. Additionally, Humalog solution subcutaneously inject per the sliding scale with finger sticks glucose monitoring before each meal and at bedtime was ordered. Review of the January 2018 MAR from 1/15/18 through 1/31/18 and the February 2018 MAR from 2/1/18 through 2/9/18 revealed the resident received additional insulin as the sliding scale 89 times out of 98 accu-check tests, to manage his glucose levels. During an interview on 2/12/18 at 8:38 AM, the Physician reviewed the MAR's for November 2017 and the accu-checks (blood sugar levels) obtained and revealed the glucose monitoring with the sliding scale should not have been discontinued since the resident was receiving coverage. Further the Physician revealed the nurse should have called with the elevated blood sugar levels in December to determine if additional coverage should be given. During an interview on 2/12/18 at 8:40 AM, Registered Nurse Resident Care Coordinator (RN #2) revealed the December 2017 elevated accu-checks (blood sugar levels) should have been called into the doctor for further direction. RN #2 also revealed closer monitoring of the resident's glucose (blood sugars) should have been considered in November and December. During an interview on 2/12/18 at 12:25 PM, Licensed Practical Nurse Unit Manager (LPN #5) revealed the December elevated accu-check results should have been called into the physician for further direction. During an interview on 2/12/18 at approximately 12:45 PM, the Director of Nursing (DON)revealed the December elevated accu-check results should have been called into the medical group. 415.12(l)(1)