Every finding on record at Elderwood of Lakeside at Brockport

Based on observations, interviews, and record review conducted during a Recertification Survey and complaint investigation (NY00365495) from 03/28/2025 to 04/02/2025, for two (2) (Resident #55 and #59) of nine (9) residents, the facility did not ensure residents who were unable to carry out activities of daily living (basic self-care tasks people perform regularly to maintain their well-being, such as bathing and nail care) received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #55 had not received a shower in four (4) weeks, had unshaved facial hair, and unclean hair and fingernails. Resident #59 had not received a shower in three (3) weeks, was unshaven, and was observed using their hands to eat with debris underneath their fingernails. This is evidenced by the following: The facility policy Activity of Daily Living Assistance and Supervision dated 01/08/2018 included the nursing assistant provides activity of daily living assistance to assigned residents and assists other nursing assistants in giving care as needed. The Unit Manager/designee and Team Leader monitors the activity of daily living assistance provided for residents throughout the shift and gives appropriate guidance and assistance to nursing staff. The facility policy Bath, Tub/Shower dated 08/07/2021 included a shower or tub bath will be given by an appropriately trained nursing assistant or licensed nurse once a week and/or as deemed necessary to all residents (unless contraindicated due to illness) or per the resident's preference. The facility policy Shaving a Female Resident dated 05/08/2018 included a nursing assistant will shave the face of a female resident as needed to remove extraneous facial hair. The facility policy Hand and Nail Care dated 01/25/2019 included residents will receive nail care for cleanliness and to prevent infection. Appropriately trained nursing assistants will provide nail care for all residents except those with diabetes or severe peripheral vascular disease. 1. Resident #55 had diagnoses that included diabetes, hypertension (high blood pressure), and depression. The Minimum Data Set (a resident assessment tool) dated 01/16/2025 included the resident was cognitively intact and required assistance with showers. Review of the active Comprehensive Care Plan and Kardex (care plan used by certified nursing assistants to guide care) reviewed on 03/28/2025 revealed Resident #55 required staff assistance with lower body bathing and was independent with personal hygiene. During an observation and interview on 03/27/2025 at 9:27 AM, Resident #55 had facial hair growing on their chin, their hair was greasy and stringy, and there was dark debris under multiple fingernails on both hands. When interviewed at that time, Resident #55 stated they should receive a shower once a week but had not received a shower in approximately four (4) weeks. They were annoyed they had not received a shower and wanted one. Resident #55 stated they used to take care of shaving and fingernail care on their own but was now unable to do so. They stated they wanted their hair washed, facial hair shaved, and fingernails cleaned and trimmed. Review of the facility document Shower Assignment last updated 02/28/2025 revealed Resident #55's shower was scheduled on Friday, day (7:00 AM to 3:00 PM) shift. Review of the Certified Nursing Assistant Documentation Survey Report (a portion of the electronic health record where baths and showers were documented) revealed Resident #55's last documented shower was on 02/28/2025. During observations on 03/28/2025 at 3:17 PM (Friday) and 03/31/2025 at 9:56 AM, Resident #55's hair remained greasy and stringy, facial hair was unshaven, and fingernails on both hands had debris underneath. During an interview on 03/31/2025 at 11:24 AM, Certified Nursing Assistant #1 stated shaving, nail care, and hair washing was completed during showers and as needed. Resident #55 was on their assignment and required assistance with shaving and nail care. Certified Nursing Assistant #1 stated they did not notice if Resident #55 was unshaven or had unclean hair and fingernails. During an interview and observation on 03/31/2025 at 11:45 AM, Licensed Practical Nurse #1 stated they were responsible for nail care of diabetic residents and the certified nursing assistants would tell the nurses when nail care was needed. They stated hair, shaving, and nails were observed during skin checks on shower day and if something needed to be done, they would make sure it was completed. When observed at that time, Resident #55's hair, facial hair, and fingernails were unchanged. Licensed Practical Nurse #1 stated it did not look like Resident #55 had a shower in a while and needed to have their hair washed, facial hair shaved, and fingernails cleaned and trimmed. Licensed Practical Nurse #1 stated in the past year they had to provide more direct resident care due to short staffing. 2. Resident #59 had diagnoses that included dementia, diabetes, and heart failure. The Minimum Data Set, dated dated dated [DATE] included the resident had moderately impaired cognition and required assistance with showers and personal hygiene. The active Comprehensive Care Plan, last revised on 09/30/2024 and Kardex reviewed on 03/31/2025 included Resident #59 required staff assistance with showers and personal hygiene, fingernails were to be trimmed and cleaned twice weekly and assisted with shaving on their shower day. During an observation and interview on 03/27/2025 (Thursday) at 1:54 PM, Resident #59 had a full beard and long jagged fingernails with dark debris underneath. They were eating watermelon with their hands. Resident #59 stated their face was itchy and they wanted to be shaved. Review of the facility document Shower Assignment last updated 02/28/2025 revealed Resident #59's shower was scheduled Wednesday, day shift. Review of the Certified Nursing Assistant Documentation Survey Report revealed Resident #55's last documented shower was on 03/05/2025 (no documented shower in three (3) weeks). During observations on 03/28/2025 at 3:32 PM and 03/31/2025 at 9:28 AM, Resident #59's facial hair and fingernails were unchanged. During an interview on 03/31/2025 at 10:44 AM, Certified Nursing Assistant Unit Clerk #1 stated they had a direct care assignment today. They stated showers, shaving, and nail care were unable to be completed due to short staffing. During an interview and observation on 03/31/2025 at 12:59 PM, Registered Nurse Minimum Data Set Coordinator stated activities of daily living should be completed per the resident's care plan and showers should be completed on the resident's scheduled day. When observed at that time, Resident #59's facial hair was long and unshaven, and their fingernails were jagged with dark debris underneath. Registered Nurse Minimum Data Set Coordinator stated it did not look like Resident #59 had a shower or their nails trimmed or cleaned in a while and should have their nails cleaned and trimmed twice weekly. During an interview on 04/02/2025 at 11:58 AM, the Director of Nursing stated activities of daily living including showers, hair care, shaving, and nail care should be completed per the resident's plan of care, as needed, and per resident preference. The Director of Nursing stated residents should not go multiple weeks without a shower, should not go unshaven, and should not have long, jagged, or dirty fingernails. The Director of Nursing stated the inability to complete activities of daily living, including showers, was due to ongoing staffing issues and not completing activities of daily living could negatively impact the residents' self-esteem and mood. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record review conducted during the Recertification Survey from 03/27/2025 to 04/02/2025, the facility did not ensure residents received care in accordance with professional standards of practice for 1 (Residents #55) of 21 residents reviewed. Specifically, Resident #55 had edema (swelling in the legs) to both legs and did not receive compression therapy per physician order and their comprehensive care plan did not include goals and interventions related to the resident's diagnosis of diabetes, chronic kidney disease, or edema. This is evidenced by the following: 1. Resident #55 had diagnoses that included chronic kidney disease (a gradual loss of kidney function that can cause swelling in the feet and legs), hypertension (high blood pressure), and diabetes. The Minimum Data Set (a resident assessment tool) dated 01/16/2025 included the resident was cognitively intact and had active diagnoses including but not limited to hypertension, renal failure, and diabetes. During an observation and interview on 03/27/2025 at 9:33 AM, Resident #55 had moderate swelling (edema) to both lower extremities and stated they were supposed to wear elastic stockings. They said staff did not consistently assist with putting on the elastic stockings and had not put the stockings on that day. A physician order, dated 08/29/2024, included to apply tubigrips (elastic compression bandages used to reducing swelling) to both lower extremities (from toes to knees) daily in the morning and remove at bedtime. The current comprehensive care plan and Kardex (care plan used by the certified nursing assistants for daily care), reviewed on 03/28/2025, revealed no information, including measurable goals or interventions, related to Resident #55's edema, or diagnoses of chronic kidney disease and diabetes. During observations on 03/28/2025 at 3:17 PM and 03/31/2025 at 9:56 AM, Resident #55 had moderate swelling to both lower extremities and tubigrips were hanging on the footboard of the bed. Review of the Treatment Administration Record revealed the following: a. In January 2025, for 6 of 31 opportunities, there was no documented evidence the tubigrips were put on. For three (3) additional opportunities, documentation revealed the tubigrips were not applied due to the resident sleeping. b. In February 2025, for 4 of 31 opportunities there was no documented evidence the tubigrips were put on. For nine (9) additional opportunities, documentation revealed the tubigrips were not applied due to the resident sleeping. c. In March 2025, for 8 of 31 opportunities there was no documented evidence the tubigrips were put on. For seven (7) additional opportunities, documentation revealed the tubigrips were not applied due to the resident sleeping. During an interview on 03/31/2025 at 11:24 AM, Certified Nursing Assistant #1 stated tubigrips were put on by the nurse. During an interview on 03/31/2025 at 11:45 AM, Licensed Practical Nurse #1 stated Resident #55 was supposed to wear tubigrips daily and instructions for applying the tubigrips should be on the resident's care plan. They stated tubigrips were placed and removed by the nurse and documented in the electronic health record. Most tubigrips are put on by the night shift nurse, removed by the evening shift, and were not checked for placement by the day shift nurse. Licensed Practical Nurse #1 stated they were not sure if Resident #55's tubigrips had been applied that day and if the tubigrips had not been put on, the night shift nurse should have reported it to them during shift report. During an interview on 03/31/2025 at 12:59 PM, the Registered Nurse Minimum Data Set Coordinator stated tubigrips were ordered by the physician and should be put on as prescribed. If the tubigrips were not put on, the information should be passed to the next shift to attempt to apply them. Registered Nurse Minimum Data Set Coordinator stated Resident #55 was prescribed tubigrips for their edema and not wearing them could cause skin breakdown or worsening edema. During an interview on 04/02/2025 at 11:58 AM, the Director of Nursing stated all physician orders should be completed as prescribed, including tubigrips. A blank box in the treatment administration record meant there was missed documentation, and the treatment would be considered not completed. The Director of Nursing stated if tubigrips were not put on it should be documented in the electronic health record, passed along in shift report, and discussed with the physician to update orders as needed. They stated if a resident was asleep and did not want to be woken up for the tubigrips to be applied, the time should be adjusted to their awake/preferred time to ensure they are put on. 10 NYCRR 415.12

Based on interviews and record review conducted during the Recertification Survey from 03/27/2025 to 04/02/2025, for one (1)(Resident #55) of three (3) residents reviewed the facility did not provide proper treatment and assistive devices to maintain vision. Specifically, the facility did not ensure Resident #55 was seen by the facility medical provider in a timely manner after reporting changes in vision, did not make an appointment with the resident's eye doctor per medical provider recommendation, and did not ensure the resident made it to a scheduled eye doctor appointment. This is evidenced by the following: The facility policy Optometry and Eye Care dated 06/18/2018 included eye examinations and other consultant optometry services will be obtained as ordered by the attending physician. The resident or legally designated representative and/or responsible party will be contacted by the nursing staff to obtain approval for service and transportation arrangements. When the Attending Physician orders optometry care for a resident, or the nursing staff determines that an optometry evaluation may be necessary, the resident or legally designated representative and/or responsible party is contacted by the nursing staff to make arrangements for services at the facility or through the specialist of the resident's choice, and to obtain transportation preferences. 1. Resident #55 had diagnoses that included diabetes, macular degeneration (a progressive disease that causes blurred or distorted central vision and/or blind spots), and glaucoma (eye disease that can cause vision loss and blindness). The Minimum Data Set (a resident assessment tool) dated 01/16/2025 documented the resident was cognitively intact, wore glasses, and had adequate vision (able to see fine detail). During an interview on 03/27/2025 at 9:42 AM, Resident #55 stated they had changes in their eyesight starting in December 2024 but had not seen the eye doctor yet. They stated they reported their vision changes to facility staff. In a progress note dated 09/18/2024, Certified Nursing Assistant #2 documented Resident #55 had a follow up appointment with the eye doctor scheduled for 03/17/2025. In a progress note dated 12/05/2024, Registered Nurse Minimum Data Set Coordinator documented Resident #55 had complained of eye heaviness and irritation and their concerns were placed in the medical book (a book used by nurses to communicate resident issues and concerns to the medical providers). In a progress note dated 12/06/2025, Certified Nursing Assistant #2 stated they called the eye doctor to schedule an earlier (before 03/17/2025) appointment for Resident #55 due to complaints of eye changes. In a progress note dated 12/30/2024 Nurse Practitioner #1 documented they saw Resident #55 for changes in eyesight and glaucoma and they needed to follow up with their eye doctor. During an interview on 03/31/2025 at 10:44 AM, Certified Nursing Assistant Unit Clerk #1 stated they were responsible for scheduling medical consult or specialist appointments and arranging transportation for appointments. They stated Resident #55 saw an outpatient (provider not affiliated with the facility) eye doctor and per the electronic health record was last seen in August 2024. Certified Nursing Assistant Unit Clerk #1 stated they did not know Resident #55 needed to be seen for changes in their eyesight, and did not know they had an appointment scheduled on 03/17/2025. They had not arranged transportation and Resident #55 missed the scheduled appointment. Certified Nursing Assistant Unit Clerk #1 stated they often had to work in a direct resident care capacity and was not able to complete their unit clerk responsibilities, as a result, Resident #55 was not scheduled for an earlier appointment and also missed their scheduled appointment on 03/17/2025. During an interview on 04/01/2025 at 3:03 PM, Registered Nurse Minimum Data Set Coordinator stated if a resident reports a concern, they should be seen timely by the facility medical provider. They stated outpatient appointments and transportation were arranged by the unit clerk, Resident #55's eye appointment should have been moved up per the facility medical provider, and the unit clerk should have ensured transportation was set up for Resident #55's appointment on 03/17/2025. During an interview on 04/02/2025 at 11:58 AM, the Director of Nursing stated all follow up appointments and consult appointments are made per medical provider recommendations and are made timely. They stated there was a 25-day gap (12/05/2025 to 12/30/2025) and Resident #55 was not seen timely between their complaint of eye changes and visit with the facility medical provider. The Director of Nursing stated the unit clerk or nurse manager should have followed up with the eye doctor in December 2024 to make an appointment for Resident #55 to be seen and transportation should have been arranged, so they did not miss their appointment on 03/17/2025. 10 NYCRR 415.12(a)(3)(b)(1-3)

Based on observations, interviews, and record review conducted during a Recertification Survey from 03/27/2025 to 04/02/2025, it was determined for one (1) (Resident #78) of seven (7) residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. Specifically, Resident #78 was on Enhanced Barrier Precautions (infection control measures used to reduce the spread of multidrug-resistant organisms and involves the use of gowns and gloves during high-contact resident care activities) due to having a wound, a nurse did not perform hand hygiene prior to entering the resident's room, did not wear gloves while handling a sterile wound dressing, and did not change gloves or perform hand hygiene after handling a soiled dressing and before applying a clean dressing to the wound. This is evidenced by the following: Review of the facility policy Pressure Ulcer, Pressure Injury & Other Skin Conditions: Initial Assessment, Care Planning, Ongoing Evaluation and Management Skilled Nursing Facility dated 02/27/2023 included the facility will ensure that every resident receives care consistent with professional standards of practice and those residents with pressure ulcers, injuries or skin conditions will receive treatment and services to promote healing and prevent infection. Resident #78 had diagnoses that included a stage three (3) (full thickness tissue loss) pressure ulcer of the sacral region (base of the spine), diabetes, and Parkinson's disease (a movement disorder of the nervous system). The Minimum Data Set (a resident assessment tool) dated 01/16/2025 revealed the resident was cognitively intact and had a stage three (3) pressure ulcer. Review of the Comprehensive Care Plan dated 01/28/2025 revealed Resident #78 had an alteration in skin integrity related to a current wound. Interventions included, but were not limited to, apply treatments per provider orders, monitor the wound for signs and symptoms of infection, and Enhanced Barrier Precautions in place. Review of a physician order, dated 03/24/2025, included but was not limited to apply calcium alginate (wound dressing) to the sacral wound daily and as needed. During an observation on 03/31/2025 at 2:03 PM, Licensed Practical Nurse #2 was performing wound care for Resident #78. Licensed Practical Nurse #2 did not perform hand hygiene prior to entering the residents room and did not apply gloves prior to handling the sterile calcium alginate dressing. Licensed Practical Nurse #2 then put on gloves, removed the soiled dressing and applied the clean dressing without changing their gloves or performing hand hygiene in between. During an interview on 03/31/2025 at 3:23 PM, Licensed Practical Nurse #2 said they did not have gloves on while handling the sterile wound dressing, did not change gloves or perform hand hygiene after removing the soiled dressing and before applying the clean dressing but should have. During an interview on 04/01/2025 at 11:17 AM, the Director of Nursing said there were two missed opportunities to prevent contamination of Resident #78's wound. They stated Licensed Practical Nurse #2 should have worn gloves while handling sterile wound care supplies and should have changed gloves and performed hand hygiene in between handling the soiled and clean wound dressings. 10 NYCRR 415.19(a)(1-3) (b)(4)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (NY00340497) for one (Resident #6) of three residents reviewed, the facility did not ensure adequate supervision and monitoring devices were in place to prevent a resident from elopement (when a resident leaves the facility without supervision creating a potential threat to their health and safety). Specifically, Resident #6 was moderately impaired of cognitive function with a history of wandering and eloped from the facility by walking out the front door. The resident was not found for 42 minutes approximately 0.3 miles away. This is evidenced by the following: The facility policy Elopement - Wandering - Missing Resident, dated 10/08/2018, documented that appropriate safety measures are put into place for residents determined to be at risk for unsafe wandering/elopement. Resident #6 had diagnoses that included cerebral infarction (stroke), cognitive communication deficit, and nicotine dependence. The Minimum Data Set Resident Assessment, dated 03/13/2024, revealed Resident #6 had moderate impairment of cognitive function and was coded as behavior not exhibited for wandering. In an interdisciplinary progress note, dated 04/01/2024, Registered Nurse #1 documented Resident #6 got on the elevator and went down to lobby and out the front door to the gazebo. In an interdisciplinary progress note, dated 04/01/2024, Director of Nursing documented Resident #6's family was notified that a wander guard bracelet (a system put in place to alert the facility that a resident was leaving the facility without supervision at a risk to their safety) was placed on the resident due to attempts to leave the unit and was found in the basement looking for an exit by a staff member. Review of the Comprehensive Care Plan, dated 04/01/2024, revealed Resident #6 was at high risk for wandering/elopement and could walk with or without devices (walker). Interventions included monitoring the resident's whereabouts due to unsafe wandering and use of a wander guard bracelet on their right ankle to alert the facility of any wandering and/or elopement. In a nursing progress note, dated 04/07/2024, Licensed Practical Nurse #1 documented that they took Resident #6 outside and noted that when they entered the elevator, the wander guard bracelet did not alarm. Resident #6 stated they cut the wander guard bracelet off and threw it out. In a nursing progress note, dated 04/09/2024, Registered Nurse Manager #1 documented Resident #6 refused to wear the wander guard bracelet on their ankle, so it was placed on the resident's walker. In a therapy progress note, dated 04/15/2024, Physical Therapy Assistant #1 documented Resident #6 had walked 300 feet in therapy. In a nursing progress note, dated 04/26/2024, Licensed Practical Nurse #1 documented they went to administer afternoon medications, could not locate Resident #6 on the unit and notified staff on floor to search for the resident. Review of the facility investigation, dated 04/26/2024 and signed by the Director of Nursing and the Administrator, revealed that on 04/26/2024, Resident #6 exited out of the front entrance at approximately 12:43 PM and that there were several staff who saw the resident, but did not realize they were a resident, or did not realize the resident was not allowed to be outside unsupervised. Resident #6 made their way to a local park across the street from the facility which was approximately 0.3 miles away and was found by staff approximately 40 minutes later. During an interview on 12/06/2024 at 1:39 PM, Certified Nursing Assistant #1 stated Resident #6 had gotten outside to the duck pond and staff had to drive around to find the resident. During an interview on 12/06/2024 at 3:10 PM, Physical Therapist #1 stated Resident #6 became independent with walking without a walker on 04/15/2024 and still liked to use their walker at times, but needed to be supervised when using it as they were not using it correctly. During an interview on 01/08/2024 at 10:58 AM, the Director of Nursing stated Resident #6 had been walking without their walker for some time. The Director of Nursing stated they emailed the Nurse Manager on 04/09/2024 to place the resident on 15-minute checks when the resident refused to wear their wander guard, but the 15-minute checks had not been completed and there was a flaw in their system. During an interview on 01/08/2025 at 1:24 PM, the Administrator stated Resident #6 had not been wearing their wander guard bracelet and like many residents, they looked like a visitor. Resident #6 left the facility at a high traffic time and walked through the lobby when the front desk staff were busy and did not see the resident leave. When therapy deemed the resident independent with walking, the wander guard bracelet should have been on the resident, but the resident had cut it off a few times. The Administrator also stated they thought that the 15-minute safety checks were being completed, but they were not. Based on the following corrective actions it was determined, through interviews and record review, the facility implemented corrective actions to correct the non-compliance effective 05/15/2024: - A full house audit was completed for all residents using wander guard bracelets. - Any wander guard bracelets located on adaptive equipment were moved to residents' bodies. Observations of current residents with wander guard bracelets revealed no issues. - Full house staff education was completed regarding wandering and elopement. Interviews with current staff revealed no issues identified. - An email is sent out to all staff monthly with pictures of residents who are at high risk for elopement. - Binders containing pictures of residents at risk for elopement were placed on all units, the basement, and in the kitchen area for all staff awareness and remain current. Observations of the binders on 01/08/2025 revealed no issues. 10 NYCRR 415.12(h)(2)

Based on observations, interviews, and record reviews conducted during the Recertification Survey from [DATE] to [DATE], it was determined that for three of three residential units the facility did not ensure that drugs and biologicals were securely stored. Specifically, multiple medications were observed stored in an unlocked and unsupervised charting room. This is evidenced by the following: The facility policy Medication Rooms on Nursing Units dated [DATE], included that medication rooms on the nursing units of the facility will be the areas where medications for residents are stored. The rooms will have included but not limited to adequate means for security. In an observation on [DATE] at 12:15 PM Resident #67 (identified by the facility as being severely impaired of cognitive function) was observed self-propelling their wheelchair behind the 4th floor unit clerks' desk near the charting room. There was no staff in the area at the time and the resident was verbalizing what am I supposed to do? Where should go? In observations and interview on [DATE] at 1:27 PM and again at 2:49 PM on the 4th floor residential unit in the charting room located behind the unit clerk's desk, the door to the room was fully open and underneath the counter was a clear plastic container that contained multiple clear packets of prescription medications and included but not limited to insulin vials, injectable medications, antipsychotic medications, cardiac medications, and multiple loose pills in the bottom of the container. Directly across from the charting room was a locked door labeled medication preparation room. When interviewed at 2:52 PM, the 4th floor unit Licensed Practical Nurse (LPN)/Nurse Manager (NM) #1 stated that non-narcotic medications are put in this container and are taken downstairs when full (to be picked up by pharmacy). LPN/NM #1 stated that generally just nurses come in the room and that the door is sometimes left open. LPN/NM #1 stated that the unit does have several residents who wander. During an observation and interview on [DATE] at 3:06 PM on the 3rd floor residential unit, the charting room door was open, and staff were observed coming in and out of the room leaving the door open. There was another clear plastic container in the room under the counter that contained numerous packets of prescription medications and loose pills. When interviewed at this time the Registered Nurse Manager (RNM) stated that when medications are discontinued, or a resident is discharged or expired the unit nurses place the remaining medications in the container to be returned to pharmacy weekly. The RNM stated that the charting room door is not always closed, that all staff have access to the room and that there are residents on the unit who wander throughout. During observation on the 2nd floor residential unit on [DATE] at 3:22 PM the charting room door was open, and a clear container located under countertop contained multiple medications of prescriptions medications. During an interview on [DATE] at 3:20 PM LPN #2 stated that medications are put in a container under the nurse's station desk in the charting room until they get sent back to pharmacy. LPN #2 said that both nurses and aides have access to the room and the door is kept open. LPN #2 said that there are residents on the unit that wander everywhere. During an interview [DATE] at 3:27 PM Registered Nurse #1 (2nd floor covering NM) stated that the former Director of Nursing (DON) instructed us to put the medication bin here (in the charting room) as no one other than staff usually comes into the chart room. RN #1 said that there is mostly someone is in the room on days but did not know about evenings. RN #1 said that they would not consider it a secure place to store medications. During an interview on [DATE] at 10:15 AM the DON stated they were not aware of the process for disposing non-narcotic medications or that the containers were being kept in the charting room. The DON stated that certified nursing assistants should not have access to medications and did not consider the charting room to be a secured area. 10 NYCRR 415.18(e)(,d+[DATE])

Based on observations, interviews and record review conducted during the Recertification Survey 7/6/23 to 7/13/23, it was determined that for one (Resident #51) of three residents reviewed for accidents, the facility did not ensure that the resident's environment remained as free of accident hazards as possible. Specifically, Resident #51, who was observed to have multiple medications left on their bedside table, had not been assessed, and care planned for safe self-administration of medication. This is evidenced by the following: The facility policy Medications Administration dated modified 7/12/22 documented that a medication must never be left at bedside or be out of sight of the nurse administering the medication. The nurse must watch each resident take the medication, and ensure the medication is swallowed, unless the resident has an order for self-administration of medications. The facility policy Self- Administration of Medication dated modified 4/10/18, documented those residents who desire to self-administer medication are permitted to do so upon review and approval by the inter-disciplinary care planning team members and with an order from the attending physician. Over-the-counter medications will be stored in a locked drawer in the resident's room. The use of self-administered medication will be monitored by licensed nursing staff. Resident #51 had diagnoses including dementia, diabetes, and dysphagia (difficulty swallowing). The Minimum Data Set assessment dated [DATE], documented that Resident #51 was cognitively intact, had impaired vision and required set up help for eating. Review of the Comprehensive Care Plan revealed no documented evidence that Resident #51 had been assessed and care planned for safe self-administration of medications. Review of current physician orders did not include orders for self-administration of medications for Resident #51. During an observation and interview on 7/6/23 at 9:34 AM approximately 19 pills were observed on Resident #51's bedside table and included but not limited to multiple torsemide (diuretic that removes excess fluid from the heart and lungs) tablets, diltiazem (cardiac medication) tablet and a losartan (high blood pressure medication) tablet. There was no nurse in sight of the open and unlabeled cup of pills. The resident stated at the time that they did not know exactly what the pills were for. During an observation on 7/10/23 at 2:04 PM, another resident (wheelchair bound) was observed [NAME] themselves into Resident #51's room appearing confused and asking if someone could tell them where they should be. A staff member (notified by the surveyor) came in the room and redirected the resident. During an observation on 07/11/23 at 9:38 AM approximately 19 pills were again observed on Resident #51's bedside table in an open unsupervised medicine cup. At approximately 9:55 AM all the pills remained at the bedside unsupervised. During an interview on 7/12/23 at 10:32 AM, Resident #51 said it takes them a long time to take their medication, so the nurses leave the medication with them (at the bedside). When asked if other residents frequently wander into their room, Resident #51 said the resident in the wheelchair often does and that it takes staff a long time to come and redirect the resident. During an interview on 7/12/23 at 11:43 AM Licensed Practical Nurse (LPN) #1 stated the unit had four residents who wander, three of who do wander into other residents' rooms. LPN #1 said none of the residents on the unit had been assessed to self- administer medication or have medication left at their bedside unsupervised. During an interview on 7/12/23 at 12:38 PM, the Director of Nursing (DON) stated that the nurses have a liberalized medication schedule (extended period of time) to pass medications so that they do not have to rush their medication pass and they can spend adequate time with each resident. The DON said they would expect that in order for a resident to have medications left at their bedside for the purpose of self- administering, the resident would have to have a locked box in their room in the event of residents who wander. The DON said that under no circumstance should any pills, or non- pill form medication be left at the bedside unsupervised. The DON said that a resident who takes 19 pills would not be appropriate for self- medication administration due to the amount of medication involved. During an interview on 7/12/23 at 1:03 PM, the Regional Nurse Consultant stated that in order for a resident to have medication left at the bedside for self- administration, there needs to be a physician's order, the resident care planned for self-administration, an observation of the resident self- administering their medications and a locked box in their room to properly secure the medication. During an interview on 7/12/23 at 2:34 PM, LPN #2 stated that there were three residents who wander on the unit and that medications should never be left unsupervised at a resident's bedside. LPN #2 said that in the event the nurse had to step away, the medication should be locked inside the medication cart. LPN #2 said that they left medication unsupervised at Resident #51's bedside on 7/11/23 because there was an overhead page for a code blue (emergency situation that could be life threatening). LPN #2 said they also left medication unsupervised at Resident #51's bedside on 7/6/23 but that there had not been an emergency that day and they did not know why they left the medication. 10 NYCRR415.12(h)(2)

Based on observations, interviews and record review conducted during an Abbreviated Survey (#NY 182) completed on 1/7/21, it was determined that for one (Resident #2) of three residents reviewed, the facility did not ensure that the resident's environment remained as free of accident hazards as possible, and the resident received adequate supervision to prevent potential accidents. Specifically, there was inadequate staff response to a door alarm which resulted in Resident #2's elopement from the facility. This was evidenced by: Resident #2 was an [AGE] year-old admitted to the facility on [DATE] for rehabilitation with diagnoses that included a stroke, [CONDITION(S)] (difficulty communicating) and right sided weakness. The facility's Admission History and Physical form, dated 2/25/21, and signed by the Physician Assistant included that Resident #2's hospital stay was complicated by [CONDITION(S)]. The form did not include Resident #2's current mental status. Review of an elopement risk assessment, dated 2/25/21 and signed by the admitting Registered Nurse (RN) #1, revealed Resident #2 was alert and oriented to name and place but not date and time and was coded as a low risk for elopement. The Certified Nursing Assistant (CNA) care card, dated 2/25/21, included that Resident #2 required supervision for transfers, ambulation, and mobility on the unit. Review of a police report dated 2/25/21 (day of admission) at 9:56 p.m., revealed the police were dispatched to a local pharmacy for a report of a person being chased by college students. The police report included the person was wearing a shirt, sweatpants, and sneakers but no coat. The police requested an ambulance due to the person's mental status. The family was notified by the police via the persons' cell phone who informed them that Resident #2 had been admitted to the Nursing Home that day. The resident was transported to the hospital and did not return to the facility. A nursing note, written by the RN #2, dated 2/25/21 at 10:32 p.m. (the night of the elopement), documented that the police department had notified the facility that Resident #2 was found at a local pharmacy approximately .5 miles away. The note included that one of the CNA's had reported that at approximately 9:45 p.m. the unit's west stairwell door had alarmed, that they had investigated and had not found any residents in the stairwell. Review of the facility Investigation Summary for the elopement, dated 2/26/21, revealed Resident #2 exited the facility undetected on 2/25/21 at approximately 9:44 p.m. from the 2nd floor unit west stairway. Staff interviews revealed that the unit door alarm did sound, and a CNA checked the west stairwell door and upper stairway and reported no one there. Video surveillance revealed the resident exited the facility from the 1st floor unalarmed door to the outside which did not have an alarm, took a fall into a snowbank but was able to get up and leave the area. The facility was later notified by the police of the resident's where abouts. The facility re-educated staff (about checking the full stairwell and outside doors) and placed an alarm on the 1st floor exit door utilized by the resident. During an observation on 1/7/22 at 12:15 p.m., with the Director of Nursing (DON) of the route taken by Resident #2 at the time of the elopement, the 2nd floor unit stairwell door did alarm but first floor door to the outside did not alarm despite an alarm unit in place. The DON stated the alarm was turned off and did not know why as it should always be on. During an interview on 1/7/22 at 12:30 p.m. the Maintenance Assistant stated the outside door alarm should always be turned on. The Maintenance Assistant again checked the door and no alarm sounded and noted that the alarm had not been reset. The Maintenance Assistant reset the alarm with a key, and it did function appropriately. In an observation on 1/7/22 at 12:35 p.m. with the DON of a second 1st floor door to the outside that also led to the 2nd floor resident unit, it was noted to have no alarm on it. The DON stated this door to the outside was not alarmed. In an interview on 1/7/22 at 1:08 p.m., the Director of Facilities stated that during the weekly check, the door alarm must be reset manually. The Director of Facilities stated that the west stairwell door was alarmed because of the wandering incident but that they had not alarmed the east stairwell door to the outside because a resident had not gone out that one. In an interview on 1/7/22 at 12:55 p.m., the Administrator stated they relied on the Maintenance department to check the exit door weekly to ensure the alarm was functioning. At 3:00 p.m., both the DON and the Administrator stated that the 2nd floor unit has residents who were able to ambulate independently who would be at risk for exiting a non-alarmed door but hopeful that staff responding to the unit stairwell door alarm would intercede before a resident reached the exit door to the outside. 10 NYCRR 415.12(h)(1)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of five residents reviewed for unnecessary medications, one of one resident reviewed for [MEDICAL TREATMENT], and one of three residents reviewed for urinary catheters, the facility did not develop and/or implement a comprehensive person-centered care plan for each resident that addressed the resident's medical, physical, mental and psychosocial needs. Specifically, Resident #84's care plan did not include the use of a [MEDICAL CONDITION] medication, Resident #54's care plan did not include the use of an urinary catheter, and the care plan for hearing aids was not revised, and Resident #17's care plan did not include the use of a central venous catheter. This is evidenced by the following: The facility policy, Care Planning, dated 1/22/19, revealed the interdisciplinary team will develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives to meet the resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment. Staff will be responsible for the evaluating and updating the care plan as needed. The Kardex will be developed, revised, and utilized by the team as a guide to provide care to the resident. 1. Resident #84 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 2/8/19, revealed the resident was cognitively intact and had received an antidepressant twice in the look back period. The Comprehensive Care Plan (CCP), dated 1/31/19, did not include the use of a [MEDICAL CONDITION] medication (Trazadone an antidepressant). Physician orders, dated 2/1/19, included Trazadone 50 milligrams (mg) as needed for restless sleep, and on 2/20/19, the physician orders [REDACTED]. When interviewed on 3/11/19 at 10:44 a.m., the Assistant Director of Nursing (ADON) stated that the care plan should include the use of a [MEDICAL CONDITION] medication, the reason for use, and interventions. 2. Resident #54 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/28/19, revealed that the resident had moderately impaired cognition, highly impaired hearing with the use of a hearing aid, and an indwelling catheter. The current CCP did not include the use of an indwelling Foley catheter and revealed that the resident's hearing was highly impaired. Interventions included a hearing aid to the right ear and to speak into the resident's right ear. The Kardex revealed that the resident was frequently incontinent of bladder and had a hearing aid for the right ear. Review of the (MONTH) 2019 Treatment Administration Records (TAR) revealed that the resident had a catheter for [MEDICAL CONDITION]. Entries starting 1/22/19 included irrigating the catheter, changing the catheter (size 16 French) as needed, and change the urinary catheter drainage bag every 15 days and as needed. During an observation on 3/6/19 at 10:36 a.m. and on 3/8/19 at 10:31 a.m., the resident was seated in a wheelchair with a Foley catheter and no hearing aids. When interviewed on 3/6/19 at 10:35 a.m., the resident stated she was very hard of hearing. She stated she had a hearing aid, but it made too much noise, so it was home. The resident said that she did not know why she had a Foley catheter. Interviews conducted on 3/11/19 included the following: a. At 10:01 a.m., the Certified Nursing Assistant (CNA) stated she thought the resident wore a hearing aid but the family may have taken them. The CNA stated the resident had a Foley catheter. She said that information would be on the Kardex. b. At 10:35 a.m., a Licensed Practical Nurse (LPN) stated the resident did not wear a hearing aid. She stated the resident told her she had one at home but did not want them. She said it would be on the Kardex if a resident wore a hearing aid and it would be kept in the medication cart. The LPN stated the resident had a Foley catheter. She said the CNAs provide catheter care and ensure that the Foley drainage bag is covered. She stated if a resident had a Foley catheter, it would be on the Kardex. c. At 10:44 a.m., the Assistant Director of Nursing (ADON) stated the Nurse Managers developed and revised the CCP. She stated the resident had a Foley catheter and it should be included in the CCP along with the reason for use and interventions and on the Kardex. The ADON stated the resident did not wear hearing aids, and the CCP and Kardex should be revised. 3. Resident #17 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/15/18, revealed the resident was cognitively intact. The medical record revealed that the resident was scheduled for placement of a central venous catheter on 2/27/19. The current physician orders [REDACTED]. The CCP, dated 3/6/19, did not include the care or use of a central line. The current Kardex included the resident's bathing schedule was Wednesday day shift and to keep the central line covered and dry. In an observation on 3/12/19 at 9:09 a.m., the resident was in bed and an undated dressing was observed on the resident's upper right chest area. When interviewed on 3/12/19 at 10:48 a.m., the Nurse Manager stated that the CCP should include the use of the central line catheter for [MEDICAL TREATMENT]. (10 NYCRR 415.11(c)(2)(i-iii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #112) of three residents reviewed for discharge planning, the facility did not discuss a change in discharge planning with the resident. This is evidenced by the following: A facility policy, Discharge Planning and Review, dated 3/21/18, revealed the Director of Social Services/Unit Social Worker of the facility will be the designated discharge coordinator to develop and periodically review an initial discharge plan for each resident based on the interdisciplinary contribution of the attending physician and other health care professionals and information from the resident or legally designated representative and/or responsible party. The decision making process for discharge will meet the physical, medical, social and emotional needs of the resident. The Social Services Progress Notes must indicate the reasons or explanation for change in discharge plan. If discharge appears imminent, the Unit Social Worker evaluates and documents the possible emotional impact of a move. Resident #112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/27/19, revealed the resident was cognitively intact, had an active discharge plan in place to return to the community, and a Medicaid number (Section A0700). Review of an Admission Record (face sheet), dated 1/31/19, included a Medicaid number. The current Certified Nursing Assistant Kardex revealed the resident was alert and oriented to person, place, and time, and is able to understand. The Discharge Planning Care Plan, dated 1/31/19, revealed the resident was admitted for a short term stay with the goal to discharge to an appropriate level of care when medically stable or upon completion of therapy. Interventions included to assist the resident/family in locating and coordinating post discharge services, contact appropriate agencies to set up community services once discharge plans are in place, and to invite and involve the resident/family in the discharge planning meeting and process. Review of Social Services Notes, dated 1/31/19 to 3/7/19, included referrals to Home Care of Rochester were placed on 2/6/19 and 2/12/19. There was no other documentation regarding discharge plans. During an observation and interview on 3/6/19 at 2:35 p.m., the resident was in her room. She was pulling her nasal cannula in and out of her nose and was both shaking and trembling. She said she did not want to transfer to another nursing home and would rather put a rope around her neck. The resident said her discharge was set for the next day (3/7/19), and she pointed to lots of paperwork scattered on the top of her bed. She said she did not want to go and did not know why she could not stay at the facility. The surveyor notified the nursing staff of the resident's statements and concerns. When interviewed on 3/7/19 at 8:39 a.m., the resident said both the Director of Social Work (DSW) and Registered Nurse Manager (RNM) came to talk to her on 3/6/19 (after surveyor intervention) and told her she would no longer be transferred. The resident said no one had talked directly to her or involved her in discharge plans until she was given the discharge paperwork. The resident said she did not want to leave the facility as she wants to remain close and convenient to her family. The resident said she has Medicaid but apparently it is not the right kind. The resident said she does not know what that means. Interviews conducted on 3/12/19 included the following: a. At 9:30 a.m., a Licensed Practical Nurse (LPN) said the resident was no longer going to be discharged to another long term care facility. The LPN said other than that, she had no idea about the resident's discharge plan. b. At 10:06 a.m., the RNM said there was a formal team meeting every Tuesday to discuss resident discharge planning needs. She said each discipline is responsible for certain things and a discharge packet is developed. The RNM said the Unit Social Worker (SW) is responsible for documenting discharge plans, including meetings with residents and families. The RNM said that she did not know for sure if a discharge packet was made for the resident. The RNM said the resident does not have Medicaid, so she discussed with the resident's family member to initiate that process because it was quite lengthy. Additionally, the RNM said she was not present for any conversation about the resident going to another nursing home. c. At 10:18 a.m., the RNM said the resident was cognitively intact and makes her own decisions. She said the SW should have talked to her about any changes in discharge plans. d. At 10:34 a.m., the SW said discharge planning starts at the time of admission, and if things change, like a resident can no longer go home and needs long term care services, the plan has to be revised with resident input. The SW said as of 2/12/19, the discharge plan remained that the resident would return home. However, insurance would not cover home meal delivery and the resident's oxygen needs changed so that was holding her back from going home. e. At 10:44 a.m., the SW said the family was directing the discharge plans as they do not have supports in place for the resident to go home. The SW said the resident does not have Medicaid. The SW said she printed out a list, dated 2/26/19, of other local nursing homes that accept the resident's insurance, and she was going to review the list with the resident that day. f. At 10:55 a.m., the SW reviewed her progress notes and said she could not find any documentation about the change in placement or that it was discussed directly with the resident. She said the changes in discharge planning should have been documented. g. At 11:00 a.m., the DSW said the resident was cognitively intact and any changes in discharge planning should have been discussed with her and documented. (10 NYCRR 415.11(d)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #92) of four residents reviewed for activities of daily living, the facility did not provide the services in the resident's plan of care to maintain functional ability. Specifically, the resident was not ambulated on a consistent basis per the resident's plan of care and therapy discharge summary. This is evidenced by the following: Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/12/19, revealed that the resident was cognitively intact, required extensive assist of one staff member for transfers, and that ambulation in the resident's room and/or unit corridor did not occur. In an interview on 3/6/19 at 11:30 a.m., and again on 3/8/19 at 11:14 a.m., the resident stated that he was upset that he was no longer receiving therapy because he wanted to get stronger so he could be discharged to another facility (ie: assisted living). He said that if staff would walk with him, he could get stronger. The resident said that no one has asked him to walk in a while. The resident said that he has refused in the past because it was not a good time for him but then the staff do not come back. He said that he has not walked in the hallway at all that week. Review of the Physical Therapy discharge summary, dated 2/22/19, under discharge plans and instructions, the therapist documented that the resident requires contact guard to minimum assist of staff for ambulation with a rolling walker 5 to 30 feet. The current Certified Nursing Assistant (CNA) Kardex included under mobility for both walk in the room and walk in the corridor to provide extensive assistance of one person with a rolling walker and a second person follow with a wheelchair for 5 to 30 feet. The Kardex does not include what to do if the resident refuses care. Review of the CNA Plan of Care Response history (the electronic system where the CNAs document a resident's activities of daily living every shift) revealed that since the resident was discharged from therapy the resident ambulated in his room [ROOM NUMBER] of the past 17 days with three refusals. The staff documented it was non-applicable 31 times. Ambulation in the corridor was documented as completed 6 of the last 17 days with 5 refusals. The staff documented that the task was non-applicable 35 times. In an interview on 3/8/19 at 2:00 p.m., the CNA stated that the resident walks on occasion and that he can go a few feet around his room, but they have not attempted to walk in the hall. Interviews conducted on 3/11/19 included the following: a. At 12:56 p.m., the Physical Therapist stated that the resident should ambulate twice a day on the unit, and if they saw a consistency of walking daily, they could consider putting him back on program. b. At 1:47 p.m., the resident stated that he would walk in the hallway if staff asked him to. The resident again said that he did refuse sometimes when he was not feeling well a few weeks ago but no one has offered to walk him that week, and he would not refuse because he knows he needs to get stronger. c. At 2:00 p.m., the Social Worker stated that the resident is doing a lot better and they are continuing to discuss a possible transfer to assisted living if he continues to improve. When interviewed on 3/12/19 at 10:37 a.m., the Director of Nursing (DON) stated that the resident was not on an ambulation program (ie: nursing rehab) and that the CNA Care Card includes his ability. The DON said that there was no reason not to ambulate the resident. He said the staff should ask the resident to ambulate and if he refuses, that should be documented. (10 NYCRR 415.12(a)(1)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #92) of two residents reviewed for urinary catheters, the facility did not ensure that the resident received the appropriate care and services to promote the removal of the Foley as soon as possible and prevent complications. Specifically, there was no reason documented as to why the resident's urology consult recommendations were not followed and proper drainage of the catheter was not consistently maintained. This is evidenced by the following: Resident #92 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/12/19, revealed that the resident was cognitively intact, required extensive assist for toileting and personal hygiene, and has a urinary catheter. The facility policy, Catheter, Daily Care (Indwelling), dated 4/11/18, included under Key Points to always attach the drainage bag in a position below the level of the bladder. In an interview on 3/6/19 at 11:31 a.m., the resident stated he has had the catheter for months and would like to get it out. He said no one has told him why they cannot take the catheter out. In an observation on 3/8/19 at 11:14 a.m., the resident was in bed, and his urine drainage bag was on the bed next to his right hip (at level of the bladder). In an observation on 3/11/19 at 1:37 p.m., the resident was self-propelling his wheelchair down the hall to an activity. The urine drainage bag was in the wheelchair next to the resident's hip, and the tubing was filled with urine. When interviewed at that time, the resident stated he put the bag in the chair because there was no place to hang it and he wanted to go to the activity. Review of the hospital discharge summary, dated 11/16/18, revealed that the resident had been hospitalized for [REDACTED]. The resident was being discharged with a urinary catheter and plans for outpatient voiding trial and urology follow up. Review of physician orders, dated 12/30/18, revealed that antibiotics were ordered for another UTI. Review of the urology consult, dated 2/11/19, revealed under recommendations to the facility to increase [MEDICATION NAME] (a medication used to improve urination in patients with enlarged prostate) to 10 milligrams (mg) daily, add [MEDICATION NAME] (another medication used to treat enlarged prostate and improve urination) 5 mg daily, and to attempt a void trial (removal of the catheter) with the next catheter change. The consult was initialed by the facility's Physician Assistant (PA) and a Registered Nurse. The Treatment Administration Record revealed that the resident's catheter was changed on 2/22/19. There was no documentation that a void trial was attempted. Review of a medical progress note, dated 2/27/19 for a 2/22/19 chronic visit and signed by the PA, revealed that the resident was seen on 2/22/19 for a chronic visit. The resident had a urinary catheter, remained on [MEDICATION NAME], needed a trial void, and was awaiting a urology consult. The current physician orders [REDACTED]. The orders did not include [MEDICATION NAME] or any orders to attempt a trial of voiding. When interviewed on 3/8/19 at 3:35 p.m., the PA stated that it was his initials on the urology consult indicating he had read it. The PA said there was no reason that the recommendations were not followed other than it was missed. The PA said that there has not been a trial void since admission. He said that the resident was doing better, and there was no reason why it could not be attempted. In an interview on 3/12/19 at 9:07 a.m., the Registered Nurse Manager (RNM) stated that both nursing and medical initial the consults to make sure they are reviewed. She said that the nurse's initials were the former manager who is no longer at the facility. She said nothing was done with the recommendations. The RNM said that the drainage bag should always be below the resident's bladder. (10 NYCRR 415.12(d)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #13) of one resident reviewed for tube feedings, the facility did not have a mechanism in place to ensure a periodic evaluation of the amount of feeding being administered for consistency with the practitioner's orders. This is evidenced by the following: Resident #13 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/27/18, revealed that the resident had severely impaired cognition, was not on a physician prescribed weight gain regimen and had an unplanned weight gain, required the use of a feeding tube, received 50 percent or greater of calories through the tube feeding and 501 cubic centimeters (cc) of fluid or more per day via tube feeding. The facility policy, Tube Feeding, Enteral Policy, dated 2/5/18, and the facility policy, Intake and Output - Monitoring Fluids Policy, dated 1/30/18, revealed that residents who receive enteral tube feedings are placed on an intake and output monitoring program, and the results are documented in the medical record. The current Certified Nursing Assistant Care Card revealed that the resident does not take any food or fluid by mouth and to record intake and output. The Comprehensive Care Plan for a Feeding Tube, revised 12/31/18, included, but was not limited to, recording intake and output and administering the tube feeding per physician orders. Physician orders, dated 3/11/19, included [MEDICATION NAME] 1.5 calorie (1.5 calories per ml; a calorically dense liquid, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long or short-term tube feedings) at 75 milliliters (mls) per hour via gastrostomy tube (tube inserted through the abdomen into stomach) every 24 hours, run over 16 hours for a total dose of 1,200 mls, start the tube feeding at 6:00 p.m. and stop the following day at 10:00 a.m. or once 1,200 mls are fed, document the total mls infused upon completion. The Medication Administration Records (MAR), from 1/1/19 through 3/7/19, revealed that each MAR was preprinted with the total volume (1,200 cc) delivered in 24 hours, and was signed off by the nurse on the day shift. There was no documented intake and output. Observations and interviews conducted on 3/7/19 included the following: a. At 8:06 a.m., the resident was in bed, asleep, and the tube feeding was running. [MEDICATION NAME] 1.5 was hung and the pump display read 75 ml/hour, 942 ml fed. The label on the bottle of the tube feeding revealed it had been started at 5:15 a.m. At that time, there were 900 mls remaining in the 1,000 mls bottle (100 mls had been given.) The tube feeding was documented on the MAR as having been turned off at 10:40 a.m. (942 mls given by 8:06 a.m., then the tube feeding would have needed to run until 11:06 a.m. to deliver 1,200 mls). b. At 3:50 p.m., Licensed Practical Nurse (LPN) #1 was asked to verify the amount of tube feeding infused in the last 72 hours. He said he does not use the history function but was able to figure out how to access that information. LPN #1 said that 1,120 mls of tube feeding was delivered in 24 hours, 2,324 mls in 48 hours, and 3,458 mls in 72 hours. He said the tube feeding amounts given to the resident were less than what was ordered by the physician. LPN #1 said the pump had been replaced about four to six months ago because it had not been running correctly. c. At 4:05 p.m., a Registered Nurse Manager (RNM) said the resident should have received 1,200 mls that day and a total of 3,600 mls in the last 72 hours. Interviews conducted on 3/8/19 included the following: a. At 2:15 p.m., a Corporate Registered Nurse said it appeared the pump might have been inaccurate in dispensing, and she would discuss that with the Director of Nursing. She said the nurses sign the MAR for turning the pump on and off, and there is a pre-printed line with 1,200 on it that signifies this amount that was given in 24 hours. b. At 3:34 p.m., LPN #1 said he hangs the tube feeding around 6:00 p.m. but does not document the amount of tube feeding in the bottle at that time. LPN #1 said there was no place on the MAR or Treatment Administration Record to document that information, unless he entered a progress note. LPN #1 said that was not the process at the facility. LPN #1 said he does not use an intake and output form to document the amount of tube feeding given on his shift. He said he sets the pump to 1,200 ml and that is it. When interviewed on 3/11/19 at 8:41 a.m., LPN #2 said she does not document the amount of tube feeding administered on her shift or use the history function on the pump. At that time, the RNM said there was nothing else in place to verify the volume of tube feeding delivered in a 24-hour period. (10 NYCRR 415.12(g)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #84) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime remained free from unnecessary medications. The issue involved the lack of documentation of non-pharmacological interventions prior to the administration of a [MEDICAL CONDITION] medication and a lack of documentation to support the implementation and continued use of a [MEDICAL CONDITION] medication. This is evidenced by the following: 1. Resident #84 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessments, dated 1/21/19 and 2/8/19, revealed that the resident was cognitively intact and had trouble falling asleep, staying asleep, or slept too much. The MDS Assessment, dated 2/8/19, revealed the resident had received an antidepressant twice in the look back period. Review of a physician admission note, dated 1/16/19, did not include the use of a [MEDICAL CONDITION] medication or complaints regarding sleep. Review of the CCP, dated 1/31/19, revealed that the resident had displayed or expressed mood symptoms that included trouble falling or staying asleep or sleeping too much. Interventions included to document mood/behavior changes and report changes to the medical provider. Review of the nursing progress notes, from 1/14/19 through 2/1/19, revealed that on 1/24/19 at 5:30 a.m., the resident complained of not being able to sleep at night. The resident admits she naps off and on during the day and sleeps following dinner until 10:00 p.m. or 11:00 p.m. The 2/1/19, 4:21 a.m. note revealed the resident was awake most of the shift. The resident stated she was not sleeping very well at night but sleeps off and on during the day. Physician orders, dated 2/1/19, included Trazadone, an antidepressant, 50 milligrams (mg) give half a tablet at bedtime as needed for restless sleep. A Physician Assistant (PA) note, dated 2/1/19, revealed the resident was seen for follow up due to a [MEDICAL CONDITION]. There was no mention of sleep issues or the implementation of a [MEDICAL CONDITION] medication. Review of the (MONTH) 2019 Medication Administration Record (MAR) and nursing progress notes between 2/1/19 through 2/20/19 revealed that the resident had received Trazadone 50 mg as needed for restless sleep 12 times. The MAR and progress notes documented the effectiveness of the medication but did not include non-pharmacological interventions attempted prior to the administration of the medication. Physician orders, dated 2/20/19, included Trazadone 50 mg give half a tablet at bedtime for restless sleep. The PA documented on 2/21/19 that the resident was assessed for ongoing nausea, poor oral intake, and decreasing weights. There was no mention of restless sleep or the use of Trazadone. The PA note, dated 3/1/19, included the resident's mood was pleasant and appropriate, and did not include the use of [MEDICAL CONDITION] medications. During an interview on 3/8/19 at 10:40 a.m., the PA stated the resident had complained of difficulty sleeping. He stated he would expect the staff to document the resident's difficulties sleeping. He said that he did not document when he started the as needed or routine dose of Trazadone. He said the resident did not like having to ask for the Trazadone, so he ordered it routinely. The PA stated the staff had not addressed non-pharmacological interventions. He said he would have expected the staff to try standard interventions that included turning the lights off and decreasing stimulation an hour before sleep. He stated that nursing should document why an as needed medication was given, what was tried before the medication was administered, and the effectiveness of the medication. When interviewed on 3/8/19 at 11:23 a.m., the resident stated that she had slept well the previous night but she usually does not. The resident said she wakes up every couple of hours. The resident said she received a sleeping pill which helped some nights. During an interview on 3/11/19 at 10:55 a.m., the Assistant Director of Nursing stated she would expect documentation in the nursing notes to support the use of the Trazadone. She said the documentation should include why the medication was given, what interventions were attempted, and the outcome. (10 NYCRR 415.12(l)(2))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #13 and #315) of three residents reviewed for hospitalization , the facility did not ensure that the resident and/or designated representative received notice of the bed hold policy. This is evidenced by the following: 1. Resident #315 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/15/18, revealed the resident had moderately impaired cognition. The MDS Assessment, dated 1/1/19, revealed the resident was discharged to the hospital with an anticipated return to the facility. Review of a nursing progress note, dated 1/1/19 at 9:21 p.m., revealed that the resident's family was notified of the intent to transfer the resident to the hospital. Review of the Notice of Transfer/Discharge Form, dated 1/1/19, revealed the resident was transferred to the hospital due to urgent medical needs. The notice does not include the bed hold policy. 2. Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/27/18, revealed the resident had severely impaired cognition. The MDS Asssessments, dated 11/27/18 and 12/16/18, revealed the resident was discharged to the hospital with an anticipated return to the facility. There was no documentation that the bed hold policy was discussed with the resident's representative or that written information was provided. Interviews conducted on 3/11/19 included the following: a. At 1:24 p.m., the medical records person stated she was responsible for the transfer/discharge notices and bed holds. She stated that she completes a notice of Discharge/Transfer Form. The medical record person stated she would call Medicare Part A residents or their representative or private pay residents/representative to determine if they wanted to pay to hold the bed. She said that she has not notified the representative of Medicaid residents since the new ruling where the facility does not get paid to hold the bed. b. At 2:13 p.m., the Administrator stated the medical record person was responsible for notifying the residents/representatives of the facility's bed hold policy. Interviews conducted on 3/12/19 included the following: a. At 8:46 a.m., the Business Office Coordinator stated she was notified by email of a resident's tranfer/discharge to the hospital. She stated the medical record person would be responsible to notify the resident/representative of the bed hold policy. b. At 10:31 a.m., the medical record person stated that she did not have a form that was used to notify residents/representatives of the facility's bed hold policy. (10 NYCRR 415.3(h))

Based on interviews and record reviews conducted during the Recertification Survey,it was determined that for one of one resident reviewed for [MEDICAL TREATMENT], the facility did not provide care and services in accordance with the resident's written plan of care. Specifically, physician orders [REDACTED]. This is evidenced by the following: The facility policy, [MEDICAL TREATMENT]: Pre-[MEDICAL TREATMENT], Post-[MEDICAL TREATMENT], Interim Care, Peritoneal [MEDICAL TREATMENT], [MEDICAL TREATMENT], directed to check and record vital signs, weight, and other parameters as ordered by the physician and report as indicated. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/9/17, included that the resident was cognitively intact for daily decision making and received [MEDICAL TREATMENT] services. The physician orders, dated 8/25/17, included to obtain vital signs pre- and post-[MEDICAL TREATMENT] on [MEDICAL TREATMENT] days. The 9/28/17 Comprehensive Care Plan and the 9/18/17 Resident Personal Care Profile do not include to check the resident's vitals post-[MEDICAL TREATMENT]. Review of the September 2017 Medication Administration Record (MAR) included to obtain vital signs pre- and post-[MEDICAL TREATMENT] on Mondays, Wednesdays, and Fridays, and document. 6 of 12 opportunities to record post-[MEDICAL TREATMENT] vital signs were circled by the nurse. Additionally, there was only one day that vital signs were documented in the medical record. Review of the [MEDICAL TREATMENT] Communication Forms, from 8/14/17 through 9/29/17, revealed that the resident's evening vital signs were taken on 9/18/17, and on two occasions the resident had low blood pressure during [MEDICAL TREATMENT] treatment. Interviews conducted on 9/29/17 included the following: a. At 11:17 a.m. and 11:21 a.m., the Registered Nurse Manager (RNM) said that the vitals should have been documented on the MAR. She said there is no vital sign documentation sheets in use. b. At 11:28 a.m., the day Licensed Practical Nurse (LPN) said that she takes the resident's blood pressure, blood glucose, pulse, and temperature prior to [MEDICAL TREATMENT] and then documents that information on the [MEDICAL TREATMENT] Communication Sheet. The LPN said that she has informed the RNM in the past if there were missing vitals. The LPN said she did not know if the evening shift nurses record the resident's vitals on the [MEDICAL TREATMENT] Communication Sheets. Interviews conducted on 10/2/17 included the following: a. At 8:52 a.m., ther resident said that the nurses never take her vitals when she returns from [MEDICAL TREATMENT]. b. At 10:50 a.m., LPN #2 said she works some evenings and did not know that the resident's vitals needed to be taken upon return from [MEDICAL TREATMENT]. She said if she sees a blank or a circle on the MAR or Treatment Administration Record (TAR), she would notify the RNM. c. At 9:00 a.m., the Director of Nursing said he added an area on to the MAR/TAR to document the resident's vital signs. (10 NYCRR 415.11(c)(3)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #102) of three residents reviewed for Activities of Daily Living (ADL), the facility did not provide the necessary care and services to maintain ADLs. Specifically, the resident was not consistently ambulated twice a day and to and from the dining room. This is evidenced by the following: Resident #102 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/16/17, included that the resident was cognitively intact for daily decision making skills, walking in the corridor did not occur, and required extensive assist of two staff for locomotion on the unit. The 9/27/17 Resident Personal Care Profile (directs care) and the 9/28/17 Comprehensive Care Plan included that the resident required an extensive assist of one staff member using a gait belt, rolling walker, and a second staff person following with a wheelchair to ambulate 50 to 150 feet twice a day and to and from the dining room. The Physical Therapy Progress and Discharge Summary, dated 9/13/17, included that the resident ambulates up to 150 feet safely with a two-wheeled walker and contact guard assist on even surfaces. To ensure the resident maintains current level of function upon discharge, the resident's Certified Nursing Assistant (CNA) was trained on how to ambulate the resident so that the daily ambulation program can be completed. This was necessary as staff had on multiple previous occasions not followed program, and then the resident declined functionally and required therapy intervention. Review of the Nursing Rehabilitation/Restorative Care Form, dated 9/15/17 through 9/28/17, included to provide contact guard assist with a rolling walker for 50 to 120 feet with a second person following with a wheelchair twice a day (day/evening) and to/from the dining room and bathroom. Seven of 29 opportunities were circled and two were left blank. Review of progress notes, from 9/1/17 through 9/28/17, revealed no documentation that the resident refused to walk. Review of the Nurse Practitioner Communication Book, dated 9/28/17, did not include any concerns regarding the resident ambulation. Interviews conducted on 9/28/17 included the following: a. At 11:07 a.m., CNA #1 said the resident uses a walker with tennis balls on it, a gait belt, and a wheelchair to follow behind her. She said that the resident's walking has declined, her left foot drags a bit and it makes it hard for her to turn. CNA #1 said the resident is supposed to walk during the day and evening but she refuses as she gets frustrated with her foot. CNA #1 said if the resident refuses, she would tell the nurse so the refusal can be documented in the medical record. She said that the resident did not want to walk that day but they walked her in her room. b. At 11:39 a.m., Licensed Practical Nurse (LPN) #1 said that if the resident refuses care, the nurse's initials are circled on the Treatment or Medication Administration Records, and the refusal is documented in the progress notes. When observed on 9/28/17 at 1:10 p.m., the resident was seated in a wheelchair, pulling herself along the wall in the dining room. She moved herself to the doorway, then started down the hallway towards her room without staff assistance. Interviews conducted on 9/29/17 included the following: a. At 9:51 a.m., the resident said she ate breakfast in the dining room that morning and staff did not walk her. At that time, the resident turned on the call light and asked the CNA to bring her to the main floor for an activity. The CNA transported the resident in the wheelchair. b. At 10:08 a.m., 1:17 p.m., and 1:35 p.m., CNA #2 said that staff were supposed to provide the resident with a two person assist to walk twice a day (one occurring on days) for 100 feet. CNA #2 said that she gets the resident up, and she walks her 10 to 15 steps in her room with the rolling walker and a wheelchair behind her. CNA #2 said that she could not get the resident to walk that morning. CNA #2 said the resident is not walking to and from the dining room because she is not always making it that far. CNA #2 said that she informed the nurse that the resident is not walking as far as she was and that her right leg is turning in more. She said the staff are supposed to document the resident's ambulation in a notebook, but she is not sure if she should document it as a refusal if the resident does not make it the 100 feet. c. At 10:35 a.m., LPN #2 said she was not aware how far or how often the resident is to be walked but it should be documented on the Care Profile. She said that no one has told her that the resident is having trouble walking. LPN #2 said if she had known she would have documented it and notified the Registered Nurse Manager (RNM) and Nurse Practitioner. d. At 1:35 p.m., CNA #3 said the resident either will not or cannot walk to the dining room. CNA #3 said that the resident will sometimes buckle at the knee and she cannot get the resident to ambulate anywhere near 100 feet. CNA #3 said at the most, the resident ambulates 30 to 40 feet. CNA #3 said she is afraid the resident is going to fall so sometimes she has a third CNA help her. CNA #3 said that the resident's ambulation had been mentioned during a huddle (sharing between staff of resident care concerns). CNA #3 said when she reported that to therapy, she was told that the resident walks 100 feet just fine with them and had no issues. e. At 1:49 p.m., the Physical Therapist (PT) said she normally works with the resident, and she is constantly picked up for therapy due to decline and her complaints that staff do not walk her. She said the resident bounces right back. The PT said when the resident was last discharged from therapy, she was walking and she was supposed to continue to walk 150 feet twice a day and to and from the dining room as tolerated. The PT said it should be documented as tolerated on the Resident Care Profile. She said that she would fix that. The PT said that therapy did staff training on ambulation at the end of the last PT session with the CNAs, specifically with CNA #3. At that time, LPN #2 said that she has never seen the resident walk to and from the dining room. At 2:00 p.m., LPN #1 said there was no way on the current documentation form to record what the resident is actually walking. The PT said therapy looks at the rehab sheets on a quarterly basis to determine if the resident is in compliance with therapy goals. The RNM said that she is trying to look at the forms at least weekly but she is new to the facility and is still trying to get used to the systems. The PT and the RNM said they would need to meet with staff and the resident to review goals, expectations, and how to document ambulation. f. At 2:27 p.m., the PT said that she walked with the resident with another therapy staff and she did just fine walking 100 feet and there was no decline. (10 NYCRR 415.12(a)(2))

Based on observations,and interviews conducted during the Recertification Survey, it was determined that for one of one shower gurney, the facility did not maintain a sanitary environment to help prevent the development and transmission of disease and infection. Specifically, the shower gurney was observed to be unclean with brown debris. This is evidenced by the following: The June 2017 facility policy, Standard Precautions, directed that shower/bathing equipment (chairs, gurneys) surfaces will be cleaned before and after use utilizing a disinfectant wipe. Observations and interviews conducted on 9/26/17 included the following: a. At 11:34 a.m., a shower gurney in the 3 East Shower Room had a blue mat on top of it for residents to lay on while receiving a shower. When the mat was flipped over, there was brown flakey material stuck to the bottom of the mat as well as on the support mesh below. In an interview at that time, the Housekeeping Supervisor said that the brown flakey material looked like leaves but he was not sure what it was. The Housekeeping Supervisor said he believed that nursing was responsible to clean the gurney. b. At 11:40 a.m., the third floor Registered Nurse Manager (RNM) said that the gurney should be cleaned after every use. The RNM said that she thought that staff would use disinfecting wipes on the entire gurney but would have to ask staff because she was fairly new to the facility. When asked, the RNM said that the shower stretcher did not look clean. c. At 11:44 a.m., Certified Nursing Assistant (CNA) #1 said that staff clean the entire shower gurney before and after every use using disinfecting wipes. Interviews conducted on 10/2/17 included the following: a. At 9:25 a.m., the Assistant Director of Nursing (ADON)/Infection Control Coordinator said there is only one shower gurney that is used in the facility. She said nursing staff are responsible for cleaning the shower gurney before and after each use. The ADON said that CNAs periodically check the shower rooms to verify that things are in order. b. At 10:52 a.m., the Unit Secretary/CNA said that she normally checks the shower rooms when she arrives in the morning. She said she saw the shower gurney in the shower room but did not lift up the pad. (10 NYCRR 415.19(b)(2))

Based on interviews and record reviews, it was determined that for two (Dietary Worker #1 and Certified Nursing Assistant #2) of five new employee hire records reviewed, the facility did not operationalize their policy for screening new hires for a history of abuse, neglect, or mistreatment prior to allowing employees to work in the facility. Specifically, these employees were not screened through the nurse aide registry. This is evidenced by the following: A review of employee hire records on 7/27/16 between 1:22 p.m. and 1:35 p.m. revealed the following: a) Dietary Worker #1 was hired on 6/26/16, and the Nurse Aide Registry Check was completed on 7/1/16. In an interview at that time, the Human Resources worker stated that she was not sure why the Registry was checked after the hire date, other than she was out of the office for a few days. b) Certified Nursing Assistant (CNA) #2 was hired on 7/11/16. The Nurse Aide Registry Check was completed on 7/12/16. In an interview at that time, the Human Resources worker stated that she normally does the Nurse Aide Registry Checks at the same time as the Criminal History Record Check (CHRC). The CHRC check was submitted for CNA #2 on 7/5/16. Review of the facility's undated/unsigned policy, Abuse, Mistreatment, Neglect and Misappropriation of Property of Residents, revealed that it did not specify that verification of licensure or certification (Nurse Aide Registry Checks) needs to be done before an employee begins to work in the facility. (10 NYCRR 415.4(b))

Based on observations, interviews,and record reviews, it was determined that for one of one Main Kitchen, the facility did not prepare food in a sanitary manner. Specifically, vegetables were washed in a sink that did not have an indirect drain and a cook was not wearing a beard guard. This is evidenced by the following: 1. Observations conducted on 7/25/16 at approximately 9:26 a.m. revealed a pan of tomatoes covered in water in a sink in the cook station. The sink was directly plumbed to the sewer system. In an interview at that time, the cook stated that she used that sink to wash produce, but she always cleans the sink out first. The Food Service Director (FSD) stated that there is no air gap on the sink. During the interview, the cook stated that she was going to use the tomatoes for hearty gravy and was observed draining the water from the tomatoes and taking the tomatoes out of the sink to prep. 2. Observation on 7/29/16 at approximately 11:59 a.m. revealed a cook with a mustache and facial hair on his chin approximately ½ inch long, unrestrained, preparing hot dogs. In an interview on 7/29/16 at approximately 12:08 p.m., the FSD stated that they have beard guards on order for the cook and that the cook was told that if he did not shave, he had to wear one (beard guard). When asked what they were doing in the meantime until the beard guards arrive, the FSD stated, We don't have anything for him. (10 NYCRR 415.14(h), 14-1.72, 14-1.140, 14-1.141)