Every finding on record at Hamilton Manor Nursing Home

Based on interviews and record review, the facility failed to ensure residents were free of significant medication errors for one of three residents reviewed (Resident #1). Specifically, Resident #1 received multiple doses of an anti-Parkinsonism medication (used to treat symptoms of Parkinson's disease) in error resulting in Resident #1 requiring hospitalization for an accidental overdose. Subsequently, Resident #1 experienced a decline in their physical functioning that required additional therapy services. This resulted in actual harm that was not Immediate Jeopardy for Resident #1. The findings include:The facility policy titled Orders, Receiving and Transcribing, dated February 2014, included verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order. The individual receiving the verbal order will read the order back to the practitioner to ensure that the information is clearly understood and transcribed, and the practitioner will review and countersign the verbal orders during his or her next visit. Resident #1 had diagnosis including Parkinson's disease (a disease that affects the nervous system and movement), depression (a mood disorder that causes persistent feelings of sadness and loss of interest) and hypertension (high blood pressure). Review of the Minimum Data Set (a resident assessment tool) dated 06/30/2026 revealed Resident #1 was cognitively intact. Review of recommendations from a Neurology appointment on 07/02/2026 instructed to stop Resident #1's Carbidopa-Levodopa (medication used to reduce Parkinson's symptoms such as tremors and stiffness) 25-100 milligrams immediate release (medication released into body/bloodstream quickly), 2 tablets three times a day and 1.5 tablets three times a day, and to start Carbidopa-Levodopa 70-280 milligrams extended release (medication slowly released into the body), 2 capsules three times a day.Review of Resident #1's active medical orders on 07/02/2026 included the following: Carbidopa-Levodopa 25-100 milligrams immediate release (Sinemet), 2 tablets three times a day and 1.5 tablets three times a day, ordered on 05/05/2026. Carbidopa-Levodopa 70-280 milligrams extended release (Crexont), 2 capsules three times a day, ordered on 07/02/2026 to start on 07/04/2026. Discontinue Sinemet immediate release once extended-release dose (Crexont) has arrived, and first dose has been given, ordered 07/02/2026.Review of the July 2026 Medication Administration Record revealed Resident #1 was administered six doses of immediate release Carbidopa-Levodopa (Sinemet) on 07/04/2026 and two doses on 07/05/2026, in addition to three doses of extended-release Carbidopa-Levodopa (Crexont) on 07/04/2026 and one dose on 07/05/2026.In a progress note dated 07/05/2026 at 11:31 AM, Registered Nurse #1 documented that they noted two different Carbidopa-Levodopa doses due at 12:00 PM, they reviewed the orders and a previous order for immediate release Carbidopa-Levodopa (Sinemet) was supposed to be discontinued when the new order for extended-release Carbidopa-Levodopa (Crexont) was started. Registered Nurse #1 documented that the resident had been receiving both doses since Saturday (07/04/2026) morning at 6:00 AM. Resident #1 was noted with increased tremors and stated that they felt lightheaded. Registered Nurse #1 documented that Physician Assistant #2 was contacted, and an order was placed to send the resident to the hospital for evaluation. Review of the facility's Investigation Report dated 07/07/2026 revealed Resident #1 received eight doses of immediate release Carbidopa-Levodopa (Sinemet) between 07/04/2026 to 07/05/2026, while also receiving extended-release Carbidopa-Levodopa (Crexont) doses. Review of Resident #1's hospitalization record revealed that on 07/05/2026, Resident #1 was transferred to the emergency room for dyskinesia (uncontrollable involuntary movements) from a non-intentional Carbidopa-Levodopa overdose. Blood work was obtained, Poison Control was consulted, and Resident #1 was admitted and treated with intravenous (IV, directly into a vein) fluids and ongoing monitoring. Resident #1 was also found to have hospital delirium (a sudden change in thinking and awareness that can lead to confusion, memory problems and hallucinations) and a urinary tract infection requiring antibiotics. Resident #1 was hospitalized from [DATE] to 07/10/2026.Review of Therapy Notes from 07/01/2026 through 07/10/2026 revealed that on 07/01/2026, Resident #1 completed a therapy program and was discharged from therapy with the ability to tolerate ambulation up to 148 feet with standby assistance. Upon return from the hospital on [DATE], Resident #1 started working with therapy and was able to ambulate up to 15 feet with the assistance of two staff members. During an interview on 07/22/2026 at 12:20 PM, Licensed Practical Nurse Manager #1 stated they provided Registered Nurse Manager #1 with in person training on transcribing orders and there was no formal education or PowerPoint. During an interview on 07/22/2026 at 2:25 PM, the Director of Nursing stated a nurse would transcribe (copying a doctor's order/instructions like name, dose and route of a medication) into the resident's electronic health record a telephone order as a verbal order and the nurse would be the second check (of a new order) because they would clarify the order with the medical provider. Resident #1 had returned from their Neurology appointment on 07/02/2026 with new recommendations. Registered Nurse Manager #1 wanted to address these orders with the medical provider the next time they were in the facility, but the Director of Nursing stated they felt it should not wait and instructed Registered Nurse Manager #1 to call the provider that day. The Director of Nursing stated Registered Nurse Manager #1 called Physician Assistant #1 and received a verbal order to make the recommended Neurology medication changes, however the orders were incorrectly transcribed by Registered Nurse Manager #1. Specifically, Registered Nurse Manager #1 did not add an end date for the Sinemet order, and they did not enter the 'Discontinue Sinemet' order to show up on the Medication Administration Record for the nurses. During a telephone interview on 07/22/2026 at 2:58 PM, Physician Assistant #1 stated they received a call on 07/02/2026 from Registered Nurse Manager #1 regarding Resident #1's medication recommendations from a Neurology visit and they gave verbal orders to discontinue Carbidopa-Levodopa immediate release (Sinemet) and start Carbidopa-Levodopa extended release (Crexont). Physician Assistant #1 stated the immediate release Carbidopa-Levodopa (Sinemet) order should have been discontinued and the new order for extended-release Carbidopa-Levodopa (Crexont) should have been activated but both orders remained active at the same time while the facility was waiting for pharmacy to deliver the extended-release Carbidopa-Levodopa (Crexont). In addition, an order was placed to discontinue the immediate release Carbidopa-Levodopa (Sinemet) order once the new medication (Crexont) arrived. Physician Assistant #1 stated this was not the typical process and both orders should not have remained active at the same time. Additionally, Physician Assistant #1 stated when a nurse enters a verbal order, they expect it to be second checked by another nurse but were unaware of how this process was implemented at the facility.During a telephone interview on 07/23/2026 at 9:13 AM, Registered Nurse Manager #1 stated on 07/02/2026 at approximately 3:30 PM, they received recommendations from Neurology for Resident #1, called Physician Assistant #1, and reviewed the recommendations. Registered Nurse Manager #1 stated they received a verbal order to discontinue the immediate release Carbidopa-Levodopa (Sinemet) and enter a new order for extended-release Carbidopa-Levodopa (Crexont). Registered Nurse Manager #1 stated they entered the new order into the electronic medical record, along with an order that instructed to discontinue the immediate release Carbidopa-Levodopa (Sinemet) order once the new medication (Crexont) arrived. Registered Nurse Manager #1 stated they were unsure if they entered these orders correctly and thought the provider signed off the orders in real time as a second check. Additionally, Registered Nurse Manager #1 stated they should have discontinued the immediate release medication (Sinemet) order, but they did not. Therefore, the other nurses were unaware the immediate release doses (Sinemet) needed to be discontinued, so it remained active, resulting in an unintended overlap of medications. During a telephone interview on 07/23/2026 at 9:56 AM, the Medical Director stated when a provider gives a verbal order, the nurse is responsible for putting the order into the computer (electronic medical record) and it will be verified by the provider. The providers do not sign off verbal orders at the time they are entered; they are signed off the next time the primary provider is onsite, which is typically the same day but can be a day or two later. The Medical Director stated that to check the accuracy of entered orders, the nurse should check the order, and they believed the pharmacy (pharmacist) also reviewed the orders. The Medical Director said if there was a medication delay from the pharmacy, there should be a stop date on the old medication order, and the new medication order should have a specific start date. The Medical Director stated Resident #1 should not have had two active overlapping orders for Carbidopa-Levodopa immediate release (Sinemet) and Carbidopa-Levodopa extended release (Crexont), and the doses of Carbidopa-Levodopa Resident #1 received in error could cause delirium, confusion, and lethargy, which Resident #1 experienced. During an interview on 07/23/2026 at 10:56 AM, Resident #1 stated on 07/05/2026, they felt weak, confused, had more involuntary movements than usual, and were hospitalized for an accidental overdose of Carbidopa-Levodopa. Additionally, Resident #1 stated while hospitalized , they were bed bound resulting in deconditioning and a decline in their mobility. During an interview on 07/23/2026 at 11:52 AM, the Director of Therapy stated prior to Resident #1's hospitalization on 07/05/2026, they were ambulating approximately 75-100 feet with assistance of one staff member. After their hospitalization, Resident #1's mobility was much worse and was not back to baseline. Additionally, the Director of Therapy stated they would attribute Resident #1's decline to their hospitalization and Resident #1 reported they remained in bed throughout their entire hospital stay. Title 10 New York Codes, Rules and Regulations 415.12(m)(2)

Based on observations, interviews, and record review, the facility failed to ensure alleged violations involving abuse were responded to timely and failed to ensure residents were protected from potential further abuse while the investigation was in progress for one (1) of four (4) residents reviewed (Resident #1). Specifically, Certified Occupational Therapy Assistant #1 reported on 04/28/2026 they witnessed Certified Nursing Assistant #1 strike Resident #1 on the head on 04/24/2026. The allegation was not immediately reported as required by facility policy, which delayed initiation of the facility investigation and delayed removal of Certified Nursing Assistant #1 from resident access pending investigation. The findings include:The facility Abuse, Neglect, and Exploitation Prohibition, Training, Investigation, and Reporting Policy, dated December 2016, included a staff person who witnesses or suspects abuse involving a resident must immediately report the suspicion to their immediate supervisor. The facility must prevent further potential abuse while the investigation is in progress. Resident #1 had diagnoses including Alzheimer's disease (a progressive brain disease affecting memory and thinking skills), epilepsy (a neurological disorder causing seizures), and vascular dementia (a decline in thinking skills caused by reduced blood flow to the brain). The Comprehensive Minimum Data Set (a resident assessment tool) dated 03/17/2026 documented Resident #1 had severe cognitive impairment.Review of Certified Nursing Assistant #1's employee disciplinary records revealed on 02/11/2026 a final written warning was issued for unprofessional interactions with residents and families, unprofessional attitude toward peers and management, and inability to care for certain residents due to poor interactions.Review of employee education records revealed Certified Nursing Assistant #1 and Certified Occupational Therapy Assistant #1 received facility training related to abuse prohibition and reporting requirements.Review of Certified Nursing Assistant Assignment Sheets revealed Certified Nursing Assistant #1 was assigned to Resident #1's care on the day shift on 04/24/2026. Additional review revealed Certified Nursing Assistant #1 worked on Resident #1's unit on 04/27/2026 and 04/28/2026.Review of Certified Nursing Assistant #1's time records revealed they worked on 04/24/2026 from 7:45 AM until 2:50 PM, on 04/27/2026 from 6:53 AM until 2:36 PM, and on 04/28/2026 from 7:49 AM until 10:14 AM.Review of the facility report submitted to the New York State Department of Health Incident Reporting Portal on 04/28/2026 at 11:23 AM documented the incident occurred on 04/24/2026 at 12:15 PM and the Administrator first became aware of the allegation on 04/28/2026 at 9:45 AM. The report further documented Certified Occupational Therapy Assistant #1 reported they witnessed Certified Nursing Assistant #1 swat Resident #1 on the head.Review of facility investigation records included a statement from the Director of Rehabilitation, dated 04/28/2026 which revealed Certified Occupational Therapy Assistant #1 reported the allegation to the Director of Rehabilitation on 04/28/2026 at approximately 9:10 AM and facility leadership was then notified. Additional review of investigation records revealed Certified Nursing Assistant #1 and Certified Occupational Therapy Assistant #1 were suspended pending investigation on 04/28/2026. Review of the facility investigation dated 04/28/2026 revealed Resident #1 was unable to provide a statement and had no recollection of the incident, Certified Nursing Assistant #1 denied the allegation, and concluded the allegation of abuse was unable to be determined.During an interview on 05/05/2026 at 1:22 PM, Certified Occupational Therapy Assistant #1 stated on 04/24/2026 at approximately 12:15 PM they observed Certified Nursing Assistant #1 strike Resident #1 on the top of the head in the dining room. Certified Occupational Therapy Assistant #1 stated they did not immediately report the incident because they were concerned Certified Nursing Assistant #1 would get in trouble. Certified Occupational Therapy Assistant #1 stated they reported the allegation to the Director of Rehabilitation on 04/28/2026.During an interview on 05/05/2026 at 1:02 PM, the Director of Rehabilitation stated Certified Occupational Therapy Assistant #1 reported on 04/28/2026 they witnessed Certified Nursing Assistant #1 strike Resident #1 on 04/24/2026. The Director of Rehabilitation stated they immediately notified the Acting Director of Nursing. During an interview on 05/05/2026 at 8:53 AM, Registered Nurse Manager #1 stated if abuse is observed, the expectation is the resident is removed from the situation immediately, a supervisor is notified immediately, and the Administrator is notified so the incident can be properly reported. During an interview on 05/05/2026 at 2:59 PM, the Administrator stated staff are expected to immediately report allegations of abuse, neglect, or mistreatment to a supervisor and the incident involving Certified Nursing Assistant #1 and Resident #1 should have been reported immediately when it occurred on 04/24/2026.Title 10 New York Codes, Rules and Regulations 415.4(b)(1)(i), (3)

Based on observations, interviews, and record review conducted during the Recertification Survey from 06/12/2025 to 06/18/2025, the facility did not ensure a resident who displayed or was diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being for one (1) (Resident #22) of one (1) resident reviewed for dementia care. Specifically, the facility did not ensure the development and implementation of a person-centered care plan that included interventions specific to Resident #22's dementia, did not address the resident's behaviors, goals, or interventions required and did not address the use antipsychotic medication or the monitoring of. The finding is: The facility policy Care Plans, Comprehensive Person-Centered, revised March 2022, included a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #22 had diagnoses that included dementia (without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety), hypothyroid (low levels of thyroid hormone in the blood), and hypertension. The Minimum Data Set (a resident assessment), dated 04/09/2025, documented the resident had severe cognitive impairment and received several medications including but not limited to psychotropic medications (medication used to treat mental illness that require close monitoring due to possible severe side effects) and exhibited wandering behaviors. Additionally, the assessment documented a gradual dose reduction had not been attempted nor had the physician documented a gradual dose reduction was clinically contraindicated. Review of Resident #22's Comprehensive Care Plan did not include any mention of the resident's behaviors with goals or interventions for staff to utilize and did not include use of multiple psychotropic medications and monitoring for side effects, goals or attempting a gradual dose reduction if indicated for the care of a resident with dementia. During multiple observations 06/13/2025 through 06/17/2025 morning and afternoon, Resident #22 was ambulating in the hallway (using a walker at times and other times not) or sitting in the main entryway. During an interview on 06/17/2025 at 11:48 AM Certified Nurse Aide #1 stated Resident #22 is easily agitated and staff need to use a calm approach. Additionally, Resident #22 required frequent reminders to use their walker. During an interview on 06/17/2025 at 11:51 AM Licensed Practical Nurse #1 stated Resident #22 exhibits behaviors such as swatting at staff, frightens easily, wanders, and becomes agitated at times. During an interview on 06/17/2025 at 12:10 PM the Social Worker stated the facility had not developed a person-centered plan of care to include psychotropic medication use and non-pharmacological interventions. During an interview on 06/17/2025 at 12:36 PM, the Director of Nursing stated they and the Social Worker are responsible to develop resident care plans. The Director of Nursing said the facility had not developed a person-centered plan of care to include psychotropic medication use, goals, and interventions to include monitoring of medications, behaviors, and nonpharmacological interventions. 10 NYCRR 415.12

Based on interviews and record review conducted during a Recertification Survey from 06/12/2025 to 06/18/2025, the facility did not ensure the Medication Review Regimen policy to address the pharmacist reported irregularities was implemented within the required times frame for two (2) (Residents #22, #23 and #28) of five (5) residents reviewed for drug regimen reviews. Specifically, the consultant pharmacist's reported irregularities were not acted upon by facility's Medical Director, attending physician or designee in a timely manner. The findings include but are not limited to: 1. Resident #23 had diagnoses that included dementia with behavioral disturbance, diabetes (a group of diseases that affects how the body uses blood sugar), and hypertensive heart disease with heart failure (condition resulting from chronic high blood pressure causing heart complications). The Minimum Data Set (a resident assessment tool), dated 04/15/2025, documented the resident had severe cognitive impairment and received several medications including an antipsychotic (medication to treat mental illnesses), an anticoagulant (a blood thinner to prevent blood clots), and a diuretic (medication that increases urine production and helps lower blood pressure and fluid retention). In a medical progress note dated 01/22/2025, the Medical Director documented that a failed gradual dose reduction of Zyprexa (antipsychotic medication) due to an increase of accusatory behaviors. The resident was restarted on Zyprexa 2.5 milligrams daily. Recommend against future gradual dose reduction due to risk of recurrence and patient being on comfort measures. The Consultant Pharmacist Medication Regimen Review note, dated 02/15/2025, included See Report. Review of Resident #23's electronic medical record did not include the Pharmacist report and the facility was unable to provide the report. The Pharmacist's Note to Attending Physician/Prescriber, dated 03/16/2025, documented a recommendation for a gradual dose reduction of Zyprexa to 2.5 mg every other day. The recommendation was not signed and dated as reviewed by the medical provider until 05/14/2025 in which the medical provider agreed with the recommendation. The Pharmacist's Note to Attending Medication Regimen Review note, dated 04/24/2025, included See Report. Review of Resident #23's electronic medical record did not include the Pharmacist's report, and the facility was unable to provide the report. 2. Resident #22 had diagnoses that included dementia, hypothyroid (low thyroid hormone), and hypertension. The Minimum Data Set, dated [DATE], documented the resident had severe cognitive impairment and received several medications including an antipsychotic, an anticoagulant, a diuretic, and an antidepressant (medication to treat depression). The Consultant Pharmacist Medication Regimen Review notes, dated 04/15/2025 and 05/22/2025, included See Report. Review of Resident #22's electronic medical record did not include either of the Pharmacist's reports and the facility was unable to provide the reports. During an interview on 06/17/2025, the Director of Nursing stated they were responsible to ensure the Pharmacist's recommendations were addressed and they were unaware there was an issue with recommendations not being addressed. The Director of Nursing stated the facility needed to improve their medication regimen review process as the process fell apart with staff changes. During a telephone interview on 06/17/2025 at 1:28 PM, the Physician Assistant stated they were responsible to review the Pharmacist's recommendations monthly, but that they were just informed of this by a colleague within the past month. They stated they have not been receiving the recommendations monthly. During a telephone interview on 06/17/2025 at 1:38 PM, the Pharmacist stated there has been a delay in getting responses from the facility providers on recommendations identified during the monthly medication regimen reviews. During an interview on 06/18/2025, the Administrator stated they were unaware the Pharmacist recommendations were not being addressed. 10 NYCRR 415.18(c)(2)

Based on interviews and record review conducted during an Abbreviated Survey (NY00336619), for one (Resident #1) of three residents reviewed, the facility did not ensure adequate supervision and monitoring systems were in place to prevent a resident from elopement (when a resident leaves the facility without supervision with a possible threat to their health and safety). Specifically, Resident #1 had mild cognitive impairment with a history of wandering and eloped from the facility during a power outage. Resident #1 was absent from the facility for approximately two hours and was found approximately one mile away. This is evidenced by the following: The undated facility policy, Elopement, included if a resident is found to be at risk for elopement, an individualized care plan will be developed. If a resident does leave the building the Missing Resident Plan (emergency procedure used to locate a missing resident), will be put into effect immediately. The facility procedure Elopement Prevention Protocol, dated 02/04/2021, included if a resident cannot be located within the unit, the nurse in charge shall be responsible to notify the Director of Nursing and Administrator. Resident #1 had diagnosis that included dementia, Parkinson's Disease and insomnia (a sleep disorder characterized by difficulty falling or staying asleep). The Minimum Data Set Resident Assessment, dated 06/04/2024, revealed Resident #1 was cognitively intact and had no wandering behavior. Review of the Comprehensive Care Plan, dated 09/08/2022, revealed Resident #1 could walk independently without devices (walker) and was at risk for elopement due to asking for door codes and to go outside alone. Interventions included, but were not limited to, routine checks/observations of the resident and a wander guard (a bracelet that triggers alarms at monitored doors to help protect a resident from elopement) applied to the left ankle. Review of an interdisciplinary progress note, dated 03/20/2025, Registered Nurse #1 documented they were notified by a Certified Nursing Assistant that Resident #1 was not in their bed. After a thorough search of the facility, the resident could not be located and 911 was called. Registered Nurse #1 documented that Resident #1 was located on Long Pond Road, fully dressed, and unharmed. Review of the facility investigation, dated 03/20/2024, revealed there was a power outage at approximately 1:00 AM that lasted approximately 2 hours and 15 minutes. The staff performed a head count at 2:00 AM and at 3:30 AM, Resident #1 was not in their room. The staff on shift called 911 and the police escorted Resident #1 back to the facility at 5:15 AM. The investigation findings included Registered Nurse #1 failed to notify Maintenance and the Leadership Team of the power outage. Review of a Police Report, dated 03/20/2024, included during the timeframe from 2:39 AM to 5:01 AM, Resident #1 was reported by Registered Nurse #1 as a missing person and was found on the corner of [NAME] Ridge Road and [NAME] Drive (approximately one mile from the facility). During an interview on 01/24/2025 at 1:06 PM, the Director of Maintenance stated when the power goes out the generator would automatically turn on, but the door alarms were not connected to the generator and would not work. The Director of Maintenance stated if the power went out, they were supposed to be notified but had not been notified at the time of this incident. During an interview on 01/24/2025 at 4:37 PM, the Administrator stated if the power went out, that staff should call Maintenance and the Director of Nursing. Staff should immediately monitor the emergency exits, complete a headcount and round (routine checks/observations) on all residents. The Administrator stated this elopement incident was a procedure failure. 10 NYCRR 415.12(h)(2)

Based on observations and interviews conducted during a Recertification Survey it was determined that for two (Wings one and three) of three wings, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, exhaust ventilation in required areas was not provided or was not functional. The findings are: Observations on 2/7/24 at 10:06 AM included a soiled utility room directly adjacent to a clean utility room with a shared a partial wall. The shared wall was observed to have approximately one-foot openings near the top and bottom. In the center between the two rooms was a ceiling exhaust fan that was not functional. The clean utility room was observed to contain storage of nursing supplies and oxygen concentrators, and the soiled utility room contained black plastic garbage receptacles and a flushing rim sink (hopper). In an interview at this time the Maintenance Manager stated that they have a couple of fan motors that they could use to replace the broken one. Observations on 2/7/24 at 10:35 AM included a closet between resident rooms five and six (Wing One) that contained a hazardous waste (sharps) collection box. In an interview at this time the Maintenance Manager stated that the exhaust fan in this room was inoperable. The Maintenance Manager also stated that they had checked it yesterday, but it has a different motor than some supplies that they have on hand. Observations on 2/7/24 at 11:15 AM included a shower room by the wing three cross-corridor smoke barrier doors. There were two bins holding 40-gallon bags of soiled linen labeled whites and colors and a 32-gallon covered plastic trash receptacle. The shower room was also observed to be equipped with a ceiling exhaust ventilation fan that only turned on with a light switch and there was no other mechanical ventilation in the room. Observations on 2/7/24 at 1:25 PM included a shower room by the Wing one cross-corridor smoke barrier doors. There were two 40-gallon bins of soiled linen and a green trash receptacle stored within the shower room. The shower room was also observed to be equipped with a ceiling exhaust ventilation fan that only turns on with a light switch and there was no other mechanical ventilation in the room. The light and exhaust fan were observed to be off at the time of these observations. During an interview on 2/9/24 at 11:07 a laundry staff member stated that the soiled linens are kept in the shower rooms, and they pick them up periodically to bring down to the laundry room. The laundry staff member also stated that laundry is processed seven days a week during the daytime only. Observations on 2/12/24 at 9:10 AM included a shower room by the Wing one cross-corridor smoke barrier doors contained storage of two bags of soiled linen and a green garbage tote. In an interview at this time, the Maintenance Manager stated that the soiled linens have always been in the shower rooms and there is not enough room in the soiled utility room. 10NYCRR: 415.29, 415.29(h)(1,2), 415.29(j)(1), 415.29(j)(6)(ii), 10NYCRR: 713-1.9(d), 10NYCRR: Part 70, Subpart 70-2.2(g)(2)(v)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined for 9 (Resident #9, #16, #20, #26, #33, #35, #38, #40, #41) of 12 residents reviewed for Baseline Care Plans, the facility did not ensure a Baseline Care Plan was developed and implemented for each newly admitted resident that included the instructions needed to provide effective care within 48 hours of a resident's admission and that a summary of the Baseline Care Plan was provided to the resident and/or their representative. Specifically, Residents #26, #33 and #38 did not have a Baseline Care Plan developed and implemented within 48 hours of their admission. For Resident #9, #16, #26, #33, #35, #38, #40, and #41, the facility could not provide documented evidence that the residents or their representatives (including for residents who had severely impaired cognition) had been provided with a written summary of the Baseline Care Plan that included, but not limited to, a summary of the resident's physician and dietary orders. The evidence includes but is not limited to the following: The facility policy and procedure Baseline Resident Care Plan, dated 11/28/17, documented that a Baseline Care Plan would be developed within 48 hours of a resident's admission. The Baseline Care Plan would include the minimum health information necessary to properly care for a resident. A copy of the Baseline Care Plan, which included but was not limited to, a summary of the resident's medications and dietary instructions would be provided to the resident and/or their representative. 1.Resident # 38 was admitted to the facility 7/21/23 and had diagnoses including congestive heart failure with a cardiac pacemaker, chronic kidney disease, and polyneuropathy (malfunction of multiple nerves). The Minimum Data Set Resident Assessment, dated 7/28/23, revealed the resident was cognitively intact. The facility was unable to provide documented evidence that a Baseline Care Plan had been developed and implemented within 48 hours of Resident #38's admission. During an interview on 2/9/24 at 3:07 PM, Social Worker #1 stated that Resident #38 was admitted on a Friday while they were off and that they had not completed a Baseline Care Plan for them. 2.Resident #26 was admitted to the facility on [DATE] and had diagnoses including vascular dementia with mood disturbance, adult failure to thrive, history of falls, and bradycardia (a slower than normal heart rate). The Minimum Data Set Resident Assessment, dated 10/29/23, revealed the resident had severely impaired cognition. Review of Resident #29's Baseline Care Plan revealed the care plan was created 10/26/23. The facility was unable to provide documented evidence that they had provided a written summary of the Baseline Care Plan to the resident or their representative or that anyone had reviewed the information with them. 3.Resident #33 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia with psychotic disturbances, dysphagia (difficulty swallowing foods or liquids), and bilateral hearing loss. The Minimum Data Set Resident Assessment, dated 11/5/23, revealed the resident had severely impaired cognition. Review of the Baseline Care Plan, dated 10/30/23, revealed the care plan was created 11/2/23. The facility was unable to provide documented evidence that they had provided a written summary of the Baseline Care Plan to the resident or their representative or that anyone had reviewed the information with them. During an interview on 2/9/24 at 12:59 PM, the Administrator stated after reviewing the Baseline Care Plans, they had found that many of the care plans had no documentation that they had been provided to the resident or their representative. During an interview on 2/9/24 at 3:07 PM, Social Worker #1 stated that Baseline Care Plans were usually mailed to family members and a call was made to the representative to review the care plan. Social Worker #1 stated they would then write a progress note in the medical record that stated the Baseline Care Plan was discussed and provided to the resident and representative. During an interview on 2/12/24 at 11:09 AM, the Interim Director of Nursing stated that the Baseline Care Plan should be completed by Social Work when a resident was admitted and should include a review of the resident's level of care at the time of admission, medication orders, and the care to be provided by the facility. A copy of the Baseline Care Plan should be provided to the resident if they were able to understand it or to the representative if the resident was unable to understand. The Interim Director of Nursing stated there should be a progress note in the resident's medical record stating that the Baseline Care Plan and the required information had been provided to the resident or their representative. 10 NYCRR 415.11

Based on observations, interviews and record reviews conducted during the Recertification Survey on 4/27/22 to 5/2/22, it was determined that the facility did not develop and implement a Comprehensive Care Plan (CCP) that included measurable objectives to meet the resident's medical, nursing and psychosocial needs that include the resident's goals, desired outcomes and preferences to attain or maintain the resident's highest practicable well-being. Specifically, there was a lack of care planning to address the use and monitoring of an anti-coagulant (blood thinner medication used to prevent strokes). This is evidenced by the following: The Long Term Care Facility Resident Assessment Instrument 3.0, dated October 2019, also referred to as the Minimum Data Set (MDS) Assessment manual includes in Section N, medications, that a resident's medications are an integral part of the care provided to residents of nursing homes. They are administered to try to achieve various outcomes. Residents taking medications in these medication categories (that include anti-coagulant or blood thinner medications) are at risk of side effects that can adversely affect health, safety, and quality of life. Target symptoms and goals for use of these medications should be established for each resident and should be evaluated routinely. Possible adverse effects of these medications should be well understood by nursing staff who should be observant for these adverse effects. Systematic monitoring of each resident taking any of these medications to identify adverse consequences early should be implemented. Resident #24 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 4/5/22, documented that the resident was cognitively intact and received an anticoagulant medication on 7 out of 7 days. Review of the current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record contained no documented evidence that a comprehensive care plan had been created for management and the monitoring of a resident on a prescribed anticoagulant medication. During an interview on 4/28/22 at 11:18 a.m., the Certified Nursing Assistant, stated they did not know what an anticoagulant medication was or what to look for until after additional insight from the Unit Manager who was nearby. During an interview on 4/29/22 at 10:26 a.m., the Registered Nurse (RN) Unit Manager stated the Director of Nursing (DON) was responsible for developing care plans and that residents should be care planned for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN Unit Manager stated medications that can have serious side effects including an anticoagulant should be monitored. During an interview on 4/29/22 at 1:35 p.m., the DON stated they develop the clinical components of a resident's care plan and that they do not care plan for all medications. The DON stated that they only care plan for the use of an anticoagulant medication if the resident is observed to be experiencing bruising or bleeding. [10NYCRR 415.11 (c)(1)]

Based on observations, interview, and record review conducted during the Standard Recertification Survey completed on 5/2/22, it was determined that the facility did not operate in compliance with all applicable State regulations and codes. Specifically, a fire incident was not reported to the New York State Department of Health (NYSDOH) and was not properly documented. The findings are: 1. On 4/27/22 at 9:35 a.m. the surveyor asked the Environmental Services Director (ESD) if there had been any fires since the last survey. The ESD stated that last winter there was a small fire in the furnace room for the kitchen. On 4/27/22 at 11:10 a.m. it was observed that there was a door leading to a small furnace room outside the facility adjacent to the kitchen. Further interview with the ESD on 4/29/22 at 9:25 a.m. included that the fire department and fire marshal inspected the furnace after it was repaired and said it was OK, but the ESD did not think that the incident was reported. 2. Record review on 4/29/22 at 9:50 a.m. revealed a service report from the furnace repair vendor dated 12/9/21 and included that the furnace located in the outside closet next to the kitchen had a melted control board and capacitor, and it looked like the relay in the board overheated. 3. During an interview on 4/29/22 at 9:53 a.m., a food service employee in the kitchen stated that they were in the kitchen at the time of the fire incident and that it was during the breakfast meal. Additionally, the food service employee stated that smoke came into the kitchen, and they got all of the residents out of the adjacent dining room. 4. During an interview on 4/29/22 at 9:56 a.m. the administrator stated that the fire incident was outside the facility and thought that it did not need to be reported. There was no documentation provided to show that a written report of an investigation containing all pertinent information was generated for the fire incident. The New York State Title Ten Part 415, Minimum Standards for Nursing Homes, requires nursing homes shall maintain a procedure to investigate fires. A written report of the investigation containing all pertinent information shall be made. The report shall remain on file for not less than six years. The New York State Department of Health (NYSDOH) Nursing Home Incident Reporting Manual requires smoke and fire in any area of the building, including unexpected situations that require evacuation or relocation of residents within the building, to be reported to the NYSDOH. 10NYCRR: 415.29(a)(3) NYS Incident Reporting Manual p.25

Based on observations, interviews, and record reviews conducted during the Recertification Survey, from ,d+[DATE]-[DATE], it was determined that the facility did not ensure for 1 (Resident #13) of 13 residents reviewed had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive that would be honored. Specifically, the physician's orders did not match the resident's Medical Orders for Life Sustaining Treatment (MOLST) wishes. Review of the facility policy MOLST - Medical Orders for Life Sustaining Treatment and Advance Directives dated as last reviewed on [DATE], revealed that a MOLST will be reviewed monthly by the nurse to ensure that each resident's code status is current and has been included on the physician's order sheet. Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact. The physician orders, dated [DATE], and the electronic medical record (EMR) documented that Resident #13 was a Full Code (indicating wishes for cardio-pulmonary resuscitation (CPR). Review of a medical progress note, dated [DATE], revealed Resident #13 was educated on the aspects of changing their code status as desired, and verbalized their wishes for Do Not Resuscitate (DNR)/Do Not Intubate (DNI) and signed the completed MOLST form. Review of the MOLST form, dated [DATE], and signed by Resident #13 revealed the resident's wishes were DNR/DNI. During an interview on [DATE] at 11:03 a.m., the Licensed Practical Nurse (LPN) stated that if a resident was coding (cessation of heart function and/or breathing), they would look at their arm bracelet and that a blue color bracelet represented the resident's wishes as full code and a white color bracelet represented wishes for DNR. The LPN stated they would look at the resident's hard chart or EMR to determine a resident's code status if they were not able to determine the residents code status via a bracelet. During an observation and interview on [DATE] at 10:37 a.m., Resident #13 was observed not wearing am arm bracelet and stated they have a bracelet, but they do not wear it because it's too big for their wrist. During an interview on [DATE] at 2:34 p.m., the Director of Nursing (DON) stated they were unsure what the colors represented on the residents' arm bracelets as it relates to code status. The DON stated that the facility does not have a formal code status system and that it is the nurse's responsibility to ensure that residents are wearing their bracelets. The DON stated that the social worker or business office is responsible for entering a resident's code status into the EMR and that if a resident were to have a change in code status, the nurses or provider should enter that updated information into the EMR. When interviewed on [DATE] at 10:05 a.m., the DON stated they did not have a set expectation as to where staff should refer to regarding code status but would expect the chart or the EMR. The DON concluded by stating that the initiation of the colored bracelets was put into place before they started working at the facility and that the process needed to be updated. 10 NYCRR 415.3 (e)(1)(ii)

Based on interviews and record review conducted during the Recertification Survey, it was determined that for two of two residents (Residents #16 and #19) reviewed for hospitalization , the facility did not ensure each resident or resident's representative received a written Transfer or Discharge Notice when the residents were transferred to the hospital, and the facility did not provide a copy of the notice to a representative of the Office of the State Long Term Care Ombudsman. This is evidenced by the following: The undated facility policy, Resident Discharge or Transfer revealed that the resident, resident's representative and the long-term care ombudsman must be provided with a Notice of Discharge or Transfer containing all the information required under state and federal law. 1. Resident #16 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/12/19, revealed the resident had severely impaired cognition. Review of the medical record revealed that the resident was transferred and admitted to the hospital on [DATE] and the family was notified. There was no documented evidence that the resident's representative and the ombudsman office were notified in writing of the resident's transfer to the hospital. 2. Resident #19 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/21/19, revealed the resident had severely impaired cognition. Review of the medical record revealed that the resident was transferred and admitted to the hospital on [DATE], 11/8/19, and 12/31/19. There was no documented evidence that the resident's representative and the ombudsman office were notified in writing of the resident's transfer to the hospital. When interviewed on 1/7/20 at 1:45 p.m., the Licensed Practical Nurse Manager stated that when a resident was transferred to the hospital, the nurse would notify the resident's family and document in the progress notes. Interviews conducted on 1/8/20 included the following: a. At 10:19 a.m., the Administrator stated he was unsure if a written notice of transfer was provided to the resident's representative. b. At 11:30 a.m., the Social Worker said that when the ombudsman comes into the facility, they will discuss new admissions and discharges. She said that she does not send a written notice regarding transfers or discharges to the Office of the State Long Term Care Ombudsman. (10 NYCRR 415.3(h)(iii)(a))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of two residents (Residents #16 and #19) reviewed for hospitalization , the facility did not ensure that each resident or designated representative received a notice of the bedhold policy upon transfer to the hospital. This is evidenced by the following: 1. Resident #16 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/12/19, revealed the resident had severely impaired cognition. Review of the medical record revealed that the resident was transferred and admitted to the hospital on [DATE]. There was no documented evidence that the resident's representative received a bedhold notice. 2. Resident #19 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/21/19, revealed the resident had severely impaired cognition. Review of the medical record revealed that the resident was transferred and admitted to the hospital on [DATE], 11/8/19, and 12/31/19. There was no documented evidence that the resident's representative received a bed hold notice. When interviewed on 1/8/20 at 10:19 a.m., the Administrator stated the business office handled bedholds, and bedholds were only needed when the facility was at capacity. The Business Office Manager stated that Medicaid does not pay for bedholds. She said if a resident was private pay, the facility would try and contact the representative to pay to hold the bed. The Office Manager stated information regarding the facility's bedhold policy was provided in the Admission Agreement. The Office Manager stated bedhold information was not given at the time of a transfer or discharge to the hospital. (10 NYCRR 415.3(h)(4)(i)(a))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 6 (Resident #5, #12, #37, #8, #11, and #18) of 16 residents reviewed for Baseline Care Plans, the facility did not develop a Baseline Care Plan within 48 hours of admission that included instructions needed to provide care, and the resident and/or representative were not provided with a written summary of the Baseline Care Plan. This is evidenced by, but not limited to, the following: The Baseline Resident Care Plan policy, dated [DATE], included that a care plan would be developed within 48 hours of admission, provided to the resident and/or their representative, utilized during the development of the Comprehensive Care Plan (CCP), and a copy given to the resident and/or representative would be filed with the CCP. 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident was cognitively intact. There was no Baseline Care Plan in the medical record. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident was cognitively intact. There was no Baseline Care Plan in the medical record. 3. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed the resident had moderately impaired cognition. A progress note, dated [DATE], revealed the resident had expired. There was no Baseline Care Plan in the medical record. When interviewed on [DATE] at 2:40 p.m., the Director of Nursing (DON) stated that after reviewing the charts and meeting with Social Work, they were unable to find a Baseline Care Plan for Residents #5, #12, and #37. He said that the care plans should have been done. The DON said that the facility's practice was to complete and present the Baseline Care Plan to the resident and/or family within the first 48 hours of admission. He said the facility was supposed to implement the Baseline Care Plans for new admissions in (MONTH) (YEAR), but he was not sure when they actually started. When interviewed on [DATE] at 9:25 a.m., the Social Worker (SW) stated that the Baseline Care Plan should be completed within the first 48 hours of admission. The SW said that she usually presents the Baseline Care Plan to the resident and/or representative, and then signs off that the care plan had been presented. She stated that once the process was complete, the Baseline Care Plan was filed in the care plan section of the chart and remained in the chart with the CCP once it was developed. The SW said that the facility started completing the Baseline Care Plans in (MONTH) (YEAR). When interviewed on [DATE] at 11:39 a.m., the Administrator stated that the facility did not start doing Baseline Care Plans until (MONTH) (YEAR) and was not sure why as he did not start working for the facility until (MONTH) (YEAR). (10 NYCRR 415.11)

Based on observations and interviews conducted during the Recertification Survey, it was determined that for one of one residential units reviewed for medication storage, the facility did not provide for the safe and secure storage of medications. Specifically, controlled substances were expired and were not secured by two locking mechanisms. This is evidenced by the following: During an observation of the medication room on [DATE] at 10:03 a.m., Registered Nurse (RN) #1 found the exterior lock on the medication refrigerator had not been secured. The refrigerator contained multiple vials of insulin and [MEDICAL CONDITION] vaccine and a small black box secured to a shelf. When interviewed at that time, RN #1 said there were injectable narcotics in the box, but she did not have a key to open the box. She said the medication refrigerator should be locked at all times. At 10:08 a.m., RN #1 returned to the medication room with RN #2 who opened the small black box which contained two vials, 2 milligrams per milliliter, of injectable [MEDICATION NAME] (Controlled Substance Level IV, uses include to treat anxiety disorders, trouble sleeping and active [MEDICAL CONDITION]) that was labeled with an expiration date of (MONTH) (YEAR). Interviews conducted on [DATE] included the following: a. At 10:14 a.m., the LPN Manager said that both vials of [MEDICATION NAME] had expired, and she would dispose of them. The LPN Manager said she thought the pharmacist consultant checked the narcotics refrigerator during their monthly visit, but she would need to verify that. b. At 10:37 a.m., the LPN Manager said the refrigerator should be double locked at all times. The LPN Manager said she had called the pharmacy and was told that a pharmacist only checks the refrigerator every three months, and they would call her back to verify when it was last done. c. At 11:06 a.m., the LPN Manager said the pharmacy had called back and told her that it was the responsibility of the facility to check the narcotic refrigerator and replace and dispose of expired narcotics. (10 NYCRR 415.18(d)(e)(,[DATE]))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #1) of four residents reviewed for accidents, the facility did not provide adequate supervision and assistive devices to prevent accidents. Specifically, a resident was transported in a wheelchair without direction to raise her feet and/or applying foot pedals to the wheelchair that caused the resident to drag her feet against the floor. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/15/18, revealed the resident had severely impaired cognition, required the extensive assistance of two staff members for transfers, and the extensive assistance of one staff member for ambulation on and off the unit. The Continuity of Care Card which directs daily cares, dated 8/30/18, included to encourage the resident to wear slippers when out of bed, ambulation only with a therapist, and that the resident uses a wheelchair without foot pedals for seating. During an observation on 10/1/18 at 1:07 p.m., a staff member pushed the resident in her wheelchair from the dining room to her room (approximately 50 feet). The foot pedals on the wheelchair were in the down position. Both of the resident's feet were behind the pedals, resting against them, and her toes were dragging across the floor. The resident had gripper socks on (nonskid socks with a tread pattern provided for improving traction). Observations and interviews conducted on 10/3/18 included the following: a. At 8:56 a.m., the resident had gripper socks on both feet and Certified Nursing Assistant (CNA) #1 pushed the resident in her wheelchair from her room to a bathroom (Team 2) on the far side of the nurses' station. The wheelchair did not have foot pedals and the resident's feet were flat and dragging against the floor. b. At 9:27 a.m., CNA #1 took the resident out of the bathroom and pushed her to a different bathroom (Team 1), again dragging her feet against the floor. CNA #1 was not observed to direct the resident to raise her feet on either occasion, and the approximate distance for both observations was 60 feet. c. At 1:25 p.m., CNA #1 and CNA #2 both said that the resident no longer uses a walker, uses a wheelchair, and can sometimes self-propel in the wheelchair. d. At 1:51 p.m. and 2:02 p.m., the RN said the resident can sometimes self-propel in the wheelchair. She said the resident wears slipper socks. She said when the resident is transported in the wheelchair, she should wear shoes or the aides should direct her to lift her feet. The RN said the resident should not drag her feet on the floor due to a risk of injury. The RN directed the resident to raise her feet, which she did, and then transported her in the wheelchair to the sitting area. e. At 2:05 p.m., CNA #1 said when transporting the resident in the wheelchair, she tries to direct the resident to lift her feet. CNA #1 said that sometimes the resident follows directions, but usually not, so she attaches the foot pedals. f. At 3:15 p.m., CNA #3 was observed pushing the resident in a wheelchair with both feet dragging against the floor from her room to the Team 2 bathroom. The resident had gripper socks on her feet. CNA #3 was not observed to direct the resident to raise her feet. g. At 3:20 p.m., CNA #3 said she directed the resident to raise her feet. Interviews conducted on 10/5/18 included the following: a. At 8:45 a.m., an Occupational Therapy Assistant said if a resident cannot self-propel in a wheelchair or lift their feet, staff are to apply foot pedals for safe transport. She said if the resident does not wear shoes or has gripper socks with good grippers, a resident could fall forward out of the chair and be hurt. b. At 9:19 a.m., a Doctorate Physical Therapist said the resident can sometimes self-ambulate in the wheelchair. He said she goes up and down the halls but she gets tired and then needs help getting around. He said the resident does not take directions that well and when she can not keep her feet up, staff need to put foot pedals on to prevent her from falling forward out of the wheelchair and getting hurt. He said the staff are to put foot pedals on to eliminate and reduce the risk of injury. (10 NYCRR 415.12(h)(1-2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #7) of one resident reviewed for choices, the facility did not allow each resident the right to make choices about aspects of life that were significant to them. Specifically, the resident was not showered weekly per their plan of care and stated preference. This is evidenced by the following: Resident #7 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/17/18, revealed that the resident had severely impaired cognition, was incontinent of urine and stool, and required extensive assist of staff for bathing. The assessment also included under customary preferences for daily routine that the type of bathing was very important to the resident. Review of the Preferences Form, dated 5/2/18 (most recent one found in the medical record), revealed that the resident's preference was for one shower a week. Review of the resident's Continuity of Care Care Plan, dated 10/2/18, revealed that the resident was scheduled for a shower once weekly on Thursdays and required two staff members. Review of the Certified Nursing Assistant (CNA) Activities of Daily Living Tracking Form, dated (MONTH) (YEAR) through (MONTH) (YEAR), included that the resident required extensive to total dependence on staff for bathing daily, and under type of bathing (i.e., partial, shower, bed bath or tub) the form is crossed out for the entire period. Observations and interviews included the following: a. On 10/1/18 at 8:19 a.m., the resident was in bed, uncovered, and incontinent of urine. At 12:42 p.m., a visiting family member stated that the resident was supposed to get a shower weekly but it was often missed, going two to three weeks and sometimes he smelled. b. On 10/4/18 at 1:24 p.m., the resident was sitting in a chair, his feet were very dry with peeling skin and he had a blackened dry scab-like area on one toe. When interviewed at that time, the visitor stated that the resident did not get a shower that day as scheduled and his hair was dirty. Interviews conducted on 10/5/18 included the following: a. At 9:09 a.m., the Licensed Practical Nurse (LPN) stated she was not informed that the resident did not get his shower as scheduled the previous day (10/4/18). The LPN said the resident needs his shower as he has skin issues and was a diabetic. She said that she did not know why staff did not document the showers on the tracking form. The LPN said that she assumes residents are getting their showers as scheduled unless otherwise noted. The LPN said she was not aware that the resident still had a skin issue on his foot as she thought it was healed. b. Between 9:27 a.m. and 9:30 a.m., CNA #1, #2 and #3 stated they did not assist CNA #4 (assigned CNA) in showering the resident the previous day (10/4/18). They all said they were not aware that the resident was not showered. c. At 12:20 p.m., the LPN/Nurse Manager (NM) stated that she called CNA #4 who was assigned to the resident the previous day (10/4/18) and was told the resident was not showered because the resident was agitated. The LPN/NM said the CNA could not remember if she told anyone. The LPN/NM said that staff should probably document if showers are given to ensure that the residents are being provided their showers as scheduled. (10 NYCRR 415.5(b)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #1) of one resident reviewed for grievances, the facility did not make prompt efforts to resolve a grievance and to keep the resident appropriately apprised of progress toward resolution. Specifically, the resident's wheelchair was not cleaned after being reported to facility staff. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/15/18, revealed the resident had severly impaired cognition, required the extensive assistance of one staff for locomotion on and off the unit, and uses a walker or wheelchair for mobility. During an interview on 10/3/18 at 3:37 p.m., a family member said the cleanliness of the wheelchair was a big issue. She pointed to a splotch (fifty cent size) of an orange colored substance on the chair and said it was food that had been there for close to three weeks. The wheelchair had visible crumbs, a dried build-up of dark colored debris along multiple surfaces of the carriage, and dark colored stains. The family member said the condition of the chair and need for cleaning had been reported to both the Licensed Practical Nurse (LPN) Manager and the Social Worker (SW). In an observation on 10/4/18 at 11:51 a.m., the wheelchair had a visible build-up of dark colored debris on the carriage and the orange splotch of debris. Interviews conducted on 10/5/18 included the following: a. At 1:03 p.m., a Registered Nurse (RN) said the family told her their concerns about the resident's wheelchair, and she knew the chair was not clean. She said night staff used to clean wheelchairs, but things had been changed, and she does not know who is responsible for cleaning. b. At 1:06 p.m., Certified Nursing Assistant #1 said evening staff clean the wheelchairs but if staff see something that needs to be cleaned, they should do it. c. At 1:09 p.m., the LPN Manager said that the resident's family reported to her a while ago that the wheelchair was dirty. She observed the resident's chair and stated the wheelchair was dirty and needed to be cleaned. d. At 1:12 p.m., the Director of Environmental Services said his staff do not clean wheelchairs, and he thinks evening staff do that. e. At 1:13 p.m., the LPN Manager was taking the resident to her room in the wheelchair. She said staff need to clean the chair, the whole thing is dirty, and that orange spot is still there. The LPN Manager said that maintenance no longer cleans equipment. She said the night staff are supposed to clean equipment. f. At 1:18 p.m., the SW said the family had notified her, about two weeks ago, that the wheelchair needed to be cleaned. She said she told maintenance, the issue had been discussed at morning meeting, and she had left it for maintenance and nursing to figure out. The SW said she did not go back to be sure the chair had been cleaned. (10 NYCRR 415.3(c)(1)(i))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #31) of two residents reviewed for non-pressure related skin conditions, the facility did not thoroughly investigate bruising and skin tears to rule out abuse, neglect or mistreatment. This is evidenced by the following: Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/12/18, revealed the resident had severely impaired cognition, used an anticoagulant daily, had skin tears, required extensive assistance of one staff for dressing, personal hygiene and locomotion on and off the unit, and the extensive assistance of two staff for toilet use, bed mobility and transfers. Physician orders, dated 9/13/18, included the daily use of [MEDICATION NAME] (steroid). The Comprehensive Care Plan, dated 8/14/18, revealed that the resident has the potential for bruising and/or bleeding related to taking anticoagulation medications. Interventions included to observe skin daily. The Certified Nursing Assistant (CNA) Continuity of Care Card that directs daily cares, dated 8/29/18, included bleeding precautions, encourage use of arm sleeves from fingers to shoulders at all times, and tubi-grips (multipurpose support bandage often used in the treatment of [REDACTED]. An Incident/Accident (I/A) Report, dated 9/10/18, revealed an unobserved bruise to the left upper extremity that was purple and had [DIAGNOSES REDACTED] (redness) and measured 6 x 7 by greater than 0.1. The measurements do not include centimeters and/or inches. There were no staff and/or witness statements including from the CNA who identified the injury. A progress note, dated 9/10/18, revealed that the resident's right hand was swollen and bruised. The resident was unable to report what happened. An I/A Report, dated 9/13/18, revealed an unobserved skin tear on the right upper clavicle that measured 2 centimeters (cm) x 0.5 cm and documented that bleeding was reported by the CNA. There were no staff and/or witness interviews including from the CNA who identified the injury. A progress note, dated 9/13/18, revealed that the resident had a skin tear to the right upper clavicle. Interviews conducted on 10/5/18 included the following: a. At 8:52 a.m., the Director of Nursing (DON) said he did not have any additional information related to the identified I/A Reports. The DON said that he usually goes back one shift when he interviews about an incident. The DON said if someone reports a bruise on the day shift, then he would interview staff from the shift before and ask if the bruise was noticed and/or reported. b. At 11:39 a.m., the Administrator said the DON was responsible to investigate injuries of unknown origin and ensure that the investigations are thorough and complete. c. At 12:15 p.m., the DON said it has been difficult to determine why the resident bruises so easily. He said he has talked to staff members but does not have any documented interviews. The DON said after the skin tear, he remembered suggesting that staff give a sponge bath because maybe the washcloth caused the tear. The DON said he has not been documenting staff interviews and he should be. (10 NYCRR 415.4(b)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 2 of 16 residents reviewed for care planning, the facility did not implement the person-centered care plans to address resident's medical, physical, mental and/or psychosocial needs. Specifically, the resident was not wearing support bandages as ordered (Resident #32), and a resident was not wearing his partial dentures per the plan of care (Resident #8). This is evidenced by the following: 1. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/12/18, revealed the resident had mild impairment of cognitive function and required extensive assistance of staff for bathing and dressing. Review of the medical record revealed the following: a. The medical orders, dated 9/21/18, revealed orders for tubi-grips (a multi-purpose support bandage often used in treatment of [REDACTED]. b. The resident's Comprehensive Care Plan, dated 9/25/18, revealed that the resident was on a therapeutic diet related to a history of [MEDICAL CONDITION] and hypertension. Approaches included, but were not limited to, review of medical notes discussing [MEDICAL CONDITION]. c. The Certified Nursing Assistant (CNA) Continuity of Care Care Plan, dated 9/25/18, included the resident requires assist with bathing and dressing. It did not include the use of tubi-grips. d. In an interdisciplinary note, dated 10/2/18, the Nurse Practitioner (NP) documented that the resident had hematomas (collection of blood in the tissues) on the arms and legs and a raised patchy rash to the legs with mild [MEDICAL CONDITION]. Under plan the note includes tubi-grips on in the morning and off at bedtime. e. Review of the Treatment Administration Record for (MONTH) (YEAR) and (MONTH) (YEAR) revealed that the tubi-grips were signed off as applied in the morning and off at bedtime from 9/21/18 through the morning of 10/5/18. Intermittent observations from 10/1/18 through 10/5/18 revealed the resident had swelling of both legs and feet and bruises to the legs and arms. The resident was not wearing tubi-grips. In an interview on 10/1/18 at 9:25 a.m. and again on 10/5/18 at 11:33 a.m., the resident stated that she does not know where the bruises on her legs and arms came from, and she was not aware of any stockings she should be wearing just her socks (slipper socks). Interviews conducted on 10/5/18 included the following: a. At 12:00 p.m., the CNA stated that the resident does not have any stockings for her legs or arms because it is not on her care plan. b. At 12:25 p.m., the Licensed Practical Nurse (LPN) Manager stated the resident did not have tubi-grips on the previous day or the day (10/2/18) the NP saw her, and she did not know why. The LPN Manager said that the tubi-grips may have been thrown in the laundry. She said sometimes the aides apply the tubi-grips and sometimes the nurses apply them. She said the nurses should be checking to ensure the resident has the tubi-grips as ordered. c. At 12:42 p.m., the Registered Nurse stated that she signed off on the Treatment Administration Record that the tubi-grips were applied for the resident because she thought the aides were applying them. 2. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/26/18, revealed the resident had severely impaired cognition and required the extensive assistance of one staff member for personal hygiene. A review of the monthly weights, from 2/27/18 through 8/29/18, revealed an 18.2 pound significant weight loss in six months. The Dental Record, dated 3/1/18, revealed the resident had a partial upper denture with dental adhesive. The Dental CCP, dated 7/3/18, revealed the resident had an alteration in dentition related to his partial upper denture and missing and fractured natural teeth. Approaches included an upper partial and to provide assistance for oral hygiene as needed. The CNA Continuity of Care Plan for Dental, dated 9/24/18, revealed the resident wears an upper partial denture and directs to use dental adhesive. During an interview on 10/2/18 at 11:00 a.m., a family member said the resident has lost a lot of weight, and she did not know if his partial denture fit him anymore. Interviews conducted on 10/3/18 included the following: a. At 11:11 a.m., CNA #1 said he was responsible for providing cares to the resident that day. He did not know if the resident wore an upper partial denture and he had not put one in that morning for the resident. Also, at that time, CNA #2 said the resident does not have a partial upper denture. CNA #2 then asked the DON if the resident had a partial upper denture. The DON said he did not know and would check the resident's room. The DON and surveyor went to the resident's room. The DON reviewed the Continuity of Care Plan and then said the resident was supposed to have a partial upper denture in place. The DON opened a denture bath set on top of the television and the partial denture was inside. The DON said the partial denture should be in the resident's mouth. b. At 11:26 a.m., CNA #1 said he had not checked or read the Continuity of Care Plan in a couple of days but he would start checking it more regularly. CNA #1 said that the resident's partial denture had not been in place for breakfast and he was sorry about that. c. At 11:39 a.m., Registered Nurse #1 said she did not know if the resident had a partial but if he had one he should wear it. d. At 12:57 p.m., CNA #1 said he put the resident's partial denture in and had no difficulty doing that. When interviewed on 10/4/18 at 12:33 p.m., CNA #1 said he provided cares for the resident on both 10/1/18 and 10/3/18 and had not put the partial denture in either day because he did not know the resident had a partial denture. (10 NYCRR 415.11(c)(2)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #6) of one resident reviewed for respiratory care, the facility did not ensure respiratory care was consistent with professional standards of practice, the comprehensive person centered care plan, or the resident's goals and preferences. Specifically, the resident did not receive continuous oxygen as ordered and the oxygen tubing was not labeled or dated. This is evidenced by the following: Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/26/18, revealed the resident was cognitively intact, had moderately impaired vision (cannot see newspaper headlines, can see objects), and received oxygen therapy. Review of the facility policy, Oxygen Administration, dated (MONTH) 2012, included to verify the physician's order of oxygen administration, review the resident's care plan to assess for special needs, and adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Physician orders, dated 8/9/18, included to administer oxygen at 2 liters per minute via nasal cannula continuously and change the oxygen tubing and clean the concentrator filter every week. The Comprehensive Care Plan for oxygen dependence, dated 7/3/18, revealed to administer oxygen per the medical provider orders and to clean and care for the oxygen equipment per manufacturer recommendations. The Continuity of Care Card which directs daily cares, dated 8/14/18, revealed the resident used oxygen continuously. Review of the Treatment Administration Records (TAR) for (MONTH) (YEAR) and (MONTH) (YEAR) included an entry for oxygen at 2 liters via nasal cannula continuously for [MEDICAL CONDITION] and was signed as completed daily through 10/5/18. The entry to change oxygen tubing every week and clean the concentrator filter every week was not signed off as completed for two of four opportunities in (MONTH) (YEAR). During an observation on 10/1/18 at 1:32 p.m., the resident was in her room and was on oxygen. The oxygen tubing was not dated. The resident asked the surveyor what the oxygen liter flow was set at as she could not see the readings on the concentrator. The oxygen liter was observed to be set at 1.5 liters per minute. The resident said that was too low. During an observation on 10/2/18 at 2:15 p.m., the resident was receiving oxygen at 1.5 liters per minute. There was no label or date on the oxygen tubing and the humidifier was in use. During an observation on 10/3/18 at 11:18 a.m., the resident was receiving oxygen at 1.5 liters per minute. There was no label or date on the oxygen tubing and the humidifier was in use. During an observation and interview on 10/4/18 at 12:16 p.m., a Registered Nurse (RN) observed the resident's oxygen concentrator and said it was set slightly above the 1.5 liters per minute mark. The RN turned the flow rate to 2 liters per minute. She said that staff may have knocked the concentrator during cares, changing the delivery rate. The RN said neither the tubing or humidifier were labeled and/or dated, and they should be. She said it was the responsibility of the night nurse to change and date the tubing and humidifier every week. In an observation and interview on 10/5/18 at 1:34 p.m., the Licensed Practical Nurse (LPN) Manager and the surveyor observed the resident being administered oxygen at 3 liters per minute and the oxygen tubing was dated 10/5/18. The LPN Manager said the oxygen liter flow was to high. She said the nurses are supposed to check the flow rate and document every shift on the TAR. The LPN Manager said that the use of humidifier had been discontinued several months ago because the resident had complaints of difficulty breathing and a nasal drip which was resolved with the removal of the humidifier. The intervention for the humidifier was not found in the medical orders or care plans. (10 NYCRR 415.12(k)(6))