Every finding on record at Ira Davenport Memorial Hospital SNF/HRF

Based on observations, interviews, and record review conducted during an Abbreviated Survey (Complaint #NY00321351) 8/4/23 to 8/7/23, for one (Resident #1) of three residents reviewed, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials in accordance with State law through established procedures. Specifically, the facility did not report an allegation of abuse, neglect, or mistreatment involving Resident #1 and a staff member on 7/31/23 until 8/3/23 and allowed the alleged staff member to continue to work on the resident's unit. The finding is: The facility policy Abuse Investigations, dated 11/21, included that all reports of resident abuse, neglect, sexual assault, and injuries of unknown origin shall be promptly and thoroughly investigated by facility management. Employees of the facility who have been accused of resident abuse may be reassigned to non-resident care duties or suspended from duty until the results of the investigation have been reviewed by the Administrator/designee. The facility policy Preventing Resident Abuse, dated 5/21, documented the facility's abuse prevention/intervention program included encouraging all personnel to report any signs or suspected incidents of abuse to facility management immediately. Resident #1 had diagnoses including dementia with behavioral disturbances, anxiety, restlessness, and agitation. The Minimum Data Set assessment dated [DATE], revealed the resident had severe cognitive impairment. Review of the Comprehensive Care Plan (CCP) dated 1/18/23, revealed Resident #1 could become very aggressive to staff and other residents due to their dementia. Interventions included, but were not limited to, to provide the resident with necessary cues, stop, and return if agitated. Review of statements obtained by the facility included: 1. In a statement, dated 8/2/23, Certified Nursing Assistant (CNA) #2 stated they asked CNA #1 and CNA #3 for assistance with care for Resident #1. The three CNAs entered the room, CNA #1 pulled the resident's chair backwards causing them to fall back in their chair and while attempting to provide care, CNA #1 placed one of Resident #1's arms in between their (CNA #1) legs to prevent them from grabbing onto CNA #1. CNA #1 then took the resident's other arm and pinned it against the resident's chest and stated, keep it up and it won't go well for you later tonight. CNA #2 stated that Resident #1 was yanked around in the chair with CNA #1 swearing. CNA #2 stated that immediately following the incident, they, along with CNA #3 reported the incident to the Licensed Practical Nurse #1 (LPN) and Registered Nurse Supervisor #1 (RNS). 2. In a statement, dated 8/3/23, CNA #3 stated they and CNA #2 had asked CNA #1 to assist with care for Resident #1 who was attempting to get into the bed and had taken their gown off. CNA #1 yanked Resident #1 back, pinned the resident's arms trying to get their gown on and then pinned the resident's other arm with their (CNA #1) legs to get the other side of the gown on. CNA #1 then stated to the resident keep it up and you won't like what is going to happen later. 3. In an undated and unsigned statement titled with CNA #1's name on it, CNA #1 stated that on 7/31/23, CNA #2 asked them for help with Resident #1. CNA #1 stated that they were in the hallway when they voiced that this place was really pissing me off today because residents were ringing every five minutes, going into other residents' rooms, and stripping their clothes off. Upon entering the room, CNA #1 stated they pulled Resident #1 back in their chair and saw the gown was off and as they were trying to put the gown back on, Resident #1 was trying to hit and pinch them. CNA #2 and #3 stood there and did nothing to help them so they (CNA #1), took the resident's right arm and held it in the resident's lap as CNA #1 was trying to get the resident's left arm in the gown. Resident #1 was still trying to hit and pinch, so CNA #1 put the resident's right arm under their (CNA #1) left arm just enough so they could get the gown on. 4. In a statement, dated 8/4/23, RNS #1 stated two CNAs reported to them that another CNA had grabbed the hands of Resident #1 and restrained one hand between their leg. RNS #1 stated Resident #1 was assessed, and no injuries or evidence of abuse noted. RNS #1 stated they spoke with the accused CNA who denied restraining Resident #1 but was directing them due to the resident trying to grab and hit. 5. In an undated statement, the Administrator stated that on 8/3/23 at around Noon, they had received a statement from CNA #2 describing an incident that happened on 7/31/23 with Resident #1 but that they (CNA #2) had not reported this to the DON or the Administrator until 8/3/23. The Administrator stated on 8/4/23 at 5:45 AM, they arrived to speak with CNA #2 again who then demonstrated how another staff member had assisted (with resident care) and what CNA #2 verbally heard. 6. In a second undated statement, the Administrator stated that on 8/3/23 at 3:00 PM they met with CNA #1 regarding the incident that allegedly occurred on 7/31/23. An addendum to the statement documented that CNA #1 had been suspended without pay pending the outcome of the facility investigation. Review of progress notes for 7/31/23 did not include documentation related to the alleged incident. Review of task documentation for Behavior Monitoring and Interventions revealed there were no behaviors observed on 7/31/23. Review of the Staffing Daily Census from 7/31/23 to 8/4/23, revealed CNA #1 continued to work on Resident #1's unit again on 8/1/23 and 8/2/23. During an interview on 8/4/23 at 10:19 AM, the Administrator stated CNA #2 reported the incident to the facility late in the day on 8/3/23. The Administrator stated they had arrived at the facility on 8/4/23 at 5:30 AM to begin the investigation and thought they had until 12:00 noon to report it to the New York State Department of Health (NYSDOH) based on the time it was reported to them. During an interview on 8/4/23 at 3:14 PM, CNA #2 stated immediately following the incident, they and CNA #3 reported it to LPN #1 and then to RNS #1 as instructed by LPN #1 shortly after it happened (on 7/31/23). CNA #2 stated that RNS #1 tried to speak to CNA #1 at that time but CNA #1 said nothing happened, that everyone was against them, and walked away. During an interview on 8/7/23 at 12:23 PM, CNA #1 stated that RNS #1 had told them what CNA #2 and CNA #3 reported. CNA #1 said that is not what happened. CNA #1 stated that after speaking with another co-worker about the incident, they calmed down and went back to work. During an interview on 8/7/23 at 12:47 PM, CNA #3 stated that CNA #2 and CNA #3 immediately reported the incident to LPN #1 who instructed them to notify RNS #1 who then spoke with CNA #1. During an interview on 8/7/23 at 3:32 PM, the Administrator stated that RNS #1 had assessed Resident #1 on 7/31/23 and did not see any bruising or other visible injury so they concluded there was no evidence of abuse. The Administrator stated the DON or themselves should have been notified on the day the incident occurred so the investigation could be started immediately. During an interview on 8/8/23 at 10:47 AM, LPN #1 stated they were informed on 7/31/23 by CNA #2 and CNA #3 immediately after an incident they witnessed involving CNA #1 and Resident #1 and told them they should report it to RNS #1 immediately. LPN #1 said they observed RNS #1 talking to CNA #1 in the hall and that CNA #1 was yelling and using foul language and continued to work until the end of shift. There were three unsuccessful attempts made to interview RNS #1. 10 NYCRR 415.4(b)(1)(i)

Based on observations, interviews, and record review conducted during a Recertification Survey, completed on 11/18/22, it was determined that for one (Resident #32) of three residents reviewed for pressure ulcers, the facility did not ensure the resident received the necessary treatment to promote healing of a pressure ulcer, prevent infection and prevent new ulcers from developing. Specifically, the facility could not provide evidence that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by the following: Review of the facility's policy Skin Monitoring Protocol, dated December 2021, revealed that all skin conditions will be assessed, documented and tracked on a weekly basis. Skin rounds will be done on all pressure areas and other designated wounds by the Nurse Manager (NM) and/or designee in a weekly basis. Wound care issues will be discussed with the Interdisciplinary team upon discovery and as needed thereafter. Resident #32 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], documented that Resident #32 was severely impaired cognitively, required extensive assistance with personal hygiene, toileting, dressing and bed mobility, had a functional limitation in range of motion to one of the lower extremities and had no pressure ulcers. Review of the resident's Comprehensive Care Plan and the Certified Nursing Assistant (CNA) Closet Care Plan (care plan used by the CNAs for daily care) did not include any interventions related to a knee immobilizer, to remove for care or any skin care interventions. In an observation on 11/16/22 at 1:15 p.m., Resident 332 was sitting in the common room of their unit with a dressing wrap to the right ankle. Review of the Hospital Discharge Instructions, dated 8/29/22, revealed that Resident #32 had a fracture of the right femur following a fall. Special instructions included to not remove the knee immobilizer. In a medical progress note, dated 8/31/22, Physician Assistant (PA) #1, documented that Resident #32's x-ray showed a fracture of the right leg with a knee immobilizer in place. A physical exam revealed the resident's skin was warm, dry and intact. Review of a Nursing Progress Note dated 8/31/22 at 9:55 a.m., revealed that Resident #32 had a Braden Score (a skin assessment used to identify residents at risk for pressure ulcers) of 16 (indicates a low risk for pressure ulcers and to use interventions to prevent issues). In a medical progress note, dated 9/12/22, the Orthopedic Nurse Practitioner (NP), documented that Resident #32 sustained a fracture of the femur, which was being treated conservatively (no surgery). The Orthopedic NP documented that the resident had a right knee immobilizer in place and recommendations included meticulous skin care with instructions to remove the knee immobilizer for assessment of skin and hygiene. In a medical progress note, dated 9/13/22, PA #1 documented that Resident #32 was seen for redness to both knees per staff. Documentation included that there was no skin breakdown, or signs of infection, and that the redness was most likely due to pressure. The plan of care included the use of the knee immobilizer, keep pain controlled, monitor the skin and to follow up with Orthopedics. Review of a telephone medical order (found in the resident's paper chart versus the Electronic Medical Record or EMR), dated 9/14/22, from PA #1 revealed orders to remove the knee immobilizer for care as needed (PRN). The order was signed by Registered Nurse (RN) #1 with three nursing checks listed (indicated two additional nurses verified the order). Review of nursing Skin Only Evaluations in Resident #32's EMR revealed the following: a. On 9/27/22 the unsigned note included the resident had no skin issues. b. On 10/13/22 the 'Skin Only Evaluation' documented the resident had a dried scabbed area on the back of their right heel and was being treated with a daily skin prep (a liquid bandage to prevent skin breakdown) and the area cushioned with an ABD pad (a thick gauze pad). c. On 10/20/22 'Skin Only Evaluation' documented a scabbed area on the right lower leg and foot and the area was treated with skin prep and padded around the lower section of the knee immobilizer. d. On 10/25/22 'Skin Only Evaluation' documented no new or current skin issues. e. On 11/2/22 'Skin Only Evaluation' documented an unstageable pressure ulcer to the back of the resident's right ankle. Review of subsequent telephone medical orders (found in Resident #32's paper chart) revealed the following: a. On 10/28/22 orders to discontinue the knee immobilizer. b. On 11/10/22, orders for [MEDICATION(S)] (wound covering) and a gauze wrap daily (to right lower leg). c. On 11/14/22 orders for Colactive (wound dressing) to the resident's right leg wound, with [MEDICATION(S)] and kling over the wound daily and PRN. The orders were all signed by nursing indicating the orders were received and signed off. Review of all provider orders placed in the EMR revealed no evidence that orders were entered for a knee immobilizer to be removed for cares or for the knee immobilizer to be discontinued. Review of a Health Status Note in the EMR, dated 11/1/22 at 1:08 p.m., revealed that Resident #32's knee immobilizer was removed from the right lower extremity (four days after the order to remove it) and no pain or discomfort noted. The note did not include any skin assessment. Review of the Treatment Administration Record (TAR) in Resident #32's Electronic Medical Record (EMR) for September 2022 and October 2022, revealed no documented evidence that the knee immobilizer was removed for cares (and skin checks done) as ordered. During an interview on 11/16/22 at 1:23 p.m., and again at 4:01 p.m., Licensed Practical Nurse (LPN) #1 stated that they believed Resident #32's wound was from pressure from the leg brace. LPN #1 stated that written orders in the residents' paper chart should have been entered into the EMR and include a knee immobilizer, if it should be removed and orders for skin monitoring. During an interview on 11/16/22 at 3:43 p.m., CNA #1 stated that they would normally find the information about a leg brace on the closet care plan including what staff should do with it (i.e., when to put on and take off). CNA #1 stated that they recalled Resident #32's immobilizer to the right leg at the end of August 2022 which was taken off within the past couple of weeks. CNA #1 stated that the knee immobilizer was supposed to be on all the time. CNA #1 stated they would loosen the Velcro on the immobilizer to check for pressure, but they did not take the take the immobilizer off completely. Upon review of previous Closet Care Plans for Resident #32 with the surveyor, CNA #1 stated that the Closet Care Plan dated 9/20/22, did not included any mention of the resident's knee immobilizer or removal of for cares. During an interview on 11/17/22 at 8:42 a.m., LPN #2 stated that the knee immobilizer was on all the time and was not removed until an order to remove it was obtained. LPN #2 stated that Resident #32's wound was on the ankle, where the immobilizer ended and that ABD pads were placed at the bottom of the immobilizer so that it did not rub against the skin, but when the resident moved the ABD pads would fall out. Once the sore started developing, the knee immobilizer was discontinued. LPN #2 stated they could not recall if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 explained that paper orders (telephone orders) should be transcribed into the EMR and that all orders require three nurses to review and check them. During observation of wound care on 11/17/22 at 9:05 a.m., Resident #32 had an open pressure ulcer approximately three centimeters (cm) long by 0.5 cm wide on the right lower extremity by the ankle. During an interview on 11/17/22 at 10:41 a.m., RN # 1 stated that the immobilizer rubbing caused the redness to Resident #32's skin so ABD pads were used to relieve it and that the PA was aware of this. RN #1 stated that there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/17/22 at 11:21 a.m., PA #1 stated that it is an expectation that written orders be transcribed into the EMR by the nurses. PA #1 stated that Resident #32's wound to the right ankle was due to the immobilizer and explained that due to Resident #32's dementia, the resident would move and try to take the immobilizer off. PA #1 could not recall when they were first notified of the skin issue but did recall looking at an unopened area of skin irritation, which was from the immobilizer due to rubbing. PA #1 stated they perform skin evaluations when there is a skin issue on a case-by-case basis. PA #1 stated that in hindsight, they may have used a foam wrap to prevent the skin breakdown but that they did not have access to it and was not sure if it was something that could have been ordered. During an interview on 11/17/22 at 1:45 p.m., LPN #3 stated that the facility began using the EMR on 9/1/22 and any paper orders after 9/1/22 should have been transcribed into the computer by the nurses. LPN #3 stated that there had been no orders entered into the EMR pertaining to Resident #32's knee immobilizer and if there had been it would have shown on the TAR with a required sign-off (for completion). During an interview on 11/17/22 at 3:21 p.m., LPN #4 stated that weekly skin evaluations are performed on the resident's shower days, which consists of the LPN looking at the resident's entire body for possible skin issues. LPN #4 stated they saw Resident #32 on 9/27/22 and 10/13/22 when skin evaluations were documented but could not recall if the immobilizer was removed during evaluation and could not recall if there were any issues with the immobilizer rubbing against the resident's skin. During an interview on 11/18/22 at 8:43 a.m., the Director of Nursing (DON) stated that expectation for care of a resident with an immobilizer would consist of staff checking the extremity's circulation and skin. The DON explained that nursing staff should know what care should be provided for a resident with an immobilizer or brace by reviewing the closet care plans, the CCP, and physician orders. The DON stated that they would expect an immobilizer to be on a care plan or closet care plan, but since it takes time to update them, they would expect staff to communicate care and review the resident's chart. The DON said that Nursing would be responsible for putting the immobilizer on the CCP and the closet care plan. The DON stated that all written provider orders should be transcribed into the computer by a unit clerk or a nurse and that each order required a three-nurse check, which consists of each nurse reviewing the written order, and reviewing the computer to make sure the order was entered. The DON explained that expectation for nurses performing skin evaluations is that the nurses perform the evaluations and review the orders to determine if an immobilizer can be removed or not. 10NYCRR 415.12(c)(1)

Based on observations, interviews and record review conducted during a Recertification Survey completed on 11/18/22, it was determined that for one (Resident #32) of three residents reviewed for pressure ulcers, the facility did not revise the resident's care plan to reflect the resident's current needs. Specifically, Resident #32's Comprehensive Care Plan (CCP) and Certified Nursing Assistant (CNA) Closet Care Card were not revised to include the use of a knee immobilizer, interventions for pressure ulcer prevention, or current interventions for an actual pressure ulcer. This is evidenced by the following: The facility policy Nursing Care Plan/Profile, dated reviewed December 2021 documented that an individualized Nursing Care Plan/profile shall be created for each resident, and they are reviewed and/or revised whenever the resident's condition warrants or at least every 90 days. The Nursing Care Plan is consistent with the medical plan of care and the multidisciplinary plan of care and reflects the facilities standard of care. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], documented that Resident #32 was severely impaired cognitively, required extensive assistance with personal hygiene, toilet use, dressing and bed mobility, had a functional limitation in range of motion to one of the lower extremities and had no pressure ulcers. In an observation on 11/16/22 at 1:15 p.m., Resident 332 was sitting in the common room of their unit with a dressing wrap to the right ankle. Review of the Hospital Discharge Instructions, dated 8/29/22, revealed that Resident #32 had a fracture of the right femur following a fall. Special instructions included to not remove the knee immobilizer. Review of a telephone medical orders in Resident #32's paper chart dated 9/14/22 revealed orders to remove the knee immobilizer for cares as needed and on 10/28/22 to discontinue the knee immobilizer. Review of medical orders in Resident #32's Electronic Medical Record (EMR) between 9/1/22 and 11/17/22 included the following: a. On 9/1/22 booties on feet when in bed, every shift. b. On 11/10/22 wound care to right lower extremity (RLE)(new onset pressure ulcer)-cleanse with Normal Saline (NS), cover with [MEDICATION(S)] (wound cover) and wrap with kling daily and as needed (PRN) until healed. c. On 11/14/22 wound care to RLE- cleanse wound with NS, apply Colactive (collagen dressing for wound healing) and cover with [MEDICATION(S)], wrap with kling daily and PRN. Review of 'Skin Only Evaluations' from 9/13/22 to 11/15/22, documented a skin integrity concern on 10/13/22 and 10/20/22, which consisted of a scabbed area to the back of the right heel, which was being treated daily with skin prep and cushioned with ABD pads around the knee immobilizer and then on 11/1/22 an unstageable pressure ulcer was identified. Review of the CCP, including all revisions, revealed that Resident #32 had limited physical mobility, with a goal to remain free from complications including but not limited to skin breakdown. The CCP did not include that the resident had had a knee immobilizer following the return from the hospital, interventions related to the care of a knee immobilizer or interventions to prevent skin breakdown. On 11/1/22 the nutrition care plan included a new pressure ulcer but did not include any person-specific interventions related to care and treatments for the pressure ulcer. Review of Resident #32's Closet Care Plan (care plan used by the CNAs for daily care), dated 9/20/22, did not include the presence of a knee immobilizer (or care of) or that the resident now had a pressure injury to the right ankle and any interventions required. Review of the Treatment Administration Record (TAR) in Resident #32's Electronic Medical Record (EMR) for September 2022 and October 2022, revealed no documented evidence that the resident had a knee immobilizer that needed to be released for cares and required consistent skin checks to monitor for any issues. During an interview on 11/16/22 at 1:23 p.m., Licensed Practical Nurse (LPN) #1 stated that Resident #32's wound was believed to be from pressure from the leg brace and care of it should be documented on the TAR. During an interview on 11/16/22 at 3:43 p.m., CNA #1 stated that they would be notified of a resident having a brace by finding the information on the Closet Care Plan or by being told by a nurse. CNA #1 stated that the information would include what staff could do with it like when to take it off for cares. Upon review of previous and the present Closet Care Plans for Resident #32 with the surveyor, CNA #1 stated that the Closet Care Plan dated 9/20/22 (prior to the order to remove their knee immobilizer for care), did not included any mention of the resident's knee immobilizer or removal of it for cares and skin checks. CNA#1 said that the knee immobilizer should have been included. During an interview on 11/17/22 at 8:42 a.m., LPN #2 stated that stated that the CNAs use the closet care plans, which are taped in each resident's closet, to guide how they will provide care. LPN #2 stated that they should be updated at least every few months or if there are changes. During an interview on 11/17/22 at 10:41 a.m., Registered Nurse Manager (RNM) stated that nursing staff would get instructions for immobilizer or brace care from the TAR or the closet care plans. During an interview on 11/18/22 at 8:43 a.m., the Director of Nursing (DON) stated that information related to the knee immobilizer should be on the CCP, medical orders or the Closet Care Plan. The DON stated that since the Closet Care Plans and CCPs take time to update, staff should be communicating and looking in the resident's chart and that nursing staff is responsible for putting the information in both care plans. 10NYCRR 415.11(c)(2)(iii)

Based on observations, interviews and record review conducted during a Recertification Survey, completed on 6/18/21, it was determined for one (Resident #85) of four residents reviewed, that the facility did not ensure the resident's environment was free from accident hazards and that the resident received adequate supervision to prevent accidents. Specifically, the resident ingested hazardous substances on two occasions and the incidents were not investigated or interventions initiated to prevent re-occurrences. This is evidenced by the following: Resident #85 had diagnoses including [CONDITION(S)], a history of alcoholism, restlessness and agitation. The Minimum Data Set Assessment, dated 5/18/21, revealed the resident was severely impaired cognitively, had behavioral symptoms such as pacing, rummaging, making vocal sounds such as screaming, and physical behaviors directed towards others such as hitting, kicking and pushing. The behaviors were coded as happening from daily to three days per week. The current Comprehensive Care Plan and Certified Nursing Assistant (CNA) Closet Care Plan , for behaviors included problems such as wandering into other resident's rooms, verbal and physical aggression towards staff, tinkers with items by taking them apart, disrobing in public, urinating in places other than the toilet and can become agitated when redirected. Interventions included for staff to identify immediate cause of behavior, assess for underlying needs such as offering food and toileting, redress as able, take to a quieter setting, offer activities of choice and provide a wander monitoring system. In an interview on 6/14/21 at 2:06 p.m., a family member said the facility notified them on two separate occasions that Resident #85 drank a half bottle of hand soap and some hand sanitizer and that Poison Control was notified. Review of nursing progress notes dated 12/31/20 to 6/17/21 revealed the following: a. On 3/7/21, staff found Resident #85 with their hands and mouth covered in foam hand sanitizer. Staff immediately cleaned the resident's mouth, assessed for irritation and notified Poison Control who instructed to give the resident a sugary drink and monitor for nausea, vomiting and [CONDITION(S)] to the mouth. b. On 4/11/21, a staff member found Resident #85 drinking body wash/shampoo and had consumed one-half or four ounces of the bottle. Poison Control was notified and instructed to observe for nausea and vomiting. In an observation on 6/14/21 at 2:23 p.m., Resident #85 was sitting in their wheelchair next to a medication cart. The resident was busy trying to open a sharps container (used to store medical waste including needles and syringes) attached to the end of the cart and had gotten the plastic top off. There were two CNA's sitting in eyesight of the resident but did not intervene until promted by the surveyor. In an interview on 6/17/21 at 2:20 p.m., again at 3:15 p.m., the Registered Nurse Manager (RNM) said she was only aware of the 4/11/21 incident. She said there were no incident reports written for either event and that there should have been. The RNM said the nurses should have reviewed the behavioral care plan at that time and added more interventions to ensure resident safety. In an interview on 6/18/21 at 10:17 a.m., the Director of Nursing said she expected staff to initiate an incident report and revise the care plan at the time of these events. [10NYCRR 415.12(h)(1)]

Based on observations, interviews and record review conducted during a Recertification Survey, completed on 6/18/21, for one (Resident #29) of two residents reviewed, the facility did not ensure the resident received the appropriate treatment and services to attain or maintain their highest practical physical, mental and psychosocial well-being. Specifically, the facility did not develop a comprehensive person-centered care plan with measurable goals and interventions to address the care and services for the resident related to their dementia and behaviors. This is evidenced by the following: The facility policy, A Policy and Procedure for Dementia Care, dated January 2021 documented that the facility will provide residents with the necessary care and services according to the plan of care. Resident #29 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 6/16/21, documented the resident had severe impairment of cognitive function and had behaviors such as hitting and kicking. Current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Comprehensive Care Plan prior to survey under dementia care, listed approaches for cognitive loss to reorient as needed using calendars and television. Under activities the CCP included approaches to participate in activities of interest, provide individual visit with 1:1 activity, and spend time enjoying leisure interests. The current CNA Mini Door Plan includes under behaviors non applicable. The Psychiatry Consultation note, dated 6/15/21, documented that Resident #29 continued to be very agitated, anxious, and paranoid but seemed to be tolerating the medicines without any problems. Review of nursing progress notes from 5/1/21 through 6/12/21 revealed multiple incidents of resident to resident altercations, verbal and physical altercations towards other residents and staff (some resulting in injuries) and requiring medication changes, the addition of [MEDICATION(S)] (another antipsychotic medication ) and the need for two staff members for care. Observations of Resident #29 on 6/15/21 at 2:08 p.m., and again on 6/16/21 at 8:56 a.m., the resident was sleeping in their bed or chair. During an interview on 6/16/21 at 3:08 p.m., the Certified Nursing Assistant (CNA) stated the non-pharmacological approaches used when the resident is agitated is to offer food and talking about truck driving. The CNA stated Resident #29 does not enjoy watching TV most times. During an interview on 6/16/21 at 3:17 p.m., the Licensed Practical Nurse (LPN) stated the resident does not go to activities because the resident would be too disruptive. The interventions that did work were approaching the resident calmly and offering food or drink. The LPN said that tv does not decrease aggressive episodes. During an interview on 6/16/18 at 4:00 p.m., the Registered Nurse Manager stated the interventions are in the care plan and as far as she knows, the tv in the resident's room works as an intervention for aggression and Dementia care. She added that the care plan should be revised. [10NYCRR415.12]

Based on observations, interviews, and record reviews conducted during the Recertification Survey, completed on [DATE], it was determined that for three (Residents #2, #42, and #92) of five residents reviewed, the facility did not ensure that information regarding residents' wishes for advance directives was consistently and accurately documented. Specifically, Resident's #2 and Resident #92's wishes included Cardiopulmonary Resuscitation (CPR) but physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by the following: A facility policy, Do Not Resuscitate, dated [DATE], includes that to indicate a DNR order has been received, the DNR orders will be denoted by a black dot placed on the face sheet in the medical record, on the nameplate beside the resident's door, and on the resident's name band (wrist). A facility policy, CPR, dated [DATE], includes residents who wish to be a full code (receive CPR) will have a blue dot posted on the face sheet, on the nameplate outside the resident's room door, on the outside of the resident's medical record chart and on resident name band. 1.Resident #92 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident was cognitively intact. A nursing progress note, dated [DATE], revealed that Resident #92 did not have Medical Orders for Life Sustaining Treatments (MOLST), declined to make a MOLST at the time and wished to be a full code. Physician orders, dated [DATE], included that Resident #92's wishes were for full code. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #92 was a DNR code status. In an interview on [DATE] at 3:07 p.m., the Physician's Assistant (PA) said the resident did not have a MOLST in place and therefore would be treated as full code even if the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The PA said that is why there was a blue dot placed on the resident's medical record. In an interview on [DATE] at 9:53 a.m., a Unit Secretary said they are responsible to review and update physician standing orders, including code status, on a 30- or 60-day basis. The Unit Secretary said they print medical orders, the nurse reviews them and gives them to the physician to review and sign. The orders are then reviewed again by two nurses. The Unit Secretary said she was not sure who changed the code status for Resident #92 on the physician orders. In an interview on [DATE] at 11:26 a.m., with Resident #92 and their Social Worker, the resident stated they were unable to state for sure what they wanted their code status to be, stating that God would give them the signal when they were going to pass away. In an interview on [DATE] at 12:10 p.m., the Registered Nurse Clinical Care Coordinator said the nurses had missed the change in code status as there had not been any order written to change Resident #92's code status to DNR. In an interview on [DATE] at 10:33 a.m., the Physician said Resident #92's response indicated CPR wishes and there should never have been a discrepancy in the orders. The Physician said once the orders were signed, those are the orders. 2.Resident #42 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated [DATE], revealed the resident was cognitively intact. A review of Resident #42's current MOLST and Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] In an observation on [DATE] at 4:00 p.m., Resident #42 had a blue dot (indicating full code status) on their medical record. 3.Resident #2 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated [DATE], revealed the resident was cognitively intact. The resident's current MOLST, dated [DATE], included that the resident's wishes for advance directive was to receive CPR. A review of medical orders, dated [DATE], directed full code and orders dated [DATE] and [DATE] changed to DNR status. In an observation on [DATE] at 9:13 a.m., a blue dot had been placed on the resident's medical record. In an interview on [DATE] at 3:17 p.m., the Director of Nursing (DON) stated that the color of the dot on the medical record binder and the nameplate on room door should be the same. She said it was the responsibility of each unit secretary to change the colored dots as needed when orders changed and ultimately, it is the nurse's responsibility to ensure that the dot system for code status and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on [DATE] at 3:45 p.m., the Licensed Practical Nurse Clinical Documentation Coordinator said a colored dot system is used to identify code status and appropriate dots are placed by a unit secretary on the front of the chart, the door and on resident name wristband. In an interview on [DATE] at 3:50 p.m., the LPN stated that if a resident was found unresponsive she would look at the resident's chart for the dot on the front, ask another nurse who is familiar with the resident and call the supervisor. [10 NYCRR 415.3 (e)(1)(ii)]

Based on observations, interviews and record reviews conducted during a Recertification Survey, completed on 6/18/21, it was determined that for 2 (Residents #26 and #66) of 21 residents the facility did not ensure a person-centered care plan was developed and implemented that addressed the residents' medical, physical, mental and psychosocial needs. Specifically, Resident #26's Comprehensive Care Plan (CCP) was not implemented to ensure their safety related to resident to resident altercations, and Resident #66's CCP did not address or implement escalating behaviors and non-pharmacological interventions for staff to utilize. This was evidenced by: The facility policy Cognitive Loss/Dementia, dated January 2021, directs staff to develop a resident centered, individualized care plan, focused on quality of life in order to maintain each resident's dignity and confidentiality. Specific Standards of Care (SOC) will be followed on all residents and incorporated into the interdisciplinary care plan. Only individualized deviations from the SOC will be documented in the CCP and nurse aide care profile. 1.Resident # 26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 3/10/21, revealed the resident was cognitively intact. The current CCP included the resident spends most of their time in their bed or chair and is dependent on staff for position changes. The CNA care profile, dated 2/17/21, revealed the resident was non ambulatory and did not exhibit behaviors. Review of the nursing progress note, dated 5/24/21, revealed that Resident #26 was heard yelling and another resident was found in their room. The facility investigation, dated 5/24/21, included another resident entered Resident #26 room and grabbed their leg. Interventions initiated included 15-minute checks and a barrier stop sign was added to Resident #26's doorway. Observations conducted on 6/14/21 at 1:57 p.m., on 6/15/21 at 2:41 p.m. and on 6/16/21 at 11:40 a.m., Resident #26 was in their room, the door was open, and there was no barrier across the doorway. When interviewed on 6/14/21 at 1:57 p.m., Resident #26 stated that another resident came into their room and grabbed their legs, but that they do not want their door shut. The resident stated they put up a stop sign, but that does not seem to stop a resident who comes in frequently. When interviewed on 6/15/21 at 2:19 p.m., the CNA stated another resident wandered into Resident #26's room, grabbed their foot and hurt them and that there was a white stop sign door barrier across Resident #26's doorway, however the barrier does not always work. When interviewed on 6/16/21 at 1:41 p.m. the Director of Nursing (DON) stated that when a resident is involved in a resident to resident altercation it should be addressed on the CCP and include interventions to prevent reoccurrence. The DON stated it was her expectation that if a resident is a victim in an altercation it would be addressed on the CCP and changes implemented. 2.Resident #66 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 5/11/21, revealed the resident was severely impaired cognitively, wandered daily and exhibited verbal behaviors towards others several times a week. The current CCP included that Resident #66 had vascular dementia and cognitive impairment. Interventions included to reorient as able, ask simple questions, sight supervision and 15-minute checks. The CCP also included that the resident received an antipsychotic medication, had periods of restlessness, and was easily distracted. Interventions included to assess for symptoms of [CONDITION(S)] and depression. The CNA care profile, dated 2/17/21, included that Resident #66 wandered and that staff were to redirect the resident out of other resident's rooms. Neither the CNA care profile nor the CCP included that a door alarm was in place on Resident #66's room. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of psychiatry notes, dated 4/27/21 and 6/1/21, revealed Resident #66 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/1/21, staff had reported that the resident was disrobing but no physical or verbal aggression. Recommendations included to continue current medications. Review of facility incident investigations revealed the that Resident #66 was involved in resident to resident altercations on 4/3/21, 4/29/21 and 5/24/21, where it was determined Resident #66 was the aggressor. Interventions included a psychiatric review and 15-minute checks. During an observation on 6/14/21 at 11:07 a.m., an alarm sounded when surveyor walked into Resident #66's room. The resident was on the floor on their hands and knees and staff were immediately notified and assisted the resident who was not injured. In an observation on 6/15/21 at 1:49 p.m., the resident was ambulating independently in the hall and observed at the door of another resident's room. There was no alarm sounding at the time. In an observation on 6/16/21 at 10:55 a.m., resident was again ambulating independently in the hall, and again there was no alarm sounding from the resident's room to alert staff that the resident was in the hall. During an interview on 6/15/21 at 2:28 p.m., the CNA stated that the resident's dementia had increased significantly, that they were wandering more and was not always easily redirected. The CNA stated the resident had an alarm on their room door that should be on to signal staff when the resident was leaving their room. During an interview on 6/16/21 at 10:31 a.m. the Registered Nurse Clinical Coordinator stated the interdisciplinary team developed the care plan from the MDS Assessment. She said the MDS nurse should have addressed the use of [CONDITION(S)] medications and the interventions. [10 NYCRR 415.11(c)(1)]

Based on observations, interviews, and record reviews conducted during the COVID-19 Focused Infection Control Survey completed on 12/4/20, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of COVID-19, other communicable diseases and infections for 8 of 114 residents reviewed for COVID-19 infections. Specifically, the facility did not protect eight residents confirmed negative for COVID-19 (Residents #1, #3, #5, #7, #9, #11, #13, and #15) who were residing in the same room with residents who were confirmed by lab testing as positive COVID-19. This resulted in a pattern of Immediate Jeopardy to resident's health and safety. This is evidenced by the following: Review of the Center for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidelines, dated 4/2/20, included that long-term care facilities should separate residents who have COVID-19 from residents who do not, or have unknown status. The Executive Order 202.11, dated March 27, 2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The New York State Department of Health Dear Administrator Letter (DAL), dated April 29, 2020, documents the following: As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-19 positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful[[NAME]] separate out patients in individual facilities. The New York State Department of Health Health Advisory, COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20 and updated 7/10/20, provides If there are confirmed cases of COVID-19 in a NH [nursing home]. Cohort residents with COVID-19 with dedicated HCP [health care personnel] and other direct care providers. Minimize the number of HCP and other direct care providers entering rooms. The facility policy, 2019 Novel Coronavirus disease COVID-19, (a policy that is shared by the acute care hospital and the long-term care facility), dated 11/20/20, included that patients with confirmed COVID-19 and patients under suspicion should not be cohorted in the same room and should be avoided if at all possible. 1. Resident #2's lab test, dated 12/3/20, revealed that the resident was positive for COVID-19. Resident #1's lab test, dated 11/25/20, was negative for COVID-19. Review of the medical and nursing progress notes, dated 11/19/20 through 12/2/20, did not reveal documentation of any signs or symptoms of respiratory issues or fever. On 12/3/20 at 6:05 p.m., Residents #1 and #2 were observed in the same room. The privacy curtain was open between the residents, and neither resident was wearing a face mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, shields and masks. 2. Resident #4's lab test, dated 11/25/20, revealed that the resident was positive for COVID-19. A review of the medical and nursing progress notes for Resident #3, dated 3/31/20 through11/19/20, did not include documentation that the resident had signs or symptoms of respiratory issues beyond their baseline or a fever. A lab test, dated 11/25/20, revealed that the Resident #3 was negative for COVID-19. On 12/3/20 at 6:06 p.m., Residents #3 and #4 were observed in the same room. The privacy curtain was open between the residents, and neither resident was wearing a face mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, shields and masks. 3. Resident #6's lab test, dated 11/25/20, revealed that the resident was positive for COVID-19. A review of the medical and nursing progress notes for Resident #5, dated 11/20/20 through 12/3/20, included documentation that the resident did not have signs or symptoms of respiratory issues beyond their baseline or fever. A lab test, dated 11/25/20, revealed that the resident was negative for COVID-19. On 12/3/20 at 6:07 p.m., Residents #5 and #6 were observed in the same room. The privacy curtain was open between the residents, and neither resident was wearing a face mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, shields and masks. 4. Resident #8's lab test, dated 11/25/20, revealed that the resident was positive for COVID-19. A review of the medical and nursing progress notes for Resident #7, dated 11/20/20 through 12/3/20, revealed the resident had no signs or symptoms of respiratory issues beyond their baseline or a fever. A lab test, dated 11/25/20, revealed that the resident was negative for COVID-19. On 12/3/20 at 6:08 p.m., Residents #7 and #8 were observed in the same room. The privacy curtain was open, and neither resident was wearing a face mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, shields and masks. 5. Resident #10's lab test, dated 11/27/20, revealed Resident #10 was positive for COVID-19. A review of the medical and nursing progress notes for Resident #9, dated 11/21/20 through 12/3/20, revealed that Resident #9 had no signs or symptoms of respiratory issues. A lab test, dated 11/25/20, revealed that the resident was negative for COVID-19. On 12/3/20 at 6:09 p.m., Residents #9 and #10 were observed in the same room. The privacy curtain was open, and neither resident was wearing a face mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, shields and masks. 6. Resident #12's lab test, dated 11/25/20, revealed that the resident was positive for COVID-19. A review of the medical and nursing progress notes for Resident #11, dated 11/21/20 through 12/3/20, revealed the resident had no signs or symptoms of respiratory issues. A lab test, dated 11/25/20, revealed that the resident was negative for COVID-19. On 12/3/20 at 6:10 p.m., Residents #11 and #12 were observed in the same room. The privacy curtain was open, and neither resident was wearing a face mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, shields and masks. 7. Resident #14's lab test, dated 12/3/20, revealed that the resident was positive for COVID-19. Resident #13's lab test, dated 11/25/20, revealed that the resident was negative for COVID-19. A review of the medical and nursing progress notes, dated 11/22/20 through 12/3/20, revealed the resident had no signs or symptoms of respiratory issues beyond their baseline. On 12/3/20 at 6:11 p.m., Residents #13 and #14 were observed in the same room. The privacy curtain was open, and neither resident was wearing a face mask. Signage was posted on the room door that revealed the residents were on contact and droplet protection and required hand hygiene, gown, gloves, shields and masks. 8. Resident #16's lab test, dated 11/18/20, revealed that the resident was positive for COVID-19. Resident #15, who continued to share a room with Resident #16, had a lab test, dated 11/18/20 and again on 11/22/20, revealed that the resident was negative for COVID-19. A review of the medical and nursing progress notes, dated 11/20/20 through 12/3/20, revealed the Resident #15 had no signs or symptoms of respiratory issues. Another lab test, dated 11/25/20, revealed that Resident #15 was now positive for COVID-19. When interviewed on 12/3/20 at 4:45 p.m., the Director of Nursing (DON) stated that she had been cohorting residents that were COVID-19 positive and presumed positive (due to exposure) for COVID-19 since 3/26/20 when the facility had the first case of COVID-19. When asked why the facility did not separate the residents that were positive for COVID-19 from the residents who were negative for COVID-19, she said she understood from epidemiology that residents who are already roommates should stay roommates because the negative resident had already been exposed. In an interview on 12/3/20 at 5:00 p.m., the Medical Director stated that moving a COVID-19 negative resident who had resided with a COVID-19 positive resident puts other residents at risk because of the potential of the COVID-19 negative resident being a vector. He stated with COVID-19 having a four to five day window (incubation), he could not see moving the COVID-19 negative resident because they could be COVID-19 positive. In an interview on 12/3/20 at 6:20 p.m., the Nursing Supervisor stated the COVID-19 positive and negative residents are still together because they were roommates. In an interview on 12/3/20 at 8:15 p.m., the Administrator stated that he was not aware that residents who were exposed could not continue to reside together. The facility's allegation of compliance to remove the Immediate Jeopardy, dated 12/03/20, included the following: a. Facility will immediately rapid test and then separate COVID-19 negative residents from COVID-19 positive residents and quarantine them. b. Facility will modify their policy to reflect the change in cohorting procedure. c. Facility will provide education to all nursing staff and provide documentation to prove they understood the changes. The Immediate Jeopardy was removed on 12/4/20 based upon surveyor observations and record review: a. Rapid tests were completed for the involved residents (Residents #1, #3, #5, #7, #9, #11, and #13) and all tested positive except for Resident #7 who tested negative. b. Resident #7 was moved to another room and placed on quarantine on 12/3/20. c. The facility policy, Nursing Home Pandemic Emergency Plan was revised on 12/4/20 and includes, Upon obtaining a positive test in a double occupied room, the facility will immediately rapid test and then separate COVID negative residents from COVID positive and quarantine them for the recommended time. d. Staff were educated regarding the policy revisions related to cohorting. [10 NYCRR 415.19(a)(1-2),(b)(1); 10 NYCRR 400.2]

Based on observations, interviews, and record reviews conducted during the Abbreviated Survey (complaint #NY 358), it was determined that for 1 (Resident #1) of 1 resident reviewed for Cardiopulmonary Resuscitation (CPR), the facility did not ensure that the resident received CPR in accordance with the resident's wishes, and for 11 (Residents #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12) of 104 residents reviewed for advanced directives, the facility did not ensure the residents' advanced directive wishes were consistently documented correctly. This is evidenced by, but not limited to, the following: 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated [DATE], revealed that the resident had moderately impaired cognition. Review of the facility policy, CPR, dated as revised [DATE], revealed that in the event of circulatory and/or [MEDICAL CONDITION] of a resident CPR will be performed unless the resident has a Do Not Resuscitate (DNR) order. All residents who wish to be a full code (CPR) will have a blue dot posted on the face sheet, nameplate outside the resident's room, on the outside of the resident's chart, and on the resident's name band. The policy includes that all staff will be offered CPR annually, and all supervisors and charge nurses will be required to be current with their CPR certification. Review of the facility policy, Advanced Directives, dated as reviewed on February 2012, revealed that all residents have the right to execute the advanced directives concerning life sustaining treatment. The policy includes that the Social Work Department will document the Advanced Directives in the front of the resident's medical record. The policy did not include any other areas where a resident's advanced directive wishes were documented. The current physician orders, Comprehensive Care Plan, and the Resident Mini Door Care Plan (posted in all residents' closets) revealed that the resident wished for CPR in the event of circulatory or [MEDICAL CONDITION]. The facility investigation summary, dated [DATE] and signed by the Director of Nursing (DON), revealed that the resident was found on [DATE] at 7:05 a.m. by two Certified Nursing Assistants (CNAs) lying in bed and not looking right. The CNAs called for Licensed Practical Nurse (LPN) #1 who responded and found the resident cold to touch. LPN #1 was unable to get any vital signs. LPN #1 then called the Registered Nurse (RN) Supervisor from the attached hospital who was covering as a supervisor for the facility. LPN #1 did not start CPR. LPN #1 then checked the resident's chart which documented the resident was a full code (wishes for CPR). LPN #1 called the RN Supervisor back who then arrived and declared the resident deceased . The RN Supervisor stated they would not initiate CPR as the resident was cold and vital signs were absent. The summary included that the staff present, in their panic, did not note the resident's code status until after reviewing the resident's chart. The CPR policy was reviewed with LPN #1 and the RN Supervisor regarding initiation of CPR per the resident's wishes until medical arrives. Interviews conducted on [DATE] included the following: a. At 10:12 a.m., LPN #1 stated she was told by two CNAs that the resident was not breathing. LPN #1 said she then went into the resident's room and found the resident was not breathing, had no pulse, and was cold. LPN #1 said she left the room and called the covering RN Supervisor from the hospital. LPN #1 stated that she then checked the resident's chart and found that the resident was a full code, so she called the RN Supervisor back. She said the RN Supervisor immediately responded and pronounced the resident dead. LPN #1 said she knew that she was not allowed to pronounce a resident's death but did not know she was supposed to initiate CPR until the RN or medical arrived and pronounced the resident dead. She said when she called the RN Supervisor back and reported that the resident was a full code, the RN Supervisor did not tell her to begin CPR. b. At 12:28 p.m., the RN Supervisor stated that when LPN #1 first called her she told her she thought the resident was a DNR. She said LPN #1 then called her back and told her the resident was a full code. The RN Supervisor said she did tell LPN #1 to start CPR. She said she did not know that she should have told LPN #1 to start CPR. c. At 8:50 a.m., 9:32 a.m., and again at 1:55 p.m., the DON stated that according to the facility policy, a blue dot means full code (CPR) and a black dot means DNR. She said the dots are posted for every resident on the resident's chart binder, nameplate on their doors, on the Mini Door Care Plans in each resident's closet, and on a wristband if worn (though many residents do not wish to wear one). The DON said that all staff are trained in CPR, and they should all know that they are supposed to start CPR until medical or an RN pronounces a resident deceased . The DON said that an LPN cannot pronounce a death. She said LPN #1 should have initiated CPR but she panicked and did not. She said both CNAs should have initiated CPR, but they did not either. 2. On [DATE] at 9:30 a.m., observations conducted on three of three residential units revealed that every resident door had a black dot or a blue dot on the resident nameplate to identify their code status. The dots did not match the code status information on the nursing report sheet that was provided by the facility to the surveyor as evidenced by, but not limited to the following: a. A Unit: Resident #2 had a black dot on their nameplate which means DNR, but the report sheet documented the resident was a full code (CPR status). b. B Unit: Resident #7 had a black dot on their nameplate which means DNR, but both the report sheet and the mini door care plan documented the resident was a full code. c. C Unit: Resident #12 had a black dot on their nameplate which means DNR. The mini door care plan in the resident's closet documented the resident was a full code (CPR status). Interviews conducted on [DATE] included the following: a. At 11:40 a.m., LPN #2 stated that a resident's code status was located on the chart spine, resident's wristbands, nursing report sheets and mini door care plans. LPN #2 said she would check the door first then the mini door care plan to determine if she needed to start CPR. b. At 11:50 a.m., LPN #3 stated she would check the resident's chart to determine a resident's code status. She said if the chart was unavailable, she would then check the nursing report sheet. c. At 1:55 p.m., the DON said she asked the unit clerks to ensure all residents' code status was correct in all areas used but it does not appear that it was done. The DON said that when a resident's code status changes, the unit clerks are supposed to update it everywhere. She said the resident's code status was listed in too many places to keep accurate and needs to be changed. The DON said she was in the process of revising the facility policy and conducting mandatory in-services for all employees. (10 NYCRR 415.3(e)(2)(iii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 3 of 36 residents reviewed for care planning, the facility did not develop and/or implement a comprehensive person-centered care plan of each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment. Specifically, Resident #71 was not wearing booties per plan of care, Resident #74 did not have a care plan developed for an actual pressure ulcer, and Resident #62's care plan did not address specific behaviors and individualized nonpharmacological interventions. This is evidenced by the following: 1. Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/7/19, revealed the resident had severely impaired cognition and one unhealed Stage II pressure ulcer. The Skin Treatment Sheet revealed that the resident had a black area on the left side of the left foot that was first observed on 3/7/19. Physician orders, dated 3/20/19, and the current Resident Door Care Plan revealed the resident was to wear green booties at all times. The Treatment Administration Record (TARs) for (MONTH) 2019 revealed that nurses had signed that the resident was wearing the booties from the first to the ninth. During an observation on 4/7/19 at 2:21 p.m., the resident was in bed and was not wearing the green booties. On 4/9/19 at 10:19 a.m., 10:43 a.m., and 11:22 a.m., the resident was in bed without green booties. Interviews conducted on 4/9/19 included the following: a. At 11:45 a.m., the Licensed Practical Nurse (LPN) stated that she signed the TAR on 4/9/19 for the green booties. She stated that the signature means that the resident's green booties are in place. She said that the resident should be wearing the green booties. The LPN said it was the Certified Nursing Assistant's (CNA) responsibility to put the green booties on the resident. b. At 12:00 p.m., Registered Nurse (RN) #1 stated that the resident was supposed to have her green booties on at all times. c. At 12:20 p.m., CNA #1 said that she knew the resident was supposed to wear green booties. She said there were none available that day or the past weekend. CNA #1 stated that sometimes the booties get wet and are sent to the laundry and are not returned. 2. Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/10/19, revealed the resident had severely impaired cognition and an unhealed Stage II pressure area. The physician orders, dated 4/5/19, included to discontinue Zeroform (petroleum dressing) and to apply [MEDICATION NAME] (moisture barrier ointment) twice per day, morning and night, until resolved. A nursing progress note, dated 1/2/19, revealed that staff reported that the resident had an open area which was described as a superficial slit running down the crease in between the buttocks, with no depth, measuring 9.5 centimeters (cm) x .5 cm. The area was previously opened but had resolved on 12/26/18. The current Comprehensive Care Plan (CCP) and the Resident Mini Door Care Plan do not include the resident's open area. Interviews conducted on 4/11/19 included the following: a. At 9:25 a.m., RN #2 stated that the resident has an area in the natal cleft caused by the buttocks separating and pulling while seated. She said the area is a slit and it comes and goes and that it should be included in the care plan. b. At 10:13 a.m., the Director of Nursing stated that the area on the resident's natal cleft should be included in the CCP and the Resident Mini Door Care Plan due to the area being a unique ongoing issue. 3. Resident #62 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/26/19, revealed the resident had moderately impaired cognition, had no behaviors, delusions or hallucinations, and reported signs of depression such as feeling down, having little or no energy, and little interest in doing things. The current physician orders [REDACTED]. Review of the current CCP revealed that the resident does wander around the unit and has delusions of bugs crawling everywhere. Interventions include to redirect as needed. Review of the Resident Mini Door Care Plan, dated 12/13/18, revealed that the resident's only behavior was wandering and for staff to redirect when confused. Review of the interdisciplinary progress notes for the past three months revealed one behavior note. The MDS nurse documented on 3/6/19 that the resident stated she was offered poisoned trays for meals. Review of the most recent tele-psych progress notes, dated 2/15/19 and 3/19/19, revealed that the resident had improved on recent medications, as evidenced by a decrease in complaints of her food being poisoned and of pest infestations in her room. In an interview on 4/9/19 at 2:01 p.m., CNA #2 stated that the resident was confused at times but had no behaviors, delusions, or hallucinations. When asked if the resident complained of bed bugs, CNA #2 stated that the resident did voice seeing bugs coming out of places in her room but not often and that she just ignored the resident. When interviewed on 4/11/19 at 9:19 a.m. and again at 10:00 a.m., the RN Manager (RNM) stated that psychiatry recently increased the resident's ant-psychiatry medication because the resident was picking at herself but she did not think the resident did that anymore either. After review of the progress notes and the resident's current care plan, the RNM said that staff should be documenting behaviors. She also said the resident's care plan should be more specific and include a discussion of the resident's actual behaviors and interventions for staff to utilize. The RNM said that she thought she had discussed a gradual dose reduction with the physician but did not document it and did not include that information in the resident's care plan. (10 NYCRR 415.11(c))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #69) of three residents reviewed for position and mobility, the facility did not identify and provide care and services to address the resident's positioning needs that were in accordance with professional standards of practice based on the comprehensive assessment, person centered care plan, and resident's choice. Specifically, the resident was not provided with safe and comfortable positioning. This is evidenced by the following: Resident #69 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the facility policy, Fall Management, dated (MONTH) (YEAR), revealed all personnel will participate in the fall management program which includes, but is not limited to, assessing the resident for underlying medical conditions, such as balance, dizziness and [MEDICAL CONDITION], that predispose the resident to falls, and for residents who slide out of a chair have a seating assessment completed by Physical Therapy (PT) or Occupational Therapy (OT). The Comprehensive Care Plan (CCP), dated 12/8/17, revealed that the resident required extensive assistance with transfers due to spastic triplegia (paralysis of three limbs) and was at risk for falls. Interventions included that the resident did not remain in chairs and will slide herself out when placed in a chair. The resident spends most of the time in the lounge on the floor with frequent observations by staff. The resident has a low bed with a floor mat on the right side of the bed. The Closet Care Plan, dated 1/3/19, revealed that the resident had a history of [REDACTED]. The resident required constant cuing to sit up in the chair. A physician note, dated 4/5/19, revealed the resident was resting comfortably in a chair during the exam. Observations conducted on 4/7/19 included the following: a. At 11:21 a.m., the resident was in a reclining chair in the lounge area. The legs of the chair were elevated, and the resident was sitting with her back and bottom on the elevated foot rest with her legs crossed and her arms under her head. The nurse entered the room and asked the resident if she wanted to sit up, and the resident shook her head no. A tap bell was located on an overbed table but was not within the resident's reach. b. At 12:15 p.m., the resident was sitting in a chair in the hallway with an overbed table in front of her waiting for lunch. The resident slid from the chair, down to the cross bar of the table, with her face at table level. Another resident called for staff to assist the resident back to the chair. On 4/9/19 at 11:25 a.m., the resident was on the bare floor in front of a chair in the lounge area. The resident was lying in front of the chair with her legs crossed and her arms under her head, which was butting up against the wall. Certified Nursing Assistant (CNA) #1 entered the room and asked the resident if she wanted to get up, and the resident shook her head no. CNA #1 asked the resident if she wanted a pillow and provided one under the resident's head. When interviewed at that time, CNA #1 stated the resident was in the chair the last time she had checked. She said the resident is checked every 15 minutes. She stated the resident was care planned to scoot on to the floor. At 12:15 p.m., the resident was still on the floor sleeping. Interviews conducted on 4/9/19 included the following: a. At 11:36 a.m., the Registered Nurse Clinical Coordinator (RNCC) stated that the resident was care planned to be on the floor. She stated the resident will let you know if she wants to get off the floor. The RNCC stated therapy evaluated the resident for seating but she was unaware of positioning interventions that may have been tried. She stated the resident was more comfortable lying flat. The RNCC said that the resident's CCP did not include person centered approaches for the resident's seating comfort. b. At 1:15 p.m., the Physical Therapist stated therapy had not been asked to evaluate the resident for seating and/or positioning. She stated the resident tended to sit on the sacral area and slide out of the chair. She said therapy was not asked to evaluate the resident for that concern. On 4/10/19 and 4/11/19 between 10:00 a.m. and 1:30 p.m., the resident was in bed lying flat, legs crossed, and arms under her head. The resident shook her head yes when askied if she was comfortable lying down. Staff took the resident to the dining room for lunch on both days. When interviewed on 4/11/19 at 10:13 a.m., CNA #2 stated the resident was more at ease lying down. (10 NYCRR 415.12)

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that for two (Residents #14 and #99) of three residents reviewed for positioning and mobility, the facility did not ensure that a resident with limited Range of Motion received the appropriate treatment and services to prevent further decrease in Range of Motion. Specifically, both residents had contractures and were not receiving hand devices per the plan of care, and the Comprehensive Care Plan did not address the residents' status of Range of Motion and treatments. This is evidenced by the following: 1. Resident #14 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/21/19, revealed the resident was cognitively intact, did not reject care, required the extensive assistance of staff for Activities of Daily Living, and had functional limitations in Range of Motion (ROM) of both upper and lower extremities. An Occupational Therapy (OT) Discharge Assessment, dated 5/16/18, revealed that education was provided to the resident that included wearing bilateral upper extremity splints, maintain clean, dry hands, especially the palms, and short nails. Equipment needs included a palm guard for the left hand and a foam roll for the right hand. Nursing recommendations included that staff were to provide routine hand hygiene, ROM, donning and doffing of orthotics in accordance with a schedule, and to report any concerns with orthotics to the therapy staff. The Closet Care Plan, dated 11/13/18, included bilateral palm guards, often refused, washcloths to both hands to be applied in the morning and worn for as long as tolerated. Physician orders, dated 12/29/18, included bilateral palm guards on as tolerated and off for cares as needed. A physician order, dated 1/14/19, included to discontinue the palm guards due to the resident's refusal to wear them. Review of the (MONTH) (YEAR) and (MONTH) 2019 Treatment Administration Records (TAR) revealed that the palm guards were signed off as worn 42 out of 45 opportunities. The palm guards were documented as refused on 1/12/19, 1/13/19, and 1/14/19. A physician note, dated 3/13/19, revealed the resident had decreased ROM with severe contractures of both hands. During an observation on 4/7/19 at 1:21 p.m., the resident had her left and right hands tightly clenched. The resident stated that the staff occasionally placed washcloths in her hands. During an observation of care on 4/10/19 at 8:39 a.m., ROM was not provided. Certified Nursing Assistant (CNA) #1 asked the resident if she was going to wear the palm guards, and the resident stated she would but she did not have any. CNA #1 located two palm guards in the resident's dresser. At 9:02 a.m., CNA #1 told the resident that the nurse told her the palm guards had been discontinued and not to apply them until the devices were re-ordered. At that time, the resident stated she did not wear the palm guards because they did not fit. CNA #2 stated she had cared for the resident since March, and the resident had not worn palm guards during that time. CNA #2 stated that palm guards would be on the closet care plan if they were worn. When interviewed on 4/8/19 at 10:00 a.m., the resident stated the staff had offered the splints and washcloths for her hands in the past but not that morning. The resident said that she allowed staff to place washcloths in her hands; however, the last time washcloths or splints had been provided was in (MONTH) (YEAR). Interviews conducted on 4/9/19 included the following: a. At 9:47 a.m., the Licensed Practical Nurse (LPN) stated that the resident would wear palm guards for a while and then want them removed. The LPN stated when an entry on the TAR is initialed that means the treatment was completed. The LPN stated if a treatment was discontinued due to refusals, there should be documentation to support why it was discontinued. b. At 1:34 p.m., the Registered Nurse Clinical Coordinator (RNCC) stated she was responsible for initiating the Comprehensive Care Plan (CCP). She stated contractures should be addressed on the CCP and interventions would include ROM. The RNCC stated CNAs receive ROM training through their CNA training and should be providing ROM to all residents during cares. c. At 1:38 p.m., the Occupational Therapist Rehabilitation Supervisor stated that she expects ROM to be provided to residents during care. The Occupational Therapist stated contractures should be addressed on the CCP, and ROM would be included as part of the plan of care. The Occupational Therapist stated if a resident refuses devices or ROM, a referral should be sent to OT so that the resident can be re-evaluated. 2. Resident #99 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/30/19, revealed the resident's cognitive skills for daily decision making were severely impaired, the resident required extensive assistance of staff for personal hygiene and dressing, had no rejections of care, and had functional limitations in ROM of both upper and lower extremities. The Closet Care Plan, dated 3/6/19, included palm guards that were often declined. A physician note, dated 3/14/19, documented that the resident had hand contractures including a right wrist extension contracture and a left wrist flexion contracture. The CCP, dated 4/2/19, revealed that Activities of Daily Living would be provided per Physical Therapy (PT/OT recommendations and PT/OT evaluations and treatment as needed). During observations on 4/8/19 at 8:47 a.m., on 4/9/19 at 11:15 a.m., and on 4/11/19 at 10:01 a.m., the resident had contractures of both hands. The resident's fingers were clenched into the palms. The resident had a wrist drop on the right side. There were no splints or devices in place. Interviews conducted on 4/9/19 included the following: a. At 11:28 a.m., CNA #4 stated that the night shift completed the resident's care. CNA #4 stated that the Rehabilitation Aides perform ROM on the residents. b. At 1:38 p.m., the OT Rehabilitation Supervisor stated the resident had an OT evaluation in (MONTH) (YEAR) for a feeding assessment and was discharged from therapy on 1/18/19. The OT stated contractures should be addressed in the plan of care and staff should provide ROM. When interviewed on 4/10/19 at 2:41 p.m., the Director of Nursing stated residents are screened on admission for contractures. She said nursing should notify therapy if the resident has a decline in function. (10 NYCRR 415.12(e)(2)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #61) of two residents reviewed for accidents, the facility did not ensure that the resident was as free from accident hazards as possible. Specifically, the resident had a fall with injury. There was no incident report initiated and the resident fell again two days later. This is evidenced by the following: Resident #61 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/26/19, revealed that the resident had severely impaired cognition and required supervision (oversight encouragement or cueing) for transfers and ambulation. Review of the facility policy, Fall Management, dated as last reviewed on (MONTH) (YEAR), revealed that following a fall, a fall log, an incident report (assessing all risk factors), and care plan revisions should be done. The Resident Mini Door Care Plan (CP), dated 12/13/19 in place at the time of the fall, included that the resident was independent with a rolling walker. On 4/7/19, the care plan was changed to include one assist with transfers and toileting and two floor mats until better. The CP still included that ambulation was independent with a rolling walker. The revised care plan did not include 15-minute checks. Review of the interdisciplinary progress notes revealed the following: a. On 4/5/19 at 12:59 a.m., Registered Nurse (RN) #1 documented that at 12:35 a.m. the resident was walking in the hall, lost her balance, and fell to the floor hitting her head and sustaining a goose egg to her left forehead. RN#1 documented No for Fall Prevention Measures in Place. b. On 4/6/19 at 1:50 a.m., the Licensed Practical Nurse documented that the resident had a goose egg/bruise from the right temple to the right eye following a fall, and that the resident was weaker than normal with a positive flu culture. c. On 4/7/19 at 8:34 a.m., RN #2 documented that at 6:30 a.m., the resident was found on the floor by her bed, moaned when the right forehead hematoma was touched, and a bruise to the right thigh was noted. Fall mats were placed on both sides of bed at that time and 15-minute checks were to be done while the resident was ill. A 4/7/19 emergency room summary included the resident had contusions to the right forehead and right hip. During observations conducted on 4/7/19 at 2:08 p.m., on 4/8/19 at 1:39 p.m., and on 4/9/19 at 10:05 a.m., the resident was in bed, had a large very black/purple bruise to the right forehead, eye orbit and cheek (whole right side of face). The resident moaned when turned for care but otherwise did not respond to staff. The bed was in a low position and floor mats were on both sides of the bed. On one occasion the resident was attempting to get out of bed by throwing her legs off the side. Review of the 15-minute checks log for (MONTH) 2019 did not include any checks following the 4/5/19 fall. When interviewed on 4/9/19 at 8:41 a.m., the Certified Nursing Assistant (CNA) stated that prior to the fall on 4/5/19 the resident was independent, but since then she has been sick, fell again, and has not ambulated at all. In an interview on 4/10/19 at 9:55 a.m., the Director of Nursing stated that an incident report was not initiated following the 4/5/19 fall and it should have been. When interviewed on 4/11/19 at 10:07 a.m., the RN Manager stated that they do not use any alarms on the unit, but they do 15-minute checks. She said that an incident report should have been started and interventions put in place to prevent further falls. She said that the resident should have been on 15-minute checks. (10 NYCRR 415.12(h)(2))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #42) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime was free of unnecessary medications. The issues involved the lack of a clinical rationale for the continued use of an anti-anxiety medication and the lack of a gradual dose reduction attempt in the past year for an anti-depression medication. This is evidenced by the following: The facility policy, dated (MONTH) 2013, [MEDICAL CONDITION] Medication Use included attempted tapering of psychopharmacologic other than antipsychotics shall be considered to demonstrate whether the resident is benefiting from a medication or might benefit from a lower or less frequent dose. The resident's target symptoms returned or worsened after the most recent attempt at tapering the dose with the facility, and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or by exacerbating an underlying medical or psychiatric disorder. Resident #42 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident had moderately impaired cognition, no behaviors, scored a ,[DATE] for signs of depression which included feeling tired or having little energy and trouble concentrating on things such as reading the newspaper, and received an anti-anxiety and anti-depression medications. The current Comprehensive Care Plan (CCP) included that the resident was at risk for falls due to [MEDICAL CONDITION] medications and that a Gradual Dose Reduction (GDR) was recommended to manage depression and anxiety at the lowest dose possible. The CCP did not address the targeted behaviors or symptoms for the use of the medications. Review of the medical record revealed the following: a. On [DATE], the physician ordered to discontinue Klonopin (anti-anxiety/mood stabilizer medication). The resident remained on [MEDICATION NAME] 100 milligrams (mg) daily for depression. b. On [DATE], the Physician's Assistant (PA) ordered to resume the Klonopin at .25 mg every morning due to a failed GDR. There was no documentation as to why the GDR failed. c. Interdisciplinary progress notes, from [DATE] through [DATE], revealed no documented evidence of the failed GDR and no clinical rationale for the resumption of the Klonopin. d. In a progress note, dated [DATE], the PA documented that the resident had failed a Klonopin taper and a GDR was not recommended but did not include any behaviors or symptoms to explain the failure. e. Review of pharmacy recommendations revealed the last GDR for [MEDICATION NAME] was on [DATE]. Interviews conducted on [DATE] included the following: a. At 9:33 a.m. and 10:30 a.m., the Registered Nurse (RN) stated that there was no formal process to review medications but it was discussed as a team at morning report. The RN said that the resident was a hypochondriac. The RN said that someone told the resident he no longer received Klonopin (after three months), he demanded to have his Klonopin given back so he was restarted on it, and the PA documented that the taper failed. b. At 10:18 a.m., the Director of Nursing (DON) said that the consulting pharmacist writes recommendations which are sent to the physician for review. The DON said that the physician will agree or disagree with the recommendation. c. At 10:46 a.m., the Licensed Practical Nurse (LPN) said the resident attends activities, resident council, talks to staff, puts puzzles together, and that he likes to complain but in a nice way. The LPN said the resident always has aches and pains. The LPN said the resident was admitted when his wife needed more care in (YEAR) and after she died , he was sad. The LPN said the resident then started seeing another resident, she moved into his room, and then one day she died suddenly. She said he was sad but he did not become depressed. The LPN said at that point staff would not have tried to reduce the [MEDICATION NAME] but that was a while ago. The LPN said that when the physician discontinued the Klonopin, the resident had no changes in his behavior. She said when he realized he was not on it anymore, he hounded the physician until the Klonopin was reordered. d. At 12:30 p.m., the PA said she could not remember why she reordered the Klonopin but she may have had a conversation with the nurses and thought he had anxiety with multiple complaints and was attention seeking. The PA said she was not aware that the nurses had not documented any behaviors. She said there was a time when he was more withdrawn and having trouble attending activities. She said she should have documented her rationale. There were no symptoms of depression or behaviors documented in the medical record for the last year. (10 NYCRR 415.12(l)(1))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #253) of two residents reviewed for hospitalization , the facility did not ensure that residents were free of significant medication errors. Specifically, multiple medications were not administered as ordered in a timely manner following admission to the facility. This is evidenced by the following: Resident #253 was admitted to the facility on [DATE] at 11:30 a.m. with [DIAGNOSES REDACTED]. The Baseline Care Plan, dated 4/1/19, revealed the resident was alert and oriented. In an interview on 4/7/19 at 10:30 a.m., the resident stated that when she arrived from the hospital it took the facility several days to get her eye drops and inhalers in, and she was never given a reason why. Physician orders, dated 4/1/19, included [MEDICATION NAME] inhaler 2 puffs twice daily and [MEDICATION NAME] inhaler one puff daily for [MEDICAL CONDITION], [MEDICATION NAME] one drop to both eyes twice daily, Latanoprost one drop to both eyes every evening, and Combigen one drop to both eyes twice daily for [MEDICAL CONDITION]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED] a. On 4/1/19, all three eye drops were signed off as administered on the evening shift. The [MEDICATION NAME] inhaler was not signed off as given. b. On 4/2/19, the [MEDICATION NAME] eye drop was not signed off as given on the day shift. c. On 4/2/19, the [MEDICATION NAME] eye drops and the [MEDICATION NAME] inhaler were not signed off as given on the evening shift. d. On 4/3/19, the Combigen eye drops were not signed off as given on the day shift. e. On 4/3/19, the [MEDICATION NAME] inhaler was not signed off as given on the evening shift. Interviews conducted on 4/10/19 included the following: a. At 1:12 p.m. the pharmacy representative stated that they did not deliver the eye drops or the inhalers to the facitlity until the morning of 4/2/19. He said the pharmacy delivered everything except the Combigen eye drops as it was non-formulary. He said that would need to be ordered from Kinney Drugs. b. At 1:58 p.m. and again on 4/11/19 at 10:10 a.m., the Registered Nurse Manager (RNM) stated that Kinney delivers medications in the evening at approximately 6:00 p.m. and at midnight. She said the hospital pharmacy was only open during the day. The RNM said that staff are supposed to order the medications on the day of admission. She said depending on the resident's insurance, the medications will come from the hospital pharmacy or Kinney. She said that some of the medications are in stock but not the eye drops or inhalers. The RNM said that she called the evening nurse who worked on 4/1/19 and was told that she knew the resident did not have any of the eye drops or the inhalers, but she accidently signed them off because it was a new computer system. When asked if the nurse told anyone, the RNM stated no but she should have. In an interview on 4/11/19 at 1:20 p.m., the Kinney Drug pharmacy representative stated that they did not deliver the Combigen until the late shift on 4/3/19 (despite it being signed off on 4/1/19 evening and on 4/2/19 day and evening shifts). When asked if there were any medication error reports for the resident, the Director of Nursing stated there was not. (10 NYCRR 415.12(m)(2))

Based on observations and interviews conducted during the Recertification Survey, it was determined that for three of three residents reviewed for food consistency, the facility did not ensure food was prepared in a form designed to meet each resident's needs. Specifically, the ground meat was not an appropriate consistency. This is evidenced by the following: During an observation on 4/7/19 at 11:35 a.m., the surveyor asked for a taste tray to include the ground roast beef. The ground beef was shredded and dry (not a ground consistency). When interviewed at that time, the cook said that she cooks the beef to 145 degrees Fahrenheit on Friday, slices it on Saturday, and then steams it on Sunday until it is tender. The cook said the ground roast beef was dry and that she would moisten it with broth. She said most of the residents would get gravy too. During an observation of the lunch meal on 4/7/19, residents that received the ground roast beef complained that they had trouble chewing and swallowing the meat. The residents left the harder pieces of meat on their plates. When interviewed on 4/10/19 at 12:00 p.m., the General Manager said she would look at a different product or different cooling process for the roast beef. She said that roast beef would be removed from the menu if the facility could not get a satisfactory product. (10 NYCRR 415.14(d)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute, and serve food under sanitary conditions. Specifically, there was a lack of monitoring of food temperatures for potentially hazardous foods, frozen packages were opened and undated, and the three-bay sink had improper sanitizer levels. This is evidenced by the following: 1. During a kitchen observation on 4/7/19 at 11:08 a.m., there were two turkeys (8 to 10 pounds each) cut in half in the cooler. When interviewed at that time, the morning cook said she took the turkey out of the oven at 10:40 a.m. and the temperature was 170 degrees (*) Fahrenheit (F). Review of the cooling logs revealed that the roast turkey had reached 70*F after a two hour period, but there was no temperature documented to show that it was in the safe zone within the designated timeframes. 2. In an observation on 4/7/19 at 11:30 a.m., there was one 5 pound bag of diced chicken and two 2 pound bags of mixed vegetables in the main freezer which were undated and unlabeled. When interviewed at that time, the Dietary Aide said that once a bag is opened it is supposed to be dated and labeled. 3. During an observation on 4/9/19 at 11:30 a.m., the sanitizer level was at 50 parts per million (ppm) in the three-bay sink (should be between 150 to 200 ppm.). When interviewed at that time, the Dietary Aide pointed to the picture on the wall which showed the recommended sanitizer level. She then proceeded to empty the water in the sink. When interviewed on 4/10/19 at 9:52 a.m., the General Manager said that the staff should have cut the turkeys into smaller pieces of meat. She said the staff should be documenting on the temperature logs. She said the proper cooling process is to cool the turkey from 140*F to 70*F in two hours, and then to 40*F within two additional hours. The General Manager said that she could not tell when reviewing the temperature logs if the turkey was cooled properly. She said that she could not determine what time the roast reached 70*F. She said the Cooling Log was not filled out correctly. She said that staff should be checking temperatures following the Hazard Analysis Critical Control Points policy. She said that she would review the cooling process with the cook. (10 NYCRR 415.14(h), sub-part14.1.40)

Based on observations and an interview conducted during the Recertification Survey, it was determined that the facility did not ensure that they were in compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the (YEAR) edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: Interviews with the Facilities Manager and Director of Facilities Engineering on 4/8/19 at 10:55 a.m. revealed they were not aware of any carbon monoxide detectors in the facility. Further observations revealed there were four sources of carbon monoxide including the diesel generator in the basement, the basement boilers, natural gas hot water heaters, and the main kitchen gas range located adjacent to the ground floor residential unit closest to Rooms #112 - #115. Observations at that time revealed no carbon monoxide detectors were present near the aforementioned areas containing fuel-burning appliances. The (YEAR) edition of the International Fire Code (IFC), requires carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance. (10 NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b))

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 657) completed on 5/29/18, it was determined that for one (Resident #1) of three residents reviewed for abuse, neglect and mistreatment, the facility did not ensure the residents were free from mistreatment and abuse. The issues involved allegations of physical abuse. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility policy, Preventing Resident Abuse, revised (MONTH) (YEAR), directed that the facility will not condone any form of resident abuse or neglect and will continually monitor facility policies, procedures, staff education and systems to assist in preventing abuse. The Administrator assumes the responsibility for the overall coordination and implementation of the facility Abuse Prevention Program policies and procedures. The Facility Report, dated 5/21/18, revealed that on 5/9/18, Certified Nursing Assistant (CNA) #1 hit the resident on the left thigh after the resident grabbed CNA #1's hair. CNA #2 reported the incident two days later on 5/11/18. Review of CNA #1's education revealed that abuse training was completed on 2/14/17. She was suspended on 5/11/18 and terminiated on 5/18/18. The resident's Temporary Care Plan, dated 3/2/18, revealed the resident had a history of [REDACTED]. Interventions included task segmentation with explanation of tasks and redirection to reduce resistance. If unable, to redirect the resident and behaviors continue, leave the resident alone and attempt care at a later time. When interviewed on 5/18/18 at 9:20 a.m., the Interim Director of Nursing stated that CNA #1 had a counseling history of complaints of roughness from other residents. She said CNA #1 admitted that she hit the resident on 5/9/18. Interviews conducted on 5/23/18 revealed the following: a. At 9:00 a.m., the Registered Nurse (RN) Supervisor stated that on 5/9/18, she worked from 5:00 p.m. through 10:30 p.m., and at no time during that period was she notified of behaviors or observations of physical abuse for any residents. The RN Supervisor stated that when residents are combative, the CNAs are expected to leave the resident safe, report the behaviors to the supervisor, and then the RN supervisor will talk with the resident. The RN Supervisor stated that the resident can be redirected if left alone until she calms down and can be reapproached. b. At 10:30 a.m., CNA #2 stated that on 5/9/18, around 8:30 p.m., she and CNA #1 went to the resident's room to put her to bed. CNA #2 stated that the resident needed to be woken up, and she thinks they startled the resident, and the resident became aggressive. CNA #2 stated that when the resident was being positioned in bed, she was screaming and pulled CNA #1's hair. In return, CNA #1 used foul language and punched the resident on her left thigh. CNA #2 said that the punch was on the resident's bare thigh and sounded pretty hard. CNA #2 said based on her training, she would consider that physical and mental abuse. c. At 11:15 a.m., CNA #1 stated that on 5/9/18, the resident was on her assignment. CNA #1 stated that the resident hits, pinches and does everything she can to get you not to do what you need to do. CNA #1 said staff are supposed to stay calm and work through it. CNA #1 stated that the resident was combative, upset and yelling, and pulled her hair. CNA #1 said her automatic reaction was to slap the resident on her left calf once. CNA #1 stated that she probably said something and slapped the resident with an open hand. CNA #1 said that she was frustrated with the resident because the resident was not working with them. CNA #1 stated that she should have stepped out of the room, called for someone else to help, or put the call light on when the resident started being combative. CNA #1 stated that because she physically touched someone that she should not have touched, she would consider that abuse. CNA #1 said she knows abuse is against the law. d. At 3:00 p.m. by telephone, the RN Unit Manager stated that she was not aware of the incident involving CNA #1 and was told about the incident the day after the state was notified. CNA #1's personnel record included the following warnings: a. On 3/25/17 for rough treatment of [REDACTED]. b. On 6/1/17, a resident and family complaint for rough treatment during cares and making statements that hurt the resident's feelings c. On 3/7/18, family and resident concerns about telling the residents they would have to wait when they requested something while she was doing other tasks like paperwork d. On 4/20/18, for sitting at the desk and not responding to a resident yelling for assistance. (10 NYCRR 415.4(b)(1)(i))

Based on interviews and record reviews conducted during an Abbreviated Survey (Complaint #NY 657) completed on 5/29/18, it was determined that for one (Resident #1) of three residents reviewed for abuse, neglect and mistreatment, there was delayed reporting of physical abuse and neglect of a resident observed by Certified Nursing Assistant (CNA) #2. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility policy, Reporting Abuse to Facility Management, revised (MONTH) (YEAR), directed prompt reporting of any incident or suspected incident of neglect or resident abuse to facility management. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing (DON) must be called at home or paged and informed of such incident. The policy defined physical abuse as hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. The Facility Report, dated 5/21/18, revealed that on 5/9/18, the resident was hit by CNA #1 during cares with no injuries seen on the resident when reported on 5/11/18. CNA #1 admitted that she hit the resident on the left thigh after the resident grabbed her hair. The facility schedule for 5/10/18 revealed that CNA #1 worked the evening shift on Resident #1's unit. Interviews conducted on 5/18/18 included the following: a. At 9:00 a.m., the Registered Nurse (RN) Supervisor stated that on 5/9/18, she worked from 5:00 p.m. through 10:30 p.m., and at no time during that period was she notified of behaviors or observations of physical abuse for any residents. b. At 9:20 a.m., the Interim DON stated that CNA #2 witnessed the incident on 5/9/18 and did not say anything until 5/11/18, two days after the incident due to fear of retaliation by CNA #1. c. At 10:10 a.m., the Administrator stated that the incident should have been reported immediately. She said there is concern all the time with CNAs reporting because of the threat of retaliation. d. At 10:30 a.m., CNA #2 stated that she reported the incident two days after it happened and it should have been reported immediately. CNA #2 said that she was afraid of losing her job and did not know what to do. CNA #2 stated she was not afraid of CNA #1 or the resident, but was afraid of what would happen to herself. When interviewed on 5/23/18 at 11:15 a.m., CNA #1 stated that because she physically touched someone that she should not have touched, she would consider that abuse. CNA #1 said she knows abuse is against the law. CNA #1 stated that she did not report the behaviors that night. She said the CNAs are expected to report resident behaviors. (10 NYCRR 415.4(b)(2))