Every finding on record at Leroy Village Green Residential Health C F, Inc

Based on interview and record review conducted during a survey, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of resident property for one (Resident #1) of three residents reviewed. Specifically, Resident #1's rings were reported missing. It was determined by local police that on 11/08/2025 at least one of Resident #1's rings were in Certified Nurse Aide #1's possession and a transaction had been made at a pawn shop. The findings include:The facility policy titled Abuse Policy Prevention and Management dated 09/08/2022, documented the facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation. Exploitation of residents /patient's property by anyone including staff, family, friends and visitors. The facility has designed and implemented processes which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment and or misappropriation/exploitation of property. The facility must provide a safe resident environment and protect residents from abuse.Resident #1 had diagnoses including dementia without mood disturbances, anxiety, and depression. The Minimum Data Set (a resident assessment tool) dated 03/24/2026 documented Resident #1 had severe cognitive impairment, was rarely understood, and rarely understands.The Care Plan Activity Report, dated 02/04/2024, documented Resident #1 had a cognitive and communication deficit and was mainly non-verbal.The Progress note written by Registered Nurse Supervisor # 1dated 11/08/2025 documented they were notified that Resident #1 was missing two (2) rings. This writer called the resident's Family Member #1 to inquire if they had taken them home. The resident's room was searched. Resident #1 had a shower yesterday and shower room and shower chair were checked. Family Member #1 stated they would check with the family if anyone took them home. Family Member #1 stated Resident #1 had lost some weight and may have slipped off, but it was doubtful.The facility Complaint Summary completed by the Administrator dated 03/19/2026 documented on 11/08/2025 Family Member #1 reported Resident #1's wedding rings were missing. The facility did a full investigation and filed a police report with the local police department. After interviewing all staff and searching the building the rings were never found. On 3/19/2026 the local police department came to the facility to notify them that one of the rings was found at a pawn shop. The person that pawned the ring was Certified Nurse Aide #1, who was an agency certified nurse aide who had been at the facility when the rings went missing.Review of an untitled unsigned document provided by the facility Administrator on 6/3/2026 at 11:15 AM documented I (Certified Nurse Aide #1) am writing this statement because I was informed by my agency that sometime between (11/7-11/8) while caring for a resident (Resident #1) or while working that unit/facility some rings have come up missing. I did work that unit a number of times since I've been there, I don't know exactly who the resident is. I have no recollection of any jewelry in any time frame from 8 PM Friday 11/7/2025 until 8 AM 11/8/2025.The Supplemental Report dated 03/25/2026, provided by Detective #1 documented on 03/16/2026 that Detective #1 went to local pawn shops to track down the missing rings. At one local pawn shop Detective #1 showed the manager a picture of the missing rings and Certified Nurse Aide #1. The manager of the pawn shop provided Detective #1 a transaction made on 11/08/2025 by Certified Nurse Aide #1. Additionally, the report documented the family of Resident #1 identified the ring as one of the rings that went missing.During an interview on 05/18/2026 at 8:44 AM, the Administrator stated they did not report the rings at the time they went missing to the New York State Department of Health because the facility did not know if the rings were just lost or if they were stolen. The Administrator stated according to the Manual (State Operations Manual- a set of regulatory guidelines issued by the Centers of Medicare and Medicaid Services) the facility did not have to report unless there was a suspicion of a crime. Law enforcement was notified, and a police report was filed. Staff were interviewed back in November, and family was notified. The family did not have possession of the two missing rings. When one of the rings was found and the facility was informed the rings were stolen, the facility reported the incident to the New York State Department of Health.Durning a telephone interview on 05/18/2026 at 2:21 PM, Family Member #1 stated they thought it was a possibility the rings could have fallen off Resident #1 hand because Resident #1 had a little weight loss recently but really didn't think they fell off. They were happy with how the facility conducted the investigation, stating a staff member realized the rings were missing and reported it. One ring was located; the other was still missing.During an interview on 05/18/2026 at 2:31 PM, Registered Nurse Supervisor #1 stated Restorative Aide #1 reported to them that Resident #1 had two (2) rings missing from their finger and that Resident #1 had them yesterday when they provided range of motion. Registered Nurse Supervisor #1 stated they completed an Accident and Incident Report and searched the resident's room and reported the rings missing to administration.During a telephone interview on 05/19/2026 at 9:05 AM, Detective #1 stated one of the rings was found at a pawn shop and returned to Resident #1's family. Additionally, they stated Certified Nurse Aide #1 did not admit to stealing the rings, but the investigation was still ongoingDuring a telephone interview on 05/19/2026 at 3:00 PM, Restorative Aide #1 stated they reported the missing rings to Registered Nurse Supervisor #1 sometime in November but could not recall the exact date. They performed range of motion to Resident #1 hands routinely and that's how they knew the rings were missing. Restorative Aide #1 stated one (1) of the rings were a little loose but did not believe it was loose enough to slide of the resident's finger.During a telephone interview on 06/02/2026 at 2:12 PM, Certified Nurse Aide #1 stated they found the rings along with other jewelry in a box of free things for staff to take in the facility breakroom, took the ring to a pawn shop, and pawned the ring.During an interview on 06/03/2026 at 10:50 AM, the Administrator with the Director of Nursing present stated staff leave items in the breakroom for other staff to take for free, like books, clothing and uniforms. They were unaware if jewelry items were ever left. The facility does not leave items for staff to take.New York Code Rules and Regulations 415.4(b)(1)

Based on interview, observation, and record review conducted during a Standard survey completed on 5/20/2025, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, one (Resident #60) of four residents reviewed for infection control during incontinent care, had issues with inadequate hand hygiene and reusing washcloths to clean the resident. Additionally, the resident had a history of urinary tract infections and was on enhanced barrier precautions for a suprapubic (an indwelling tube that is through a small incision in the abdomen into the bladder) catheter. The finding is: The policy and procedure titled Hand Hygiene dated 6/2024 documented this facility considers hand hygiene the primary means to prevent the spread of infections. Practicing hand hygiene is a simple effective way to prevent infections. Hand hygiene is to be performed before and after contact with a resident's skin. The policy and procedure titled ADL (Activities of Daily Living) Care: Toileting, Bowel and Bladder Incontinent Care dated 3/2025 documented the facility will ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections. The policy and procedure titled Transmission Based Precautions dated 4/2025 documented enhanced barrier precautions are indicated for residents with any indwelling medical devices including suprapubic catheters. Resident #60 was admitted to the facility with diagnoses of neuromuscular dysfunction of the bladder (a problem between your brain or spinal cord that causes incontinence of the bladder), spastic hemiplegia of the left side (paralysis of the left side of the body), and urinary bladder infections. Review of the Minimum Data Set (a resident assessment tool) dated 2/15/2025 revealed Resident #60 is cognitively intact; understands others and is understood by others. They are dependent on two staff members for toileting hygiene and has an indwelling catheter (including supra catheter) as indicated. Review of Resident #60's comprehensive care plan dated 1/2025 revealed the resident is to receive foley catheter care every shift and as needed; is to have activities of daily living assist of two staff members with their lower body cleaning; and is on enhanced barrier precautions that needed gown and gloves for high contact care. Review of Physician Orders revealed the following orders for Resident #60: -11/29/2024 Nitrofurantoin monohydrate/ macrocrystals (an antibiotic) 1 capsule (100 milligrams) 2 times per day for 7 days for acute cystitis (a bladder infection). -12/13/2024 Cipro (an antibiotic) 1 tablet (500 milligrams) every 12 hours for 10 doses and Tetracycline (an antibiotic) 2 capsules (500 milligrams) 4 times per day for 20 doses for acute cystitis. -1/10/2025 Nitrofurantoin monohydrate/ macrocrystals 1 capsule (100 milligrams) 2 times per day for 4 days give for 4 more days related to UTI (urinary tract infection). -2/10/2025 Levaquin (an antibiotic) 1 tablet (500milligrams) once daily for chronic interstitial cystitis (a bladder pain syndrome). -3/25/2025 Cipro 1 tablet (500 milligrams) for acute cystitis. -3/27/2025 Bactrim DS (a combination antibiotic to treat urinary tract infections) (800 milligram-160 milligram) 1 tablet 2 times per day for 3 days for acute cystitis. -3/31/2025 Bactrim DS (800 milligram-160 milligram) 1 tablet every 12 hours for 4 days for acute cystitis. -5/17/2025 Sulfamethoxazole 400 milligrams-trimethoprim 80 milligram tablet (generic for Bactrim DS) 1 tablet 2 times per day for 4 days for acute cystitis. During on observation on 5/19/2025 at 10:00 AM outside Resident #60's room was signage for enhanced barrier precautions. At 10:02 AM, catheter and incontinent care was performed on Resident #60. During this observation, Certified Nurse Aide #1 donned (put on) a gown and gloves and proceeded to wash, rinse, and dry the front perineal area of Resident #60. Washcloths were then placed on the barrier on the resident's bed. Resident #60 was then placed on their side, Certified Nurse Aide #1 then took the same used washcloths from the barrier and cleaned, rinsed, and dried the resident's back perineal area. The washcloth used to wash the back perineal area had a scant amount of brown debris. Without removing their gloves or washing their hands, Certified Nurse Aide #1 then applied barrier cream (cream to prevent skin breakdown) to Resident #60's buttocks and replaced the brief. Certified Nurse Aide #1 then removed their gloves and washed hands before they dressed Resident #60. During an interview on 5/19/2025 at 10:15 AM Certified Nurse Aide #1 stated they should have washed their hands and changed their gloves between cleaning the resident and putting on barrier cream as this could cause cross contamination. They stated they always re-use used washcloths when performing perineal care on a resident. During an interview on 5/19/2025 at 10:17 AM Licensed Practical Nurse #1 Unit Manager stated Certified Nurse Aide #1 should have washed their hands and changed their gloves between cleaning the resident and before putting on the barrier cream. They stated that Certified Nurse Aide #1 should have used clean washcloths to clean the resident to prevent any kind of cross contamination. During an interview on 5/19/2025 at 10:24 AM Registered Nurse #1 Infection Preventionist and Nurse Educator stated they expect their staff to change gloves and wash hands anytime they perform incontinent care when there is any chance of cross contamination. They stated Certified Nurse Aide #1 should have used clean linens to clean Resident #60. They stated that Certified Nurse Aide #1 should have changed gloves and washed hands after performing perineal care and before they applied barrier cream. They stated Certified Nurse Aide #1 had infection control training and has been audited for hand hygiene. During an interview on 5/20/2025 at 10:02 AM the Director of Nursing stated they expect their staff to change gloves and wash hands when performing catheter or incontinent care on a resident. They stated that it is to prevent cross contamination for residents. They stated staff are trained in proper hand hygiene and infection control at least annually. 10NYCRR 415.19(b)(4)

Based on interview and record review conducted during a complaint investigation (Complaint # NY00319793) completed on 8/8/23 the facility did not ensure completion of the discharge summary that included a recapitulation of the residents stay, a final summary and a post (after) discharge plan of care for three (Resident #1, #2 and #3) of three residents reviewed. Specifically, the residents were discharged without a recapitulation of their stay, a final summary of their status and a post discharge plan of care. The findings are: The policy and procedure titled Discharge Transition Packet Instructions revised on 6/23 documented the facility will complete discharge transition instructions when the resident is anticipating discharge to a private residence, or personal care/assisted living. The instructions will assist the resident to adjust to returning to their previous living environment safely or to a new living environment in a safe manner. The process is managed by Social Services. They will open the Discharge Transition Packet UDA (User Defined Assessment) and monitor it for completion. Once the UDA is completed it should be printed and given to the resident. The last page must be signed by the Discharging Nurse and the Resident/Representative. A copy of this page must be made and placed on the chart. This page should be scanned and placed under the Miscellaneous tab in the resident's electronic health record. 1. Resident #1 had diagnoses including epilepsy (a neurological disorder that causes seizures), aphasia, (absence or difficulty with speech) and encephalopathy (disease of both brain and spinal cord). The Minimum Data Set (MDS, a resident assessment tool) dated 6/21/23 documented Resident #1 was severely cognitively impaired. The MDS documented the resident had an active plan to return to the community and was discharged on [DATE]. The Discharge History and Physical dated 6/24/23 completed by Physician (#7) documented that Resident #1 was stable and suitable to be discharged home. The resident should have a follow up appointment with their primary care physician. The Social Work Progress Notes dated 6/16/23 at 12:36 PM documented Resident #1 had plans to return home. Resident #1 lived with three family members and was open to home health care. Review of the electronic medical record (EMR) Miscellaneous tab revealed there was no document evidence that a discharge summary including a recapitulation of Residents #1 stay at the facility, a final summary of their status and a post plan of care was completed. The unsigned Discharge Instructions dated 6/24/23 provided to Resident #1 per Registered Nurse (RN) Unit Manager (UM) #3 documented the residents name, date of birth, discharge date , activity level (as tolerated), an appointment that was made and confirmed for a primary care physician, a referral made for nursing and therapy at home with a home health care agency, diet as per speech therapy recommendations, and that paper prescriptions were given for all of the medications resident was on at the facility. 2. Resident #2 had diagnoses including unspecified fracture of left femur (long bone of leg), urinary tract infection (UTI) and hemiplegia (paralysis on one side of body). The MDS dated [DATE] documented Resident #2 was cognitively intact and had an active plan to return to the community. Resident #2 was discharged on [DATE]. The Discharge History and Physical dated 6/22/23 completed by Physician #7 documented that Resident #2 was suitable for discharged to home. The Social Work Progress Notes dated 6/23/23 at 8:47 AM documented that Resident #2 will be discharged with a summary and a referral to home health care. Review of the electronic medical record (EMR) Miscellaneous tab revealed there was no document evidence that a discharge summary including a recapitulation of Residents #2 stay at the facility, a final summary of their status and a post plan of care was competed. The unsigned Discharge Instructions dated 6/24/23 provided to Resident #2 per RN UM #3 documented the residents name, date of birth, discharge date , activity level, follow appointment that was made for orthopedics and primary care provider, a referral for a home health care agency, diet, and paper prescriptions were given for all the medication's resident was on at the facility. 3. Resident #3 with diagnoses of congestive heart failure (CHF, hearts capacity to pump blood cannot keep up with the body's need) and rheumatoid arthritis, (RA, a chronic inflammatory disease that affects the joints) and hyperlipidemia (elevated fat levels in the blood). The MDS dated [DATE] documented Resident #3 was cognitively intact. The MDS documented the resident had an active plan to return to the community and Resident #3 was discharged on [DATE]. The Discharge History and Physical Examination dated 7/27/23 completed by Physician #7 documented that Resident #3 participated in physical therapy, occupational therapy restoration and was stable and suitable to be discharged home. A referral was made for home health care services. The Social Work Progress Notes dated 7/28/23 at 4:28 PM document that Resident #3 was being discharged with a family member and a referral for home health care. The electronic medical record (EMR) Miscellaneous tab revealed there was no document evidence that a discharge summary including a recapitulation of Residents #3 stay at the facility, a final summary of their status and a post plan of care was competed. The unsigned Discharge Instructions dated 7/26/23 provided to Resident #3 per RN UM #3 documented the residents name, activity level, follow up appointment with primary care physician, a follow up with a gastroenterologist, a follow up with a physician's assistant and a list of the medications the resident was on at the facility. During an interview on 8/7/23 at 10:51 AM, Social Worker (SW) #6 stated that nursing was responsible to provide the resident and/or responsible party with a discharge summary that would include a list of medications and time they were last administered, any special instructions, level of assistance required, and a recapitulation of the residents stay. SW #6 stated the discharge paperwork should contain all the information to ensure the resident received proper care after discharge. During an interview on 8/7/23 at 11:10 AM, RN UM #3 stated the facility does not utilize a standardized form for discharge instructions. Residents and/representatives receive a typewritten summary of their stay at the facility and paper prescriptions for their prescription and over the counter medications. RN UM #3 stated they were unaware of the facility's specific policy and procedure for discharge. During an interview on 8/8/2023 at 9:16 AM, the Administrator stated that all medical instructions, medications, education, residents' mobility status, follow up visits and referrals should be included in the discharge packet to ensure residents receive proper care after discharge. Additionally, the Administrator stated Residents #1, 2 and 3 were not provided with complete discharge instructions. During an interview on 8/8/23 at 12:33 PM, the Director of Nursing (DON) stated the discharge paperwork should include a summary of the residents stay, medication list, diagnoses, physical therapy recommendations, occupational therapy recommendations, speech/language pathology recommendations, dietary recommendations, activity recommendations, any follow up appointments, and home care services. The DON stated all discharge paperwork should be scanned in to the EMR under the miscellaneous section. Additionally, the DON stated Residents #1,2 and 3 were not provided with compete discharge instructions that included a recapitulation of their stay, a discharge summary, and a post plan of care. NYCRR 415.11 (d)(1)(2)(3)

Based on observation, interview, and record review conducted during a Standard survey completed on 3/3/23, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one main kitchen. Specifically, the Cook did not change their gloves or wash their hands in accordance with professional standards, touched multiple surfaces, and did not use appropriated utensils to prepare pureed food. Additionally, milk was served at the lunch meal on 3/2/23 at unsafe temperatures. The findings are: The policy and procedure (P&P) titled Hand Hygiene dated 8/2022 documented the facility considers hand hygiene the primary means to prevent the spread of infections. Practicing good hand hygiene is an effective way of preventing infection. The P&P titled Food and Supply Storage/Production, Purchasing and Storage dated 1/2022 documented all food, non-food items and supplies will be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Milk will be refrigerated, and temperatures must be maintained at 41 F or below. a. During a lunch meal preparation observation on 3/2/23 between 10:00 AM and 10:40 AM (with the Dietary Manager present) the Cook had latex disposable gloves on their hands and proceed to put four gray handled scoops of the cooked chicken tetrazzini (chicken and pasta casserole prepared in a cream-based sauce) from a large bowl on the prep station and added it into the blender and blended till smooth. The Cook using a flat spoon then mixed the contents in the blender and then with their gloved hand (finger) the Cook wiped the pureed mixture off the spoon back into the blender with the rest of the pureed food. While wearing the same gloves, the Cook touched the prep surface and readjusted their face mask. The Cook added another 4 scoops of chicken tetrazzini holding on to the blender handle, applied the blender top and turned on the blender. The Cook proceeded to pick up the spoon and mixed the contents in the blender, with the same gloved hand (finger) the cook wiped the pureed mixture off the spoon back into the blender with the rest of the pureed food. While wearing the same gloves the Cook then touched the prep surface; picked up a spatula and poured the chicken tetrazzini into a pan; wrapped the top of the pan with plastic wrap; opened the oven doors and place the pan in the oven leaving the pureed food from their gloves on the pan, plastic wrap, and oven door. The Cook at this time removed their gloves and washed their hands and put on clean gloves. The Cook removed a tray of steamed mixed vegetables from the steamer; placed the tray on the prep station; picked up a few of the vegetables with their gloved fingers checking the texture and tossed them back on the pan. While wearing the same gloves proceeded to pick up a large flat spoon and with their gloved hand in the same motion scoop 4-5 spoons full of vegetables and placed the vegetables in the blender till the vegetables were smooth. The Cook then with a flat spoon mix the contents in the blender, with their gloved hand (finger) the cook wiped the pureed mixture off the spoon back into the blender with the rest of the pureed mixture. The Cook then added another 4 scoops of mixed vegetables holding on to the blender handle applied the blender top and turned on the blender. The cook proceeded to pick- up a gallon sized bottle of liquid butter from under the prep station and added approximately 1/2 cup to the blender. The Cook then picked up the spoon and mixed the contents in the blender, with their gloved hand (finger) the cook wiped the pureed mixture off the spoon back into the blender with the rest of the pureed content. With the same gloved hands, the Cook touched the prep surface, picked up a spatula and poured the content the blender into a pan, cover it with plastic wrap and placed the pan in the oven leaving the pureed vegetables from on their gloves on the pan, plastic wrap, and oven door. During an interview on 3/2/23 at 10:41 AM with the Dietary Manager and the Cook the Dietary Manager stated, I thought the cook did great, we pride ourselves with everything we do in here. The cook should have changed their gloves after touching other surfaces and the food. The Cook agreed. b. During an observation on 3/2/23 between 11:30 AM through 12:26 PM during the lunch tray line service, 1/2 pint milk cartons were observed at the beginning of the tray line on a tray over a pan of ice. During a test tray observation on 3/2/23 at 12:38 PM the milk was served at 52.2 degrees Fahrenheit ( F). During an interview on 3/2/23 at 12:39 AM, the Dietary Supervisor stated juices and milks were pre poured, some milks were served in cartons and placed on trays at the beginning of tray line they were taken out of the cooler ten minutes before tray line starts and stored on a tray over ice. The Dietary Supervisor stated when the carts hit the units it should be no more than ten degrees less than when it left the kitchen the pass took a long time. During a test tray observation on 3/2/23 at 12:42 PM the milk was served at 61 F. During an interview on 3/3/23 at 11:47 AM, the Director of Dietary/Registered Dietitian (RD) stated the cook should have changed their gloves and washed their hands after touching multiple surfaces and not touched the pureed food with their gloves. Ideal milk temperatures are below 40 F and 60 F was not acceptable. 10 NYCRR 415.14 14-1.80(b)

Based on observation, interview, and record review conducted during the Standard survey completed on 3/3/23, 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 for one (Resident #117) of two residents reviewed for positioning and mobility. Specifically, Resident #117's hand devices (palm protector/ABD (abdominal) pad) were not utilized per the plan of care to maintain range of motion (ROM) and to prevent complications in skin integrity for a resident with contractures. The finding is: The facility policy and procedure (P&P) titled Restorative Nursing Program Policy dated 1/2020 documented that restorative aide/nurse aide will complete daily documentation to indicate performance in the established program, and if a decline is noted in the resident's participation a referral may be made to the therapy department for an evaluation. 1. Resident #117 had diagnoses that included Parkinson's disease, unspecified dementia, and peripheral vascular disease (PVD, poor circulation of the lower extremities). The Minimum Data Set (MDS, a resident assessment tool), dated 12/6/2022 documented Resident #117 had severe cognitive impairments, required the extensive assistance of staff for Activities of Daily Living (ADL's), and had functional limitations in range of motion (ROM) of both upper extremities. An Occupational Therapy note dated 12/2/22 documented the palm protector splint to the right hand and the ABD pad to left hand was for contracture management and to prevent skin breakdown. An Occupational Therapy (OT) Discharge Assessment, dated 1/6/2023, documented that instruction and training was provided to Resident #117 that included proper body mechanics, selfcare/skin checks, splinting/orthotic schedule and compensatory strategies in order to return to previous level of ROM. Education was provided to the resident on the use of the lamb's wool palm protector to their right hand and a rolled ABD pad to the left hand to optimize skin integrity, and to remove for hygiene daily. In addition, the assessment documented that a range of motion program was established and staff were trained for PROM (passive range of motion, exercises completed by staff) to both upper extremities (arms, wrists and hands). Resident Nursing Instructions (care plan used by staff to provide care) for dated 8/25/2022 documented Resident #117 required PROM to upper and lower extremities. Additionally, on 11/1/22 Restorative Nursing for lamb's wool palm protector to Resident #117's right hand, on at all times (AATs) and off for hygiene. Restorative Nursing Program for splinting/bracing dated February and March of 2023 documented that staff were to maintain integrity of affected area through appropriate application of brace/splint per the care plan. Provide ROM, donning (putting on) and doffing (removing) of lamb's wool palm protector splint to right hand and to report any concerns with splint/brace to the nurse in-charge or any rehabilitation supervisor. The Care Plan dated 6/12/2022, documented ADL and mobility deficits. Interventions included to provide restorative physical therapy (PT/OT (occupational therapy) program and to update PT/OT with changes in functional status. The Care Plan also documented restorative nursing for ROM and splinting per therapy recommendations. Review of the physician orders dated 11/1/2022 revealed orders for a lamb's wool palm protector to Resident #117's right hand AAT's except hygiene. Additionally, orders dated 1/9/2023 documented to cleanse the resident's left hand daily, dry thoroughly and to place a rolled ABD pad in the left hand. Review of the January and February 2023 Treatment Administration Records (TAR) revealed the lamb's wool palm protector was signed off as worn 151 out of 177 opportunities. The order to cleanse left hand daily, dry thoroughly, and to place a rolled ABD pad in the left-hand daily was signed off 37 out of 51 opportunities. A physician note, dated 1/23/23, documented Resident #117 had hand contractures and documented a plan to continue with Tylenol for pain management and to continue PT/OT for ROM and strengthening. A nursing progress note, dated 3/2/23, documented Resident #117 was having increased difficulty and decline in ROM in bilateral hands. Staff unable to apply proactive hand equipment at this time after multiple attempts. The physician was made aware and gave new order for OT to evaluate and treat. During observations on 2/27/23 at 12:11 PM, 3/1/23 at 7:47 AM, 3/1/23 at 9:31 AM, 3/1/23 at 11:30 AM, 3/1/23 at 1:25 PM, 3/2/23 at 8:40 AM, 3/2/23 at 9:39 AM, Resident #117 had bilateral hand contractures, their fists were tightly clenched, and the resident had no protectors (lamb's wool or ABD pad) in either hand. Resident #117 had approximately 3/4 cm (centimeter) long fingernails above the tip of the fingers on all fingers. During an interview on 3/1/23 at 1:25 PM, Resident #117 was asked if anything was in their hands, and they stated fingernails. The resident stated it bothered them that staff do not keep anything in their hands as sometimes their fingernails hurt the palms of their hands. During an interview on 3/2/23 at 9:29 AM, temporary certified nursing assistant (CNA) #1 stated the CNAs were responsible for range of motion and that they document as well. The nurses or therapy were responsible to put the lamb's wool palm protector in Resident #117's right hand and the ABD pad in the left hand. CNA #1 stated they did not complete this task. During an observation on 3/2/23 at 9:39 AM, temporary CNA #1 when asked to observe ROM, both of Resident #117's hands were contracted, clenched shut and the resident had no protectors (lamb's wool or ABD pads) in either hand. The CNA stated the nurses or therapy were responsible to put the protectors in the resident's hands. During an observation on 3/2/23 at 11:24 AM, Occupational Therapist (OT) #1 used warm wet washcloths to try and loosen Resident #117's hands and fingers stating, they were tight today. The OT had difficulty with ROM and putting the palm protector in Resident #117's hand, and was observed taking the rolled ABD pad and having to work it into palm pulling the pad from under the curved pinky finger. The resident stated it felt snug. During an interview on 3/2/23 at 9:46 AM, Registered Nurse (RN) Manager #1 stated the expectation was that if staff were signing off for something that it should be done. Resident #117 should have had a lamb's wool palm protector in their right hand and ABD pad their left hand for protection and cleanliness per the resident's plan of care. RN Manager #1 further stated the resident did not have the devices in their hands. During an interview on 3/2/23 at 9:58 AM, Licensed Practical Nurse (LPN) #1 stated they were responsible to ensure the devices were in place and for signing off in the Treatment Administration Record (TAR). During an interview on 3/2/23 at 12:47 PM, OT #2 stated the lamb's wool palm protector and ABD were for skin protection, to reduce injury and keep skin integrity intact secondary to the resident's fingernails digging into the palms of their hands. The aides have been trained for ROM and they wanted a nurse to be the one to apply the palm guards daily. During an interview on 3/3/23 at 10:53 AM, the Director of Nursing (DON) stated the lamb's wool palm protector and ABD pad should have been in place per Resident #117's plan of care. If staff had any difficulty with applying the lamb's wool or the ABD pad the DON stated they would have expected the Nurse Manager/Supervisor and/or therapy to be notified. 10 NYCRR 415.12(e)(2)

Based on observations, interviews, and record reviews conducted during the Standard survey completed 3/3/23, the facility did not ensure results of the most recent New York State Department of Health (NYSDOH) survey results were not readily accessible to residents, family members and legal representatives without having to ask a staff person. The findings are: Review of the Facility's Admission Packet included a booklet titled Your Rights as a Nursing Home Resident in New York State dated 2022 documented; as a resident in this facility, you have rights guaranteed to you by state and federal laws. The facility is required to protect and promote your rights. Your rights strongly emphasize individual dignity and self-determination, promoting your independence and enhancing your quality of life. In section Access documented; You have the right to: Read the results of the most recent State or Federal inspection survey and the facility's plan to correct any violations. During a Resident Council Meeting, held on 2/28/23 at 10:08 AM, Resident #102 stated they were unaware of where the NYSDOH survey results were located and unaware they had a right to read the results. During observations on 2/27/23 at 10:55 AM and 2/28/23 at 10:40 AM in the hallway near the C WING 100 hall was a posted pink laminated sign that documented, The latest New York State Survey results are located on the wall outside of the Director of Nursing (DON) Office in the C WING 100 hall. Please feel free to review the results and direct any questions to the social work office. Observations of the bulletin board in the hallway near C WING 100 hall outside the DON's office revealed there was no evidence of the most recent NYSDOH survey results. During an interview and observation on 2/28/23 at 10:44 AM, the Administrator stated the NYSDOH survey results should be hanging on the bulletin board outside the DON office. Upon observation the Administrator stated the survey results were gone and does not know why they were not hanging on the bulletin board at the designated location. During an interview on 3/1/23 at 12:03 PM, the Administrator stated they were aware the most recent NYSDOH survey results were to be readily accessible to all residents, family members and legal representatives. 10 NYCRR 415.3(d)(1)(v)

Based on observation, interview and record review conducted during a Standard Survey completed on 8/18/21 the facility did not meet the nutritional needs of residents in accordance with established national guidelines. Two (lunch and dinner) of two meals did not provide the residents receiving the posted main entrée with proper protein amounts to meet their nutritional needs. This involved Resident #6. The finding is: Review of the undated policy provided by the facility on 8/18/21 entitled Menu Planning revealed meals will be provided to meet the nutritional needs of the residents which are balanced, nutritious, and adequate in amount to meet the daily dietary needs of the residents. Menus will be planned to conserve nutritive value, flavor and appearance and provide food and drink that is palatable and attractive. Menus will be written in accordance with federal/ state/ local guidelines to meet the nutritional needs of the population. All menus, including regular and therapeutic/ mechanically altered extensions, will be developed by the facility, and be approved by the Registered Dietitian Nutritionist (RDN) or designee. Menus will be compliant with the facility's written diet manual. In the event that a menu substitution must be made, it will be approved by the Registered Dietitian Nutritionist (RDN) or designee and be recorded on the Menu Item Substitutions list. Review of the undated policy provided by the facility on 8/18/21 entitled Diet Manual revealed an approved diet manual will be available and used for menu planning of regular, therapeutic, and mechanically altered diets and will reflect current diets used within the facility. Review of the facility Diet and Nutrition Care Manual dated 2019 revealed the following Dietary Guidelines for adequate daily nutrients: Protein Foods (i.e. fish, seafood, lean meat, poultry, eggs, dry beans/peas/lentils, soy products, nuts) the amount each day should be 5-6oz (ounces) or equivalent. Review of the Diabetic Exchange List designed by a committee of the American Diabetes Association and The American Dietetic Association revealed 1oz (one meat exchange) equals 7g (grams). Review of the facility's posted menu dated 8/12/2021 Monday Week 1 revealed the following: Lunch: Sausage Gravy Biscuit, Green Beans, Raspberry Banana Jello Dinner: Stuffed Pepper, Marinara sauce, Glazed Carrots, Hawaiian Cake During an observation on 8/16/21 at 9:19 AM, the Director of Dietary opened a large can of Country Sausage Gravy and placed 13 white handled #6 scoops (equivalent to 5/8 cup) of the gravy in the blender and added 1 cup of broth and blended it to a puree consistency. At this time the Director of Dietary stated they have 13 residents on a puree diet consistency and did not have a specific recipe for this food item as it was an already prepared food item. They stated that the puree diet consistencies would get a #6 scoop of sausage gravy over mashed potatoes instead of the biscuit. During an observation of the Lunch tray line on 8/16/21 between 11:35 AM - 12:20 PM, the following was revealed. Residents on a regular and ground consistency diet receiving the main entrée were provided on their plates 1 biscuit with a 5oz (5/8 cup) ladle of sausage gravy and ½ cup green beans. Residents on a puree diet consistency receiving the main entrée were provided 1/2c mashed potatoes with a white handled #6 scoop (equivalent to 5/8 cup) of puree sausage gravy and white handle #6 scoop of puree green beans. During this observation at 11:51 AM, the Director of Dietary poured thickener into the puree sausage gravy. Amount unknown as no measuring cup was used, it was poured right out of the container into the pan of sausage gravy. The Director of Dietary stated at that time that it was thickener they were adding because the gravy was getting too thin. During an observation of the Dinner tray line on 8/16/21 between 5:30 PM- 5:50 PM, the following was revealed. Residents on a regular and ground consistency diet receiving the main entrée were provided on their plates 1 serving (observed as 1/2 stuffed pepper) and ½ cup of carrots. Residents on a puree diet consistency receiving the main entrée were provided two blue handled #16 scoops (equivalent to ½ cup total) of puree stuffed pepper and one blue handled #16 scoop (equivalent to ¼ cup) of puree peas. The Director of Dietary during tray line stated that the puree consistencies were given two blue handled #16 scoops (equivalent to ½ cup total) of puree stuffed peppers because that would provide 1 serving size (1/2 stuffed pepper). Review of the LVG 5 Week Menu Extension sheet for Monday Week 1 dated 8/16 revealed residents on regular, ground, and puree consistencies should receive 2 oz sausage gravy over biscuits at lunch and 1 each stuffed pepper with sauce at dinner. Review of the product Nutritional Facts for the Country Sausage Gravy revealed one serving size ¼ cup provides 2g protein. Review of the product Nutritional Facts for the Stuffed Pepper revealed one serving size provides 7g protein. During a meal observation on 8/16/21 at 5:36 PM Resident #6 was observed to have a 1/2 stuffed green pepper with sauce on their plate. At that time, Residnet #6 stated sometimes the meat portions here are small. During an interview on 8/17/21 at 12:12 PM, the Registered Dietitian (RD) stated they use the Diet and Nutrition Manual, and the liberalized diets goes by the diet manual guidance. The RD stated the menus are reviewed and discussed with the Director of Dietary. The RD stated they are aware of what is being served. After the surveyor showed the RD the nutritional facts for the sausage gravy, they stated the protein level would be too low as a ½ cup portion would only be 4 grams of protein, which isn't even one serving size for meat. They stated the portion size given at dinner for the stuffed peppers would receive 7g of protein which is also too low in protein amount and that they would have needed 2 stuffed peppers to meet the dinner protein needs. The RD stated the protein needs to be provided for both lunch and dinner should be between 14-21g per meal and that by their calculations residents only received a total of 11g of protein between the two meals. This would only provide 1.5 serving sizes for meat/ protein. The RD stated they should have added additional protein like cottage cheese to the trays. The RD stated they did not calculate the changed menu. The RD stated, I believe this day was not per usual. We do not usually use two of these already prepared products on the same day. Most everything here is prepared from scratch and the protein levels are on the high side. I would say the protein amount yesterday was light and that the protein was not up to what it should be and did not meet adequate protein amount. In addition, the RD stated The main chef was on vacation and the other one had just quit, and the Director of Dietary had a student with them. I think the Director of Dietary was trying to make the food easier to prepare. I think they were short staffed, and this was an easier way to get things done. I believe this was a freak thing and I do not think yesterday's meals are a good representative of what we serve. We always serve a high amount of protein. During an interview on 8/17/21 at 1:11 PM, the Director of Dietary stated I changed the menu because I did not have a cook and I had to cook that day. I put already prepared foods on both meals so that I only would have to heat them up and not have to do a lot of preparation. I normally would have had turkey sandwiches on at lunch, but I only had a [AGE] year-old to help, and they could not use the slicer to slice the turkey up. I never have 2 already prepared dishes on the same day, yesterday was just a bad day. I did not calculate up the nutritional part, nor did I call the RD about this. During an interview on 8/18/21 at 8:28 AM with the Director of Nursing present, the Administrator stated yes, they would expect dietary to provide adequate nutrition daily to the residents. The Administrator stated, I think it would be a joint effort between the RD and the Director of Dietary to make sure adequate nutrition is being provided. 415.14(c)(1-3)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not ensure essential equipment was maintained in effective operating condition. Specifically, the high temperature dishmachine did not meet the minimum temperature specifications for the sanitizing rinse. This is evidenced by the following: The policy, Recording Dish Machine Temperatures, last reviewed in 2012, revealed that the staff will be trained to record dishmachine temperatures for the wash and rinse cycles at each meal. The food service manager will spot check the log to assure temperatures are appropriate and staff are monitoring the dish machine temperatures. The food service manager will promptly assess any dish machine problems and act immediately to assure proper sanitation of dishes. During an observation on 1/18/19 at 11:12 a.m. in the main kitchen, the high temperature dish machine (Jackson EC -44) final rinse temperature was 140 degrees (*) Fahrenheit (F) after multiple racks were pushed through the machine. The manufacture's specifications revealed the sanitizing temperature should be 180 *F. The Dishwasher Temperature Logs, from 1/1/19 through 1/18/19, revealed all final rinses were less than 180 *F. The Ecolab Report (vendor for dish machine), dated 1/7/19, documented the final rinse temperature was 185 *F. When interviewed on 1/18/19 at 11:12 a.m., the Director of Food Service (DFS) and the Kitchen Supervisor both said that the dishmachine was a high temperature machine, and the final rinse temperature should be 180 *F. The DFS said that when the final rinse is below 180 *F, the vendor directs the staff to reset the booster heater. The Dietary Aide said that morning she documented the final rinse temperature was 165 *F, and she reset the booster. She said that she did not tell anyone about the low temperature or the need to reset the booster. When interviewed on 1/18/19 at 11:48 a.m., the Director of Food Services said that the facility has a single tank dual temperature dishmachine. She said if the temperature gets too high, the switch will turn it off. She said that Ecolab was coming to turn up the thermostat and convert the dishmachine to bleach. When interviewed on 1/18/19 at 1:19 p.m., the representative from Ecolab stated that the thermostat would be replaced. He said that he would be converting the dishmachine to chlorine sanitizer until next week when the part was available. He said that the booster heater puts wear and tear on the thermostat and really needs to be repaired or replaced. (10 NYCRR 415.29(b))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for three (Residents #26, #50, and #117) of six 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 documentation of an adequate indication for the continued use of [MEDICAL CONDITION] medications and non-pharmacological interventions attempted prior to the administration of a [MEDICAL CONDITION] medication. This is evidenced by the following: The facility policy, [MEDICAL CONDITION] Medications, dated 11/28/17, revealed that each resident would receive a comprehensive assessment and the facility would ensure that residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the medical record. 1. Resident #26 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/4/19, revealed that the resident's cognitive skills for decision making were severely impaired, behavioral symptoms were not present, the resident received an antipsychotic, an antianxiety, and an antidepressant medication, and there was no physician documentation that a Gradual Dose Reduction (GDR) was clinically contraindicated. The Behavioral Care Plan, dated 10/19/17, included the resident was agitated and combative. Interventions included music, ambulation, aromatherapy, and to engage the resident before episodes begin. The Comprehensive Care Plan (CCP), dated (MONTH) (YEAR), revealed the resident had generalized anxiety and [MEDICAL CONDITION] with behaviors that included yelling out and combativeness with cares and [MEDICAL CONDITION] medication use that included Trazadone, [MEDICATION NAME], and [MEDICATION NAME]. Goals included target behaviors will be effectively controlled and behaviors will be minimized. Interventions included to reapproach if combative and to provide a doll or teddy bear for comfort. The undated Certified Nursing Assistant (CNA) Care Plan revealed the resident exhibited behaviors that included yelling, verbally agitated at times due to frustration with expressive asphasia (partial loss of ability to produce language), and can be combative with hands on care. Interventions included to reapproach the resident and/or provide a doll or stuffed animal for comfort and/or diversion. Physician orders, dated 3/21/18, included a weighted blanket to be utilized for comfort during periods of increased restlessness and [MEDICATION NAME] (an antipsychotic) immediately. The Physician Assistant (PA) note, dated 3/22/18, revealed the resident had no acute concerns and was maintained on [MEDICATION NAME] (an antidepressant) 200 milligrams (mg) daily, [MEDICATION NAME] (an antianxiety) 20 mg three times a day, and Trazadone (an antidepressant) 50 mg three times a day. The resident's episodic restlessness and anxiety had subsided significantly with the medications. A physician order, dated 4/5/18, included [MEDICATION NAME] immediately for increased agitation. The PA documented on 4/19/18 that per the staff the resident was doing well, was comfortable, and would be continued on her current medications. Review of the nursing progress notes, from 4/6/18 through 4/22/18, revealed that on five occasions the resident refused medications or was agitated, combative, or yelling out. The notes did not include non-pharmacological interventions utilized. The Nurse Practitioner (NP) psychiatric evaluation, dated 4/25/18, included the resident had periods of documented agitation which correlated with the discomfort of toileting and or the need to move her bowels. The NP documented the family reported a history of sexual abuse, complicating the current situation, and the resident had difficulties with toileting and hands on care. The note documented [MEDICATION NAME], and Trazadone were utilized for anxiety to manage frustrations. The NP recommended [MEDICATION NAME] the [MEDICATION NAME] with [MEDICATION NAME] (an antipsychotic). The plan included to start [MEDICATION NAME] 2.5 mg every day. Physician orders, dated 4/27/18, included [MEDICATION NAME] 2.5 mg at 10:00 a.m. The physician increased the resident's [MEDICATION NAME] to 5 mg every morning at 10:00 a.m. on 5/9/18. Review of the nursing progress notes, from 4/23/18 through 6/2/18, revealed that on 11 occasions the resident refused medications or was agitated, combative, or yelling out. The notes did not include non-pharmacological interventions utilized. The PA note, dated 5/17/18, documented the resident remained on [MEDICATION NAME], Trazadone, and [MEDICATION NAME]. The resident was followed closely by the Psychiatric NP and had episodes of combative behavior especially during incontinence care. A physician note, dated 6/21/18, documented the resident was doing well per the staff. [MEDICAL CONDITION] medications included [MEDICATION NAME], and Trazadone. The NP Psychiatric evaluation, dated 6/22/18, revealed the resident was last seen on 4/22/18, the [MEDICATION NAME] was started on 5/22/18 and on 6/9/18 increased to 5 mg every day. Staff reported the resident was still combative when needing to move her bowels. There was some improvement and a decrease in emotional outbursts. The NP recommended increasing the [MEDICATION NAME] to 7.5 mg every day. Physician orders, dated 6/22/18, included to increase the [MEDICATION NAME] to 7.5 mg every day. During observations on 1/16/19 at 3:09 p.m. and on 1/22/19 at 1:29 p.m., the resident was in bed with her eyes closed and the bed was in the low position with mats on both sides of the bed on the floor. In an observation on 1/23/19 at 8:59 a.m., the resident was sitting in a geri chair in her room, her eyes were closed, and her brow was furrowed. When interviewed on 1/22/19 at 1:31 p.m., CNA #1 stated staff do what they can for the resident. She said staff have to talk the resident into cares. She said if the resident was agitated or says, No staff let her be or let another staff member attempt cares. CNA #1 stated the resident liked to yell out. CNA #1 stated the resident had a behavioral care plan that listed all the things that work for the resident. During an interview on 1/22/19 at 3:31 p.m., Licensed Practical Nurse (LPN) #1 stated the resident was on Trazadone, [MEDICATION NAME], and [MEDICATION NAME] for agitation. She stated when the resident exhibits behaviors, staff should document in the medical record. LPN #1 stated the note should include specific behaviors and what the staff did to prevent the behaviors. She stated staff should chart what symptoms are exhibited not just agitated or combative. LPN #1 stated staff should document precipitating factors to behaviors and the interventions utilized. She stated the resident's behaviors were predictable and the behavior plan did not address the predictable behaviors. She stated the behavior plan, dated (MONTH) (YEAR), had not been revised because the approaches still worked. Interviews conducted on 1/23/19 included the following: a. At 9:55 a.m., the PA stated he wrote the orders for the [MEDICATION NAME]. He stated he was not aware of the non-pharmacological interventions that were tried before the [MEDICATION NAME] was ordered. The PA reviewed the psychiatric evaluations and then stated you would have to ask the NP about the target symptoms for the use of the [MEDICAL CONDITION] medications. The PA stated the resident was on to many antidepressants. He stated he just followed the recommendations of the consultant. b. At 10:52 a.m., CNA #2 stated the resident had extensive behaviors, was restless, agitated, combative, and anxious at times. She stated staff provide 1:1, calming activities, like music or talking her down. CNA #2 stated the resident had a weighted blanket but she had never used it. 2. Resident #50 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission History and Physical, dated 4/12/18, revealed the resident received [MEDICATION NAME] (antidepressant) and Klonopin (anti-anxiety). The MDS Assessment, dated 8/7/18, revealed the resident had severely impaired cognition with no behaviors, delusions, or hallucinations. The CCP, dated (MONTH) (YEAR), revealed the resident used psychoactive drugs. Approaches included to involve the resident in activities of interest and provide 1:1, redirect, reorient, limit sensory environmental stimuli when agitated, medications as ordered, and refer to the psychiatric NP as needed. The PA note, dated 7/12/18, revealed the resident had no acute concerns and staff reiterated the same. The plan was for the psychiatric NP to review the resident's [MEDICAL CONDITION] medications. The psychiatric NP initial visit, dated 7/20/18, documented that the resident denied pain or discomfort and her sleep and appetite were adequate. The resident was able to give some history which appeared to be correct, and she felt she had adjusted well to the facility. The resident admitted she was confused a lot of the time and her only complaint was her concentration and memory. The resident was not an imminent risk to harm self or others, staff anticipate and meet her needs, and the resident can provide input regarding her wants, needs, and care. The recommendation included to increase the resident's antidepressant [MEDICATION NAME] and start [MEDICATION NAME] (a cognition enhancing medication). Review of the progress notes, from 7/20/18 through 8/8/18, revealed three progress notes that mention behaviors of being sarcastic (7/27/18, 7/29/18, and 7/31/18), and two notes documented the resident was resistive with activities of daily living. None of the notes document any interventions that were attempted with these behaviors. PA orders, dated 8/8/18, include to start [MEDICATION NAME] (a sedative and antidepressant) 12.5 mg twice daily. There was no corresponding NP or PA note for that date describing the specific condition, whether symptoms were clinically significant enough to administer an antipsychotic medication, and what non-pharmacological interventions were attempted prior to the initiation of the [MEDICAL CONDITION] medication. The physician note, dated 8/14/18, revealed the resident was alert, pleasant, and cooperative. The resident's orders were reviewed and renewed. The psychiatric NP note, dated 8/23/18, documented the resident did not appear to be as irritable since the start of the [MEDICATION NAME] on 8/8/18. Recommendations included to continue the [MEDICATION NAME] as the resident has benefited from the implementation of [MEDICATION NAME] to decrease anxiety and agitation. During an observation and interview on 1/22/19 at 9:20 a.m., the resident was sitting in the hall watching people walking by and stated she felt fine and her mood was good. When interviewed on 1/17/19 at 9:22 a.m., CNA #3 said the resident laughs, makes jokes, and was sometimes miserable calling staff names but never combative. She said the resident has poor vision and sometimes thinks she sees her daughter down the hall. Interviews conducted on 1/22/19 included the following: a. At 10:25 a.m., Registered Nurse Manager (RNM) #1 said there was not adequate documentation of the resident's behaviors to justify adding a [MEDICAL CONDITION] medication. She said the staff should also be documenting the non-pharmacological interventions they tried. b. At 11:00 a.m., RNM #2 said they did a phone conference with the psychiatric NP and she reviews her recommendations. She believed the reason for adding the [MEDICATION NAME] on 8/8/18 was because the resident had falls and it would help her. When asked how that would occur, she did not provide an answer. RNM #2 said the resident was on a lot of medications, and she does not know why the PA does not document. She said the nurses should be documenting their interventions. c. At 11:02 a.m., the Director of Nursing (DON) said there should be documentation including the [DIAGNOSES REDACTED]. d. At 11:05 a.m., CNA #4 said the resident does get confused at times and they leave her alone. CNA #4 said the resident then settles down and can be pleasant and cooperative. e. At 11:45 a.m., the PA said he did not remember the case well but it sounded like they contacted the psychiatric NP. He said he did write the order but did not review any of the notes. He said he lets the psychiatric NP manage the [MEDICAL CONDITION] medications. He said he needs to review the record more before writing any orders. f. At 11:52 a.m., the psychiatric NP said they had a conference call and staff must have reported something going on with the resident. She said if the staff are reporting behaviors to a specialist, they should have the documentation in the notes describing what they are seeing and what they do for it. The psychiatric NP said she can be involved in reduction of [MEDICAL CONDITION] medications if the physician asks. She said some of the physicians want to be in control of reductions. She said the long-term goal for [MEDICAL CONDITION] medications was to get at the lowest dose or discontinue. 3. Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/3/18, revealed the resident had severely impaired cognition, delusions, some physical behavior directed toward others for one to three days which had no significant risk impacting the resident or others, and received antipsychotic and anxiolytic (anti-anxiety) medications. The CCP, dated 7/18/18, revealed the resident had a cognitive loss, behaviors, and used psychoactive drugs. Approaches included 1:1 as needed, engage in activities of interest, monitor behavior, and document specific incidents, interventions, and results, and to limit sensory/environmental stimuli when agitated. The CNA behavioral care plan revealed the resident was restless, repetitive, calls out, agitated, and wanders. Interventions included to look out the window, set up large print Bible or spiritual readings, and/or read to her, try word finds, offer cookie or treat, offer hymns, Bible study, and educational programs. The psychiatric NP note, dated 7/24/18, revealed the resident was currently on [MEDICATION NAME] (an antipsychotic) and [MEDICATION NAME] (an anti-anxiety) medications. At that time, the resident continues to be elevated and talking impassively, has periods of paranoia, and looks for a way to go home. Recommendations include to trial [MEDICATION NAME] 12.5 mg three times daily to calm her down. PA orders, dated 7/25/18, included [MEDICATION NAME] 12.5 mg three times daily. The PA note, dated 8/2/18, documented the resident has been stable over the past year and seems to have adjusted to the nursing home. The resident's current [MEDICAL CONDITION] medication regimen seems to be appropriate for her, and no changes to the plan of care. The PA order, dated 8/8/18, included to increase [MEDICATION NAME] to 25 mg three times daily. There was no corresponding PA note or psychiatric note for that date. There was no documentation that the medication was used to treat a diagnosed specific condition, whether symptoms were clinically significant enough to increase the [MEDICAL CONDITION] medication, and what non-pharmacological interventions were attempted and their results. The psychiatric NP note, dated 8/22/18, includes the [MEDICATION NAME] was increased on 8/8/18. Review of the progress notes, from 7/24/18 through 8/8/18, revealed that on eight occasions behaviors such as being confrontational with staff, want to know directions, exit seeking (7/28/18), anxious, fearful of men coming in her room (7/30/18 and 8/8/18), and chatting away with herself all night (7/31/18). These notes do not include what interventions were attempted with the behaviors or the effectiveness. During an observation on 1/16/19 at 3:10 p.m., the resident was in the main hall in her wheelchair with her feet on the floor. The resident's head was down and to the side and she appeared to be asleep. Two CNAs said the resident likes to sit there and does not like to lie down in the afternoon. They both said if staff try to lay her down, she will fight you. Interviews conducted on 1/18/19 included the following: a. At 1:18 p.m. and 1:50 p.m., RNM #3 said she did not know about the 8/8/18 order to increase [MEDICATION NAME]. She said based on the nursing notes she just read she did not see enough information to warrant an increase in the [MEDICATION NAME]. She said the nurses should write their notes with more in depth information. b. At 1:19 p.m. and 3:30 p.m., the education RN said she does not know why there was no documentation regarding the increase of [MEDICATION NAME]. She said there should be documentation to support the increase in medication. She said interventions should be documented in order to determine if the medication is working or not. She said the care plan should include specific interventions that work. c. At 2:26 p.m., LPN #2 said if the resident has behaviors, she does an activity with her or tries to call her sister. LPN #2 said she was not told specifically what to document in a behavior note. LPN #2 said her documentation should include what non-pharmacological interventions were tried for the resident. d. At 3:11 p.m., the PA said there was a phone conference with the psychiatric NP regarding the resident, however, he may have just been told by the nursing staff what she recommended and written the order. The psychiatric NP was not there so he should have dictated something about what he was ordering and why. (10 NYCRR 415.12(l)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for dental and one of one resident reviewed for [MEDICAL CONDITION], the facility did not ensure the implementation of each resident's care plan. Specifically, Resident #61 was not provided oral care per the plan of care, and Resident #230's lower extremities were not elevated per the plan of care. This is evidenced by the following: The facility policy, Comprehensive Care Plan, dated (MONTH) (YEAR), revealed the service provided or arranged by the facility shall meet prevailing standards of care and service and be provided by qualified persons in accordance with each resident's plan of care. 1. Resident #230 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/7/19, revealed the resident had moderately impaired cognition and required the extensive assistance of two staff for transfers and bed mobility. A Physical Therapy (PT) note, dated 12/31/18, revealed the resident had [DIAGNOSES REDACTED] (redness) of bilateral lower extremities and significant [MEDICAL CONDITION]. The PT educated the resident regarding the importance of keeping the legs elevated during the day to reduce [MEDICAL CONDITION] and provided the resident with bilateral elevating leg rests for the wheelchair. The physician Admission History and Physical, dated 1/3/19, revealed the resident had chronic dependent leg [MEDICAL CONDITION] with [MEDICAL CONDITION] of the left leg. and the plan included to keep the resident's legs elevated. The Comprehensive Care Plan (CCP), dated (MONTH) 2019, revealed the resident had bilateral leg [MEDICAL CONDITION], and interventions included to off load heels in bed with a pillow. The Certified Nursing Assistant (CNA) Care Card included the resident used bilateral elevating leg rests in the wheelchair or a recliner chair when out of bed, rest periods in bed in the afternoon, and to offload the resident's heels in bed with a pillow. Observations included the following: a. On 1/15/19 in the morning and at 2:27 p.m., the resident was seated in a wheelchair and her legs and feet were not elevated. b. On 1/16/19 at 11:26 a.m., the resident was seated in a wheelchair with both of her legs dependent (down) and her feet were resting on the floor. The resident's legs were [MEDICAL CONDITION] from the feet to the knees. The resident was wearing slipper socks, and the left sock was causing indentations in the skin. c. On 1/17/19 at 9:54 a.m., the resident was seated in a chair with her feet flat on the floor. At 10:31 a.m., the resident was resting in bed and both feet were resting directly on the mattress. Interviews conducted on 1/17/19 included the following: a. At 10:56 a.m., CNA #1 stated the resident's heels were suppose to be elevated when in bed and they were not. She stated the resident usually sits in her recliner with her legs elevated. a. At 11:00 a.m., the Licensed Practical Nurse (LPN) stated if the CNA Care Card directed to elevate the resident's heels when in bed and to utilize the elevating legrest in the wheelchair, then her expectation would be that the staff were following the Care Card. b. At 11:08 a.m., CNA #2 stated that she had transferred the resident into bed. At that time, the CNA reviewed the resident Care Card and stated the resident's heels should always be elevated on a pillow. CNA #2 said that she did not elevate the resident's heels. c. At 11:37 a.m., the Registered Nurse Manager stated the staff should have elevated the resident's heels in bed, and the resident should have elevating legrests on the wheelchair. When interviewed on 1/22/19 at 10:31 a.m., the Physical Therapist stated she added the bilateral elevating legrests to the resident's wheelchair. The Physical Therapist said the resident should utilize the legrests at all times due to bilateral leg [MEDICAL CONDITION]. 2. Resident #61 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/20/18, revealed the resident had severely impaired cognition and required total dependence upon staff for all Activities of Daily Living. The current CCP and the CNA Care Card both directed to provide oral care twice daily and assist the resident as needed. During an observation and interview on 1/15/19 at 10:18 a.m., the resident was sitting up in his wheelchair in his room. The resident's bottom teeth had thick white debris along the gum line. When interviewed the resident said his teeth are not brushed. When observed on 1/17/19 at 8:37 a.m., the resident was dressed and sitting up in his wheelchair in his room. The resident's teeth had thick white debris along the gum line. When interviewed the resident said his teeth were not brushed that day. Interviews and observations on 1/17/19 included the following: a. At 9:10 a.m., primary CNA #3 said the resident has some teeth but no dentures. CNA #3 said she has not brushed the resident's teeth. She said she works the 6:00 a.m. to 2:00 p.m. shift and must get people ready and up. CNA #3 said she cannot brush the resident's teeth while they are in bed, and it totally slips her mind. She said the resident did have a toothbrush in the second drawer in the dresser. At 9:18 a.m., CNA #3 stated the resident's toothbrush was in the second drawer and was in an unopened package. CNA #3 brushed the resident's teeth and he said they felt better. b. At 12:56 p.m., LPN #2 said she checks the residents for completion of their Activites of Daily Living as she passes her medications throughout the day. LPN #2 said she asks the CNAs at the end of the day if they completed all of the resident's care. LPN #2 said that she did not notice that the resident's teeth needed to be cleaned. c. At 1:03 p.m., RNM #2 said the CNAs should be brushing the resident's teeth as directed in the plan of care. (10 NYCRR 415.11(c)(2)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #120) of seven residents reviewed for non-pressure related skin conditions, the facility did not document or investigate an injury of unknown origin to rule out abuse, neglect, or mistreatment. This is evidenced by the following: Resident #120 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/22/18, revealed that the resident had severely impaired cognition and received an anticoagulant (blood thinning) medication daily. The Comprehensive Care Plan, dated 10/18/18, revealed that the resident received an anticoagulant and was at risk for bruising and bleeding. Approaches included to monitor for signs of abnormal bruising and bleeding and report changes to the medical staff. During an observation on 1/15/19 at 12:59 p.m., the resident had a large dark blue bruise on the right posterior hand extending up the wrist, and her left hand had a smaller long and narrow dark blue bruise. When asked about the bruising, the resident said she did not know how she got them. During an observation and interview on 1/17/19 at 1:22 p.m., the resident was seated in her room. The assigned Certified Nursing Assistant (CNA) #1 and the Licensed Practical Nurse (LPN) were both shown the resident's bruises. CNA #1 said she just saw the bruises that day and she was going to tell someone. She said she does not know where the bruises came from. The LPN said she did not notice the bruises that day. Review of the nursing progress notes, from 1/1/19 through 1/15/19, revealed no documentation regarding bruising to the resident's hands. Review of Incident and Accident Reports for the last three months revealed no reports related to bruising of the resident's hands. During an interview on 1/17/19 at 1:28 p.m., the Registered Nurse Manager (RNM) said the resident did not have any bruising after she returned from the hospital on [DATE]. She said the resident had an attempted blood draw on 1/12/19 but she did not know the location. She said when the nurse was unable to get the blood they called the lab. The RNM said staff should be reporting any bruising. She said that she would start an investigation to determine the cause of bruising. When interviewed on 1/17/19 at 1:44 p.m., CNA #2, who was assigned to care for the resident on 1/16/19, said she did not notice the bruising. When interviewed on 1/18/19 at 8:59 a.m., CNA #3, who was assigned to care for the resident on 1/14/19, said she did not notice any bruising. After surveyor intervention, an Incident and Accident Report, dated 1/17/19, revealed that the bruise on the resident's right hand measured 10 centimeters (cm) x 11 cm, and the bruise on the left hand measured 3 cm x 1 cm. The RN attempted a blood draw on 1/12/19 and the vein blew with an attempt. The lab was contacted and the RN did not attempt another blood draw. (10 NYCRR 415.4(b)(3))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #116) of one resident reviewed for hydration, the facility did not ensure sufficient fluid intake to maintain proper hydration. The issue involved the lack of monitoring of fluids consumed for a resident with a urinary tract infection [MEDICAL CONDITION]. This is evidenced by the following: Resident #116 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/20/18, revealed the resident was cognitively intact and required set-up for eating. The facility policy, Intake and Output Measurement, directed that all residents with a UTI are placed on intake and outputs until treatment is completed. Each shift is responsible for documenting the intake and output when required, and the evening shift is responsible for totaling the 24 hour amounts. Documentation of intake and outputs during treatment of [REDACTED]. The Comprehensive Care Plan (CCP) for UTI, dated 10/18/18, included approaches to monitor and report signs and symptoms of UTI and encourage to consume all fluids offered. The CCP, dated 3/13/18, included that the resident was at an increased risk for dehydration due to anxiety. The CCP was revised on 1/14/19 to include that the resident was being treated for [REDACTED]. Physician orders, dated 1/11/19, directed to obtain a urine sample. Orders, dated 1/14/19, include [MEDICATION NAME] (antibiotic) twice daily for one week. The Dietary Assessment, dated 1/14/19, identified the treatment for [REDACTED]. The resident's fluid needs with a UTI are 1,500 cc to 1,750 cc. The plan was to have the snack cart person offer at least 120 cc additional fluid twice daily and yogurt has been added to all meals. The Physician Assistant note, dated 1/15/19, documented that the resident had a UTI, and the plan was to administer the [MEDICATION NAME] for one week, increase her fluids, and monitor for improvement. Review of the resident's fluid intake sheets, from 1/14/19 through 1/21/19, revealed 23/24 meal amounts were documented. The daily totals of fluids consumed was not documented on the fluid intake sheets or in the resident's medical record. The surveyor totaled the daily fluid intake for the resident from 1/14/19 through 1/21/19 and the intake averaged 683 cc. Interviews conducted on 1/22/19 included the following: a. At 12:25 p.m. and 1:46 p.m., the Assistant Nurse Manager said that there was inconsistent documentation of the resident's oral intakes. She said the night nurse should be adding up the fluid intake for the resident. b. At 12:38 p.m., the Dietary Technician said when a resident begins an antibiotic, she documents the resident's baseline fluid needs, stress needs, and the amount of fluids served on meal trays. She said extra fluids are added to meet the stress need as well as yogurt for the duration of the antibiotic. She said nursing was supposed to keep track of fluid intake because she does not know what the resident is given between meals and with medications. She said there was an intake and output sheet in the chart for nursing to total. c. At 12:49 p.m., the Licensed Practical Nurse (LPN) said when a resident is on an antibiotic for a UTI they document the fluid intake and outputs, but she was not sure who totaled the amounts at the end of the day. She said it would be good to know the total amount of fluids consumed so that the resident could be provided and or encouraged to drink more fluids if needed. d. At 12:51 p.m., LPN #2 said she did not think anyone was responsible to determine the amount consumed in 24 hours. e. At 2:17 p.m., the Registered Dietician said nursing was supposed to total the amount of fluids the resident consumes in a 24 hour period. (10 NYCRR 415.12(j))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #89) of three observations of incontinence care, proper infection control techniques were not followed. The issues involved lack of appropriate glove changing after incontinence care and lack of thorough and appropriate incontinence care. This is evidenced by the following: Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/26/17, revealed that the resident was frequently incontinent of urine, occasionally incontinent of stool, and required extensive assist of staff for personal hygiene. The current Comprehensive Nursing Care Plan directs incontinent management as needed and protective ointment to the sacrum and buttocks with care. During an observation of care on 9/15/17 at 9:50 a.m. with the Licensed Practical Nurse (LPN) and the Certified Nursing Assistant (CNA), the CNA donned gloves and cleaned a large amount of liquid stool from the resident's bottom area. The area was reddened, slightly excoriated, had two small pinpoint open areas, scarring from previous healed pressure areas, and several non-blanchable (indicative of new pressure injury) areas. Neither the frontal peri area or groin creases were assessed or cleansed. Without removing gloves, the CNA touched the resident's hand, her clothing, clean linens, and the bathroom door handle before removing her soiled gloves. Additionally, no preventive skin ointment was applied to the reddened, fragile, non-blanchable areas of skin. Interviews conducted on 9/15/17 included the following: a. At 10:30 a.m., the LPN said she thought the resident received a skin ointment once a shift. The LPN said the resident should have some preventive ointment applied after incontinence care but was not sure what kind. b. At 10:35 a.m., the CNA stated that she did not change her gloves after cleaning the stool from the resident's bottom. The CNA said she should have changed her gloves and cleaned the resident's front peri area. The CNA said that she thought the resident should have some cream applied to her bottom. She said she thought the LPN would apply the cream. c. At 11:40 a.m., the Physician's Assistant said the resident should absolutely have protective cream applied with each incontinence care as her skin is very fragile and has broken down before. In an interview on 9/19/17 at 8:40 a.m., the Registered Nurse Infection Preventionist stated that she expects staff to change their gloves following incontinence care and before touching anything clean. She said that staff should clean the resident's peri area including the back, the front, and the creases especially if the resident had loose stool. She said staff may even need to change their gloves and change the water while providing care. She said the preventive cream should be applied after incontinence care. (10 NYCRR 415.19(a)(1-3)(b)(4))

Base on observations, interviewss and record reviews conducted during the Recertification Survey, it was determined that for two of four residential units reviewed for medication storage, the facility did not ensure that drugs and biologicals were discarded when expired. This is evidenced by the following: An inspection of the medication cart for the 300 Unit on 9/18/17 at 11:10 a.m., revealed a vial of Lantus Insulin 100 units/milliliters dated as opened on 8/7/17. When interviewed at that time, Licensed Practical Nurse (LPN) #1 said that the insulin should be discarded 28 days after being opened. An inspection of the medication cart and medication storage room for the 100 Unit was conducted on 9/18/17 at 11:30 a.m. and revealed the following: a. One opened bottle of Tab-A-Vite (multivitamin), dated as expired June 2017, was found in the medication cart. b. One opened bottle of D3 50 Cholecalciferol (supplement), dated as expired August 2017, was found in the medication cart. c. One vial of Humulin 70/30 Insulin was found in the medication refrigerator, labeled as opened on 8/9/17, and had an expiration date of 9/16/17. A second vial of Humulin 70/30 Insulin that was in use was not labeled with an open date or expiration date. When interviewed at that time, LPN #2 said that the nurses are suppose to check expiration dates before administering medications. She said any medications found to be expired should be discarded. When interviewed on 9/18/17 at 11:51 a.m., the Registered Nurse Manager (RNM) stated that the night shift is supposed to check for expired medications weekly. The RNM said it is the responsibility of the nurse administering medications to check expiration dates. The current facility policy, Medication Storage, revealed that the insulin vials will be discarded 28 days after opening, and that all medications, including stock medications, will be discarded after the expiration date on the bottle or package. (10 NYCRR 415.18(d)(e)(1-4))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of three residents reviewed for notification of change, the facility did not notify the physician of a significant change in each resident's status. The issues involved loose stools and deteriorating health (Resident #99), and significant weight loss (Resident #72). This is evidenced by the following: 1. Resident #99 was admitted to the facility for rehabilitation on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the resident was cognitively intact. Review of the Medical Orders for Life Sustaining Treatment, dated [DATE], revealed the resident did not want to be resuscitated or intubated but did want all other treatments. The [DATE] Comprehensive Care Plan (CCP) documented that the resident was at risk for [MEDICAL CONDITION] and to monitor and report to medical staff signs and symptoms of [MEDICAL CONDITION], such as changes in behavior, sleep patterns, and hallucinations. Review of nursing progress notes from [DATE] to [DATE] revealed the following: a. The resident had three loose stools on [DATE], two extra large stools on [DATE] and [DATE], one loose stool on [DATE], three on [DATE], four on [DATE], and three on [DATE] (one was described as brown mucous stools), and [DATE]. b. On [DATE], the resident complained of being short of breath and his oxygen saturation (measure of how much oxygen blood is carrying) level was 91 percent. c. On [DATE], the resident complained of not feeling well, had a poor appetite, and refused his supplement. d. On [DATE], the resident had a poor appetite and poor intake, refused his supplement, and had a temperature of 99.5 degrees Fahrenheit. The resident's transfer ability was poor and he was confused, seeing bugs crawling everywhere. The resident refused hospitalization and his wife was aware. The medical staff were not notified. e. On [DATE], the resident became sweaty on the night shift. On that same day during the day shift, the resident was found to be very clammy and dusky. The resident's oxygen saturation level dropped to 86 percent. The resident's blood pressure was documented as 60/?, pulse 90, and respirations 22. The resident requested to go to the hospital and the physician was notified. Review of the [DATE] Physician's Assistant (PA) note did not document that the resident was having loose stools. There were no additional PA or physician's notes until two days after the resident was transferred to the hospital. Review of the [DATE] diagnostic summary record revealed that the resident was transferred to the hospital, was admitted with acute kidney injury,[MEDICAL CONDITION] of unknown origin, and expired that day. Interviews conducted on [DATE] included the following: a. At 10:31 a.m., Registered Nurse Manager (RNM) #1 said that she does not remember the resident, but in general, she would expect staff to report loose stools to medical staff within 24 hours and she would expect medical staff to assess the resident. She said that if loose stools went on for days, even if every other day, the PA should have been notified. RNM #1 stated that on the evening shift on [DATE], when the resident was seeing bugs crawling everywhere, the medical staff should have been notified. She said that the resident's request of no hospitalization at that time would have been honored, but the medical staff should have been notified of the resident's condition. RNM #1 stated that there are oncall medical services 24 hours a day. She said the physician may have ordered tests for [MEDICAL CONDITION] ( a bacterium that causes diarrhea and more serious intestinal conditions such as [MEDICAL CONDITION]), lab work, and the Stop and Watch Tool. She said that tool is used to closely monitor residents. She said that if the tool had been used when the resident started with loose stools, it would have made it much clearer that the resident's loose stool was more serious. She said that the standard is to report if a resident's oxygen saturation levels fall below 92 percent. RNM #1 said that medical staff should have been notified on [DATE] when the resident reported shortness of breath and the oxygen saturation level was 91 percent, and when his oxygen saturation level was 88 percent on [DATE]. b. At 11:20 a.m., the physician stated that if the loose stool is watery, bloody, or mucous, he would want to be notified. He said that is not documented. He said he wants to be notified if an oxygen saturation level falls below 92 percent for more than one reading. The physician said he would have expected to have been notified of the resident's condition on [DATE] and [DATE] as he deteriorated. He said he would have recommended sending the resident to the hospital. The physician stated that if a resident is at the facility for rehabilitation and his medical health deteriorates, he wants the resident to go to the hospital. He said if he had been notified when the resident was sick, he would have explained to the resident that he needed to go to the hospital. Interviews conducted on [DATE] included the following: a. At 11:24 a.m., the PA stated he would expect staff to notify him if a resident is having four to five loose stools a day, and especially if there are symptoms. He said that when the loose stools continued for days with [MEDICATION NAME], even though it was not daily, he would have expected to be notified. The PA said that staff should have notified him of the resident's condition on [DATE] because he was probably dehydrated by that time. He said a couple of things could have been done differently if medical had been called even though the resident did not want to go to the hospital. b. At 11:54 a.m. by telephone, the RN Supervisor stated that she worked on [DATE] and did not call the physician after being notified of the resident's condition. She said that she did not know that the resident was having loose stools for weeks. She said she talked to the resident and he did not want to go to the hospital and his wife was aware. The RN Supervisor said sometimes she calls the medical staff and sometimes she does not. She said she thinks that because the resident did not want to go to the hospital, she did not call the physician. The [DATE] facility policy, Physician Notification of Resident Status Changes included to consult with the resident's physician whenever there is a significant change in the resident's condition, for example, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications. Clinical complications include such things as development of a Stage II pressure ulcer, onset of [MEDICAL CONDITION], depression, or recurrent urinary tract infections. 2. Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident was severely cognitively impaired. The CCP, dated [DATE], documented that the resident was comfort care and weights were not being obtained. Review of the medical record revealed the resident had been weighed from [DATE] through [DATE]. Physician orders, dated [DATE], included comfort care. The medical record documented that the resident's weight was 119 pounds on [DATE], 109 pounds on [DATE], and 111 pounds on [DATE]. When interviewed on [DATE] at 12:24 p.m., RNM #2 stated that nursing weighs the residents and dietary reviews the weights. She stated dietary would notify nursing of those residents who required weekly weights. RNM #2 stated nursing would notify the physician of a resident's weight loss. She said per the facility policy they did not have to obtain weights on residents who were comfort care. Interviews conducted on [DATE] included the following: a. At 8:46 a.m., the PA stated residents on comfort care are usually not weighed. He stated when a resident chooses comfort care, there should be documentation on what the resident wants done for comfort care. The PA stated it would be included in the physician orders for no weights. The PA stated he would want to be notified of an eight pound weight loss. b. At 10:30 a.m., the physician stated weights are usually not done on residents who are comfort care. He stated he should be notified of a ten pound weight loss. He said if weights are being done, then the weight loss needs to be addressed. When interviewed on [DATE] at 9:50 a.m., the Food Service Director (FSD) stated monthly weights are completed by the tenth of the month. She said that she reviews the weights for a five pound loss or gain and then requests a reweight. The FSD stated if a resident lost more than 5 percent, she would initiate weekly weights and have a discussion with nursing. The FSD said that nursing would notify the physician of weight loss. The FSD stated weights are not completed on residents who are comfort care and nutritional parameters are not calculated. She stated if weights were completed on a resident on comfort care and weight loss had occurred, it would need to be addressed. Review of the facility policy, Weight Monitoring, dated [DATE], revealed weight monitoring is not indicated if a resident is deemed end stage status and has requested only comfort care. (10 NYCRR 415.3(e)(2)(ii)(b))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #123) of three residents reviewed for non-pressure related skin conditions, the facility did not investigate bruises to rule out abuse, neglect, or mistreatment. The issue involved bruising that was not identified or investigated. This is evidenced by the following: Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/27/17, revealed that the resident was cognitively intact. The Comprehensive Care Plan, dated August 2017, included to monitor the resident's skin daily for signs of abnormal bruising and bleeding and report issues. Review of Incident/Accident Reports, from 7/1/17 through 9/18/17, revealed the resident had no reports of bruises. Review of nursing progress notes, from 8/17/17 through 9/18/17, revealed no documentation that the resident had bruises or ecchymosis (purplish patch caused by blood under the skin). Observations conducted on 9/14/17 at 12:45 p.m., on 9/15/17 at 2:02 p.m., and on 9/18/17 at 8:58 a.m., the resident had a large dark purple bruise on the top of the left hand covering 75 percent of the area and a bruise on the top of the right hand. The resident was wearing arm protectors that extended to her wrist. Interviews conducted on 9/14/17 included the following: a. At 12:45 p.m., the resident stated that she hits her hands on the edge of the overbed table. b. At 2:59 p.m., Certified Nursing Assistant (CNA) #1 stated that the resident had bruises at times but she did not recall any current bruises. c. At 3:15 p.m., CNA #2 stated the resident had bruises and purpura all over and that she reports everything she sees to the nurse. Interviews conducted on 9/18/17 included the following: a. At 9:14 a.m., a Licensed Practical Nurse, Assistant Nurse Manager stated weekly skin observations are completed by a nurse on the resident's bath day. She said if any skin issues, including bruises, were identified, the Registered Nurse (RN) would be notified. She said the RN would assess the area and document it. She stated bruises would be documented in the progress notes and an Incident and Accident Report would be completed. The LPN stated the resident had multiple area of ecchymosis. b. At 8:52 a.m., the Physician's Assistant stated he did not know if the resident had purpura (purple discolored spots from bleeding under skin). He stated if the resident had any skin issues it should be documented in the progress notes or monthly visit notes. c. At 9:22 a.m., the Registered Nurse Manager (RNM) stated an Incident/Accident Report should be completed if a resident has ecchymosis or a bruise. The RNM stated the resident probably had bruises because her skin is fragile. She stated there had not been any Incident/Accident Reports for bruising in the last two to three weeks. The RNM stated that when a bruise is identified, it should be reported to the nurse and an investigation should be initiated. During an observation and interview on 9/19/17 at 10:15 a.m., the RNM observed the resident's hands and stated the tops of both hands were bruised. She said that an Incident/Accident Report and investigation should have been completed to rule out abuse, neglect, or mistreatment. When interviewed on 9/19/17 at 10:29 a.m., the Director of Nursing (DON) stated when a bruise is found the supervisor is notified, and Incident/Accident Report is completed, and an investigation is started. The DON said that staff statements would be obtained, the root cause of the bruise would be determined, and a conclusion would be drawn to rule out abuse, neglect, or mistreatment. She said the resident's bruise should be documented in the progress notes. (10 NYCRR 415.4(b)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #123 and #144) of four residents reviewed for choices, the facility did not allow residents the right to choose health care consistent with their preferences. Specifically, residents were not given showers as their choice of bathing. This is evidenced by the following: 1. Resident #144 was admitted to the facility on [DATE] for rehabilitation with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 8/11/17, included that the resident has moderately impaired cognitive function, is frequently incontinent of urine and stool, is dependent on staff for bathing, and that it is somewhat important to the resident to have a choice of bathing type. The current Certified Nursing Assistant (CNA) Assignment Sheet directed staff that the resident's bath is on Wednesdays day shift. It did not include the type of bath the resident prefers. In an admission Social Work progress note, dated 8/14/17, the Social Worker documented that the resident requires a lot of assistance for Activities of Daily Living and can be involved in choices. The unsigned admission Resident Interviews form for resident preferences, dated 8/7/17, documented the resident's choice for bedtime but did not include the resident's bathing preferences. In an observation and interview on 9/13/17 at 1:17 p.m. and again on 9/14/17 at 3:43 p.m., the resident stated that he had not had a shower since he arrived at the facility. He said that he receives bed baths but would prefer a shower. The resident said that he had a bed bath the day before and did not know why he could not have a shower. He said staff have never offered him a shower. When interviewed on 9/14/17 at 2:16 p.m., the Social Work Assistant said they conduct the resident interviews for choice of bedtimes and bathing on admission. She said she could not find one for this resident and did not know why. Interviews conducted on 9/15/17 included the following: a. At 1:17 p.m., CNA #1 said that the resident receives bed baths because he is transferred with a mechanical lift. She said the protocol on the unit was that all mechanical lift residents received bed baths. She said the resident is no longer transferred with a mechanical lift. b. At 1:20 p.m., CNA #2 said that the resident receives bed baths but she does not know why. c. At 1:30 p.m. and again on 9/19/17 at 11:40 a.m., the Registered Nurse Manager (RNM) said that all lift transfers are bed baths because they do not have shower slings for the lifts. The RNM said the resident has not been a lift transfer since 8/21/17, so he should have been changed to a shower. She said that there are shower slings available in the facility but her unit does not use them. She said the resident was probably never asked his preferences but he should have been. d. At 12:03 p.m., the Director of Rehabilitation stated that she was not aware that some units were not offering showers to residents because they were transferred with a mechanical lift. She said the resident has not been a lift for a while now and that he could absolutely have a shower. 2. Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/7/17, revealed that the resident is cognitively intact. The current CNA Care Sheet revealed that the resident's bath day was Wednesday (evening shift). The Comprehensive Care Plan, dated August 2017, revealed the resident was alert, oriented, and able to express her needs. Approaches included to involve the resident in choices. During an interview on 9/14/17 at 8:24 a.m. and again on 9/18/17 at 8:58 a.m, the resident stated that she did not get a choice in the number of showers or baths she takes in a week or her preference between a tub bath, shower, or bed bath. The resident said she was told her shower day was on Thursdays. She said that she has not showered in at least three weeks. The resident said if she was offered a shower, she would have taken one and not refused. The resident said staff told her if she does not shower when it is offered, then she would have to wait until the following week. During an interview on 9/14/17 at 3:15p.m., the CNA stated the care plan should include when a resident is scheduled for a shower. She said the resident is scheduled for a shower on Wednesday evenings. The CNA said the resident refused her shower the evening before. The CNA said the resident did not like showers so she received a bed bath. The CNA said that when a resident refuses a shower it would be offered the next day. Interviews conducted on 9/18/17 included the following: a. At 9:14 a.m., the Licensed Practical Nurse (LPN) stated if a shower was not given it should be reported to the nurse and documented. The LPN said that the resident did not receive showers because she required a mechanical lift for transfers and had fragile skin. She stated the resident chose to receive a bed bath and has been receiving bed baths for over a year. The LPN said the resident would still be offered showers. b. At 9:22 a.m., the RNM stated if a resident did not want to take showers, the reason would be documented on the resident's care plan. She said the resident should be included in the decision. (10 NYCRR 415.5(b)(1-3))

Based on observations and interviews conducted during the Recertification Survey, it was determined that for two (C and D-units) of four residential units, the facility did not ensure that the resident environment remained as free of accident hazards as possible. The issue was related to resident accessible bathrooms that lacked a nurse call system, lacked emergency door hardware, had water temperatures exceeding 120 degrees Fahrenheit (*F), and could not readily be accessed when locked from within. This is evidenced by the following: 1. Observations on 9/13/17 at 2:35 p.m. revealed the D-unit nurses' restroom next to Resident Room #117 was unlocked, open, and accessible. The water temperature in the sink, at that time, was measured at 130.6*F. There was a sign posted on the door that read: Please Keep Door Closed. Also, the door to this restroom was not equipped with emergency hardware to allow the door to swing in or out, and there was no nurse call station within the restroom. 2. Observations on 9/15/17 at 8:30 a.m. and again at 1:00 p.m. revealed the nurses' restroom next to Resident Room #117 (D-wing) was unlocked, open, and accessible. The water temperature in the hand wash sink was 128.1*F. The door to that bathroom only opened inward and was equipped with a push button on the knob that allowed the door to be locked from the inside. 3. Observations on 9/15/17 at 8:40 a.m. and again at 12:10 p.m. revealed the C-wing nurses' restroom across from the MDS Coordinator office was unlocked, open, and accessible. Additionally, there was a sign posted on the door that read: Please Close Door. The door to the restroom was not equipped with emergency hardware to allow the door to swing in or out, and there was no nurse call station within the restroom. The door to this bathroom only opened inward and was equipped with a push button on the knob that allowed the door to be locked from the inside. In an interview at that time, the Nurse Manager (NM) said there is a master key that should unlock the door. The NM then attempted to unlock the staff bathroom using the master key and several others with no success. The NM then stated that she would have to call maintenance to unlock the door. 4. When interviewed on 9/15/17 at 12:01 p.m., Registered Nurse Manager (RNM) #2 said that there is one male resident with dementia on the D unit that ambulates independently but needs supervision in the halls. 5. During an interview on 9/19/17 at 11:43 a.m., RNM #2 stated that there is one male resident with dementia on the C unit that wanders and ambulates in the hallway. RNM #2 stated that she does not know if they have a key for the staff bathrooms. (10 NYCRR 415.29, 415.29(a)(1))

Based on observations, interviews, and record reviews, it was determined that for one (Resident #93) of three residents reviewed for accidents and incidents, the facility did not thoroughly investigate bruises of unknown origin to rule out abuse, neglect, or mistreatment. The issue was lack of investigation of a bruise of unknown origin on the resident's left hand. This is evidenced by the following: Resident #93 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/6/16, described the resident with moderately impaired cognitive skills. Review of physician orders, dated 6/20/16, revealed a lack of prescribed orders for blood work. In a progress note written that day, the physician documented that there were no acute concerns with the resident's skin integrity. Review of nursing progress notes, dated 6/23/16, revealed that the resident had a large ecchymotic area on top of the left hand and had blood work done on 6/21/16. During an observation on 7/6/16 at 9:34 a.m., there was a fading bruise covering the top of the resident's left hand. Licensed Practical Nurse (LPN) #1 said she thought the bruise might be from a blood draw. Interviews conducted on 7/7/16 included the following: a. At 9:27 a.m., a Registered Nurse/Nurse Manager (RN/NM) said, The bruise is not brand new, definitely old, there is a little hematoma on it, and so you could see where it might be from a blood draw. But there are no orders for blood work. She stated that an investigation should have been initiated when the bruise was discovered. b. At 9:56 a.m., the RN/NM said she had not been able to find an investigation and would start one. c. At 10:30 a.m., a family member reported that he did not know what caused the bruise and that nursing staff had not talked to him about the bruise. d. At 10:40 a.m., Certified Nursing Assistant (CNA) #1 Mentor said she usually takes care of this resident on the day shift. CNA #1 reported that she had seen the bruise and was told it was from a blood draw. Review of an Incident/Accident Report, dated 7/7/16, revealed that the bruise on top of the resident's left hand measured 7.3 centimeters (cms) x 5.2 cms, and there was a slight puffy area measuring 2 cms. The involved LPN statement included she did document the bruise but could not recall the situation. Review of the facility's policy, Alleged Abuse, Mistreatment, Neglect, Misappropriation of Resident Property, Internal Investigation and Reporting Procedure, dated April 2016, revealed that allegations of abuse, neglect, or mistreatment will be investigated. (10 NYCRR 415.4(b)(3))

Based on an interview and record review, it was determined that for one of five employee files reviewed for the Nurse Aide Registry Check, the facility did not operationalize their policy for abuse prescreening for all new hires. Specifically, Dietary Porter #1 was not checked through the Nurse Aide Registry Check prior to beginning employment at the facility. This is evidenced by the following: A review of employee files on 7/6/16 at approximately 9:59 a.m. revealed that Dietary Porter #1 was hired on 4/4/16. In an interview at approximately 10:03 a.m. that day, the Office Manager stated that they could not find documentation of the Nurse Aide Registry Check for Dietary Porter #1. The Office Manager stated that the job duties for a Dietary Porter would include delivering food carts to resident living areas. (10 NYCRR 415.4(b)(1)(ii))