Every finding on record at M.M. Ewing Continuing Care Center

Based on observations, interviews and record review conducted during the Recertification Survey from 7/17/23 to 7/21/23, it was determined that for one (Resident #8) of three residents reviewed for communication and sensory deficits, the facility did not ensure that each resident was treated with respect and dignity and care for each resident in a manner that promotes enhancement of their quality of life. Specifically, staff did not identify themselves as requested and per Resident #8's comprehensive care plan (CCP) and did not provide clear communication when providing care to the resident who has communication and sensory deficits. This is evidenced by the following: Resident #8 had diagnoses including legal blindness, acquired absence of the left eye, and hemiplegia (paralysis) of the left upper and lower extremities. The Minimum Data Set assessment dated [DATE], documented that Resident #8 was cognitively intact, required limited to extensive assist of staff for activities of daily living, has limited vision (not able to see newspaper headlines but can identify objects) and wears hearing aids. Review of the Comprehensive Care Plan revealed that Resident #8 and their family requested a sign on their door requesting staff knock, introduce themselves and state their role before entering the resident's room. During an interview on 7/17/23 at 12:41 PM, Resident #8 said that at times they have had to request a substitute meal and staff would leave a menu on their bedside table without reading it to them. The resident said staff do not sit with them to complete their weekly menu, so they eat whatever the kitchen delivers. During an observation and interview on 7/20/23 at 10:22 AM, Licensed Practical Nurse (LPN) #1 entered Resident #8's room (private room) without knocking or identifying themselves prior to entering and engaged with another staff member who was administering care to Resident #8 without any explanation to the resident. A family member stated at the time that they visit almost daily, and that staff routinely disregard the sign (that requests staff to knock and identify themself). Resident #8 stated that sometimes staff enter without talking to them at all, but they can hear the sound of them in their room. During an interview on 7/20/23 at 11:52 AM, LPN #1 said the sign on Resident #8's door was put in place due to the resident's blindness and the confusion the resident would experience when hearing sounds outside their room. LPN#1 said the sign is not followed consistently due to Resident #8 being acclimated to staff. LPN #1 said they were not aware if anyone had asked the resident if they still wanted the sign followed. During an interview on 7/20/23 at 12:17 PM, Resident #8 stated that despite being in the facility awhile, they would still prefer staff to tell them who they are when entering their room because there are too many staff for them to differentiate everyone's voice. During an interview on 7/20/23 at 3:11 PM, the Administrator stated that residents have a right to know who is entering their room to provide care to them and that staff should consistently knock, wait for the resident to reply, and introduce themselves when entering. During an interview on 7/21/23 at 11:40 AM, the Director of Nursing (DON) stated that in addition to knocking and introducing themselves, for a resident with a visual or hearing impairment, staff should communicate with the resident every step of the process and be specific about the care they are providing. 10 NYCRR 415.3

Based on observations, interviews and record review conducted during the Recertification Survey from 7/17/23 to 7/21/23, it was determined that for one (Resident #16) of three residents reviewed for choices, the facility did not ensure the resident's right to retain and use personal possessions as space permits unless to do so would infringe upon the rights or health and safety of other residents. Specifically, Resident #16 was not given permission to purchase a small personal item to keep in their room without a valid reason. This is evidenced by the following: The undated facility policy Residents Rights and Grievance Policy documented that residents have the right to have and use personal possession such as furniture, clothing, and electronics. Resident #16 had diagnoses including Multiple Sclerosis (a disease that affects the immune system and nerves) and hemiplegia (paralysis of one side of the body). The Minimum Data Set (MDS) assessment dated [DATE], documented that Resident #16 was cognitively intact. The MDS Assessment also documented that it was very important for the resident to take care of their personal belongings and things. Review of the Resident #16's Comprehensive Care Plan revealed the resident prefers to take care of their personal belongings and for staff to ensure the resident has access to their favorite things. During observations and interviews on 7/19/23 at 12:29 PM and again at 2:14 PM Resident #16 stated they would like to order a tiny (about 6 inches tall) figurine that they saw online for their room but was told by their (unit) Social Worker (SW) #3 not to order it until the staff checked it out first due to concerns of clutter. The resident's room was a private room with a clear visible path for the resident to transfer and self-propel in their wheelchair and a bookshelf against the wall with figurines and family photographs. Resident #16 pointed to an empty area on the top shelf where they said they wanted to place the figurine but was told several days ago to wait for permission to order it but has not heard anything back. During an interview with the Director of Social Work (DSW) and Registered Nurse Manager (RNM) #1 on 7/19/23 at 1:45 PM, both stated that they told Resident #16 that they could not order the figurine because the resident orders a lot of stuff, and then it becomes a safety issue if it starts to clutter. Neither the DSW or RNM #1 were able to clarify the specific safety concern. At 2:26 PM the DSW stated that they have guidelines for the rooms and that they would ask Resident #16 if they would like to give something up in their room in order to buy the figurine. During an interview on 7/19/23 at 3:06 PM, SW #3 stated they spoke with Resident #16 about decluttering their room and their safety concern was that the figurine was fragile and could get broken. In addition, SW #3 said a staff member from maintenance would have to inspect the resident's room prior to ordering the figurine to ensure that the resident's room was safe. During an interview on 7/20/23 at 10:58 AM, maintenance staff member #4 stated they were there to inspect Resident #16's room (after surveyor interventions) and where the resident wanted the figurine to go for safety issues and stated they had no safety concerns regarding the figurine. During an interview on 7/20/23 at 3:11 PM, the Administrator stated that it is their policy that residents can order decorations as long as the interdisciplinary team did not feel there was a safety concern. The Administrator stated it was the resident's right to order decorations for their room without needing permission from staff. During an interview with Resident #16 on 7/21/23 at 10:55 A.M., the resident said needing permission from staff to order personal items upset them because they felt staff did not listen to or try to understand them. 10 NYCRR 415.3

Based on observations, interviews, and record reviews conducted during a Recertification Survey from 7/17/23 to 7/21/23, it was determined that for one (Resident #271) of one resident reviewed for edema (swelling due to excess fluid in the body's tissues, usually occurring in the lower extremities), the facility did not provide services, as outlined by the resident's person-centered comprehensive care plan (CCP) and physician orders, that met professional standards of quality. Specifically, Resident #271 was observed without [NAME] stockings (compressions stockings used for edema and to prevent blood clots in the lower extremities) as ordered by the physician. Additionally, staff documented that the [NAME] stockings were applied to the resident when they were not. This is evidenced by the following: Resident #271 was recently admitted to the facility with diagnoses that included acute respiratory failure, cirrhosis (liver disease), and a stage IV (full thickness tissue loss involving dead tissue, muscle or bone) pressure ulcer. In nursing progress notes dated 7/15/23 to 7/17/23 several nurses documented that Resident #271 was alert and oriented and had 2+ (grading scale to measure degree of edema from 1+ to 4+) edema to both legs. During an observations and interview on 7/18/23 at 11:52 AM, Resident #271 (identified as alert and oriented by facility and surveyor) stated that they had edema to both lower legs, and that Physical Therapy staff had said that they should start wrapping the resident's legs. Resident #271 was observed to have edema to both legs with a blister-like area to the outside of the right lower leg, near the ankle and was not wearing any compression stockings and legs dependent. Resident #271 stated that they did not have any leg stockings, but that staff told them to elevate their legs, but this caused pain to the resident's buttock area. In a medical note dated 7/19/23 the physician documented that Resident #271's legs were firm with 2+ edema, which extended to the resident's knees. Current physician orders, initiated on 7/19/23 at 10:22 AM, documented thigh high (thighs to toes) [NAME] stockings to be applied in the morning (6:00 AM to 9:00 AM) and removed in the evening (7:00 PM to 10:00 PM). During an observation and interview on 7/20/23 at 1:21 PM, Resident #271 was not wearing [NAME] stockings and their feet were not elevated. Resident #271 stated they (staff) would begin wrapping their legs with stockings. Thigh high [NAME] stockings were observed on the resident's bedside stand. Review of Resident #271 Progress Notes all dated throughtout the day on 7/20/23 and authored by nursing staff did not include any documentation that Resident #271 had refused to wear the thigh high [NAME] stockings. During an observation on 7/21/23 at 11:42 AM, Resident #271 was sitting in their room, their feet were on the ground (versus elevated), and the thigh high TEDS stockings remained on the resident's bedside stand in the same spot as previous observation. Resident #271 stated that they had not yet used the stockings. Resident #271 stated they had not told any staff member that they would not wear the stockings. Review of the July 2023 Treatment Administration Record (TAR) for Resident #271 revealed the thigh high TEDs were documented as removed on evening shift on 7/19/23, applied in the morning on 7/20/23 and removed in the evening and refused on 7/21/23. During an interview on 7/21/23 at 11:53 AM, RN #2 stated that for most residents with lower extremity edema, interventions would include some type of compression ([NAME] stockings, ACE wraps or Tubi-grips), encourage elevation, and sleeping in bed (versus a recliner). RN #2 stated that [NAME] stockings are ordered by the physician and that the nurses are responsible for ensuring that the [NAME] stockings are applied and documented in the TAR. RN #2 stated they thought Resident #271 had the [NAME] stockings but that that they had not put them on Resident #271. RN #2 stated that Resident #271 had not refused to wear them. Upon reviewing the July 2023 TAR, RN #2 confirmed that they had documented that they applied the [NAME] stocking but observation at this time revealed Resident #271 was not wearing the [NAME] stockings. During an interview on 7/21/23 at 12:10 PM, Registered Nurse Manager (RNM) #3 stated that [NAME] stockings, ACE wraps or Tubi-grips require a physician order and that the nurses should document putting them on and taking them off. During an interview on 7/21/23 at 1:23 PM, the Director of Nursing (DON) stated that nursing staff are expected to follow medical provider orders, and if the order is questioned, they would expect staff to contact the provider. The DON stated if a resident refused a provider order, they would expect staff to provide education to the resident and reapproach (depending on the resident). Additionally, the DON stated staff are expected to notify the provider if a resident refused an order and to discuss a potential alternative. 10 NYCRR 415.11(c)(3)(i)

Based on observations, interviews and record reviews conducted during a Recertification Survey, completed on 11/16/21, it was determined that for one (Resident #115) of five residents reviewed for unnecessary medications and one (Resident #19) of three residents reviewed for indwelling (Foley) catheter, the facility did not develop and implement a plan of care for each resident that included measurable goals and objectives to address the residents' medical, physical, mental, and psychosocial needs. Specifically, The Comprehensive Care Plan (CCP) for Resident #115 did not include person-centered goals and interventions to address the use of [CONDITION(S)] medications (including both antipsychotic and antidepressant medications) and the CCP for Resident #19 did not include the care of a Foley catheter (indwelling catheter into the bladder and drains urine into a bag), medical indication for, and measurable goals and objectives. This is evidenced by the following: 1.Resident #115 was admitted with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 4/5/21, revealed the resident's cognitive skills for daily decision making were severely impaired, that the resident received antipsychotic and antidepressant medications, had behavioral symptoms and was experiencing delusions. Review of current medical orders included [MEDICATION(S)] (antidepressant)15 milligrams (mg) every morning, and [MEDICATION(S)] (Antipsychotic) 25 mg in the evening for hallucinations. A medical note dated 10/29/21, included Resident #115 was seen for depressive symptoms and suicidal statements. Review of the CCP, dated 3/30/21, revealed that the CCP did not include the use of [CONDITION(S)] medications, the targeted symptoms, potential side effects, or plans for a gradual dose reduction. When interviewed the 11/15/21 at 1:51 pm, the Assistant Registered Nurse Manager stated they did not see [CONDITION(S)] medications addressed in the care plan, and it should have been. When interviewed on 11/16/21 at 2:11pm, the Director of Nursing stated the expectation is the CCP should include [CONDITION(S)] medications with the potential side effects. 2. Resident # 19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 8/21/21, included that Resident #19 had severely impaired cognition, required the extensive assistance of staff for toileting and was frequently incontinent of bladder. Review of the current Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The current CCP and CNA Assignments Summary (care plan used by the CNAs to direct daily care) included only that Resident #19 had a Foley inserted on 10/11/21 following hip surgery. Neither care plan included daily care of the Foley catheter or any measurable goals and objectives. When interviewed 11/16/21 at 12:54 p.m. CNA #1 stated the care card did not explain the care to be provided but that they provided what they had learned in school. When interviewed 11/16/21 at 9:50 a.m. the Assistant Nurse Manager (ANM) stated the care for a Foley catheter should be included on the Treatment Administration Record and include securing the Foley and peri (area surrounding the Foley insertion site) care. The ANM stated there was a protocol for care of a Foley and it should be on the care card (care plan used by CNA). The ANM stated that a Foley should be addressed in the CCP including goals and interventions. 415.11 (c)(1)

Based on observations, interviews and record review conducted during a Recertification Survey, completed on 11/16/21, it was determined that for one (Resident #326) of one resident reviewed, the facility did not ensure that proper fluid intake was monitored and provided to maintain proper hydration and health. Specifically, physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evidenced by the following: Resident #326 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical admission history and physical report, dated 11/3/21 documented that Resident #326 was alert and appropriate, that the [CONDITION(S)] was slowly improving and to continue a fluid restriction of 1000 milliliters (mls) fluid daily and if the resident's sodium level improved the restriction could increase to 1500 mls daily. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Comprehensive Care Plan (CCP) and the Certified Nursing Assistant Care Card both documented that Resident #326 was on a fluid restriction of 1500 mls. The CCP also included for staff to encourage fluids. In the Nutritional Assessment, dated 11/4/21, the Registered Dietician (RD) documeted that the resident was on a 1500 ml fluid restriction and also that the fluid needs were for 1680-2000 mls/day. Review of the Treatment Administration Record (TAR), dated 11/3/21 through 11/15/21, revealed the 1000 mls fluid restriction started on 11/4/21 and the 1500 mls restriction was not started until 11/6/21. The TAR did not include any fluid totals per shift or 24-hour totals. Review of the Intake Summary Sheets dated 11/3/21 through 11/15/21, revealed documentation of fluid intakes per shift and totals for each day. Totals revealed the resident's fluid restriction orders were exceeded on four of the 13 days with totals as high as 2070 mls. The report also included that the fluid daily totals were significantly lower than ordered by as much as 700 mls and that 13 shifts were reported as zero or blank for fluid intake (including several day shifts). During and observation and interview at 11/10/21 at 1:37 p.m., Resident #326 stated they were not aware of how much fluid they can have per day but that they drank whatever the staff brings them. Observed at the time were two 240ml cups on the bedside table that were empty. During an observation on 11/12/21 at 2:47 p.m. Resident #326 was in bed. Signage on the room door included the resident was on a 1500 ml fluid restriction and had received 60 mls at 6:30 a.m., 240 mls at 10 a.m., and 118 mls at 12 p.m. for a total of 423 mls so far. Three 240 ml drinking cups were observed on the residents over bed table. During an observation 11/15/21 at 8:22 a.m. Resident #326 was in bed. There were two 240 ml drinking cups on the resident's overbed table. When interviewed on 11/15/21 at 1:49 p.m. The CNA stated that Resident #326 was on a 1500 ml fluid restriction and that when staff give the resident fluids it is supposed to be written on the paper on the door and the total added up. The CNA stated it was on the resident's meal ticket how much fluid was on the tray and they documented how much the resident took in for that meal. During an interview on 11/15/21 at 3:47 p.m. the Registered Dietician (RD) stated for a resident on a 1500 ml fluid restriction dietary would be allotted 750 mls and nursing would be allotted 750mls. The RD stated Resident #326 should receive 250 mls on each meal tray which would include meals and supplements. The RD stated it was left up to nursing to monitor the 24-hour totals. When interviewed on 11/16/21 at 8:30 a.m. and at 11:04 a.m. the Director of Nursing (DON) stated the facility did not have a policy/procedure for fluid restrictions. The DON stated nursing should determine the number of fluids allotted for medication pass and include the per shift total. The DON stated dietary and nursing should be reviewing the 24-hour totals and if the fluid restriction is exceeded it would be communicated to the medical provider. When interviewed on 11/16/21 at 9:34 a.m. the Assistant Registered Nurse Manager (RNM), stated their expectations for residents on fluid restriction included intake sheets on the resident's door for staff to document. The Assistant RNM stated it should be passed on in report the number of fluids provided on each shift but that they would have to review the policy to see the allotment of fluids per shift for medication pass. The Assistant RNM stated the night nurse should check the 24- hour total and if the resident exceeded their restriction the medical provided would be notified. The Assistant RNM stated the CNAs should ask nursing prior to giving any fluids to a resident on a fluid restriction. The Assistant RNM viewed the intake summary sheet for 11/15/21, totaled it and stated Resident #326 had exceeded the fluid restriction but it had not been reported to her or put on the 24-hour report. The facility did not provide any documentation that Resident #326's intakes were reported on any 24 hour report for that time period or that the medical provided was notified. 10NYCRR 415.12 (i)(1)

Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 501) completed on 7/24/19, it was determined that for three (Residents #2, #4, and #5) of three residents reviewed for abuse, the facility did not investigate and report allegations of possible abuse, neglect or mistreatment to the New York State Department of Health (NYSDOH) timely. Specifically, staff members suspected that Licensed Practical Nurse (LPN) #3 was not following physician orders [REDACTED]. An investigation was not initiated until 11 days later, and the accused LPN continued to work during that time. This is evidenced by the following: The (MONTH) (YEAR) facility policy, Abuse Prevention Program included that all allegations of resident abuse, neglect, mistreatment, and injuries of an unknown source shall be promptly and thoroughly investigated by the facility. The facility will maintain a safe environment for the residents during the investigation. Associates of the facility who have been accused of resident abuse may be reassigned to non-resident care duties or suspended from duty until the results of the investigation have been reviewed. It is the responsibility of our associates, facility consultants, attending physicians, family members, visitors, etc. to promptly report any incident or suspected incident of neglect or resident abuse. Associates, facility consultants and/or attending physicians must report any suspected abuse or incidents of abuse to the Administrator immediately. Neglect is defined as failure of the facility, its employees or service providers, to provide goods and services necessary to avoid physical harm, mental anguish, or emotional distress. Review of the facility investigation, dated 9/18/18, revealed that the Registered Nurse (RN) Manager was notified on 9/11/18 by LPN #1 that she had a concern that LPN #3 was not taking blood glucoses (BGs) as ordered. The investigation concluded that on nine separate occasions, Resident #2's BG was not documented on the glucometer or in the laboratory documentation which was verified with the laboratory director. The facility identified that additional residents did not have BGs obtained and concluded that no harm occurred. The Nurse Practitioner (NP) was notified on 9/18/18 and the NYSDOH was notified on 9/18/18. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/19/18 Minimum Data Set (MDS) Assessment included that the resident had moderately impaired cognition and received insulin injections seven days a week. The 8/10/18 physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Adminsitration Record (MAR) revealed all BGs were documented. Review of the BG printout from the laboratory revealed that on ten occasions, from 9/1/18 through 9/17/18, Resident #2's BGs were not obtained. Review of the resident assignments and the laboratory nurse report revealed that LPN #3 was the nurse assigned to Resident #2 on all the days where BGs were missing. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/15/18 MDS Assessment included that the resident had severely impaired cognition. The 8/28/18 physician orders [REDACTED]. The (MONTH) (YEAR) MAR included that on 9/10/18 the blood sugar was 148 at 8:00 a.m. Review of the hospital laboratory clinical chemistry report, dated 9/10/18, revealed there was no BG taken at 8:00 a.m. and that LPN #3 was the assigned nurse. 3. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/9/18 MDS Assessment included that the resident was cognitively intact and received insulin injections seven days a week. The 8/20/18 physician orders [REDACTED]. The (MONTH) (YEAR) MAR included that on 9/3/18, the BG was 148 at 8:00 a.m., and on 9/10/18, the BG was 176 at 8:00 a.m. Review of the hospital laboratory clinical chemistry reports, dated 9/3/18 and 9/10/18, revealed there were no BGs taken at 8:00 a.m. and that LPN #3 was the assigned nurse. Interviews conducted on 7/9/19 included the following: a. At 9:50 a.m., the RN Manager said that on 9/10/18 or 9/11/18 late in the day, LPN #1 came to her and told her that LPN #2 had concerns that LPN #3 did not do Resident #2's BGs. The RN Manager said she asked for more details and LPN #1 said to ask LPN #2. The RN Manager said she did not work from 9/12/18 through 9/16/18. When she returned to work, LPN #1 reminded her about the issue. She said on 9/17/18 she asked the lab to give her a printout of all of Resident #2's BGs from the glucometer. She said she cross referenced the MAR and the glucometer readings and found that results were missing from the glucometer and the laboratory printout. She said she then expanded her investigation back to 9/1/18 and to other residents on the unit that needed BGs. She said when she expanded the sample to other residents, she found that Residents #4 and #5 also had BGs missing. The RN Manager said that the delay between 9/11/18 and 9/17/18 was due to a personal emergency. She said knowing what she knows now, she did not think there was anything else she could have done differently. She said the two LPNs brought it to her attention when she returned to work. The RN Manager said that an accusation of abuse, neglect, or mistreatment should be reported within 24 hours, but the investigation would continue. She said there was no harm to Resident #2, so she could not conclude that abuse, neglect, or mistreatment occurred. LPN #3 was suspended on 9/18/18 and terminated for falsification of documentation on 9/25/18. b. At 11:05 a.m., LPN #1 said that on 9/8/18 and 9/9/18, LPN #2 told her that she did not think LPN #3 was completing BGs as ordered for residents. LPN #2 told her she watched LPN #3 on 9/7/18 and she did not see her use the glucometer. She said LPN #2 reported that she checked the glucometer review results and found no BG result for 9/7/18 at lunch time for Resident #2. LPN #1 said she then checked the MAR and there was no BG documented for lunchtime. She said she probably should have notified the Director of Nursing (DON) on 9/10/18 when LPN #2 told her about the incident but she waited until the RN Manager returned to work on 9/11/18 to report it. LPN #1 said she told the RN Manager that LPN #3 was not doing BGs and that LPN #2 had checked the history in the glucometer and there were missing BGs but the MAR had BGs documented. LPN #1 said that on 9/17/18 when the RN Manager returned to work, LPN #1 reminded her about the incident and was told she was working on it. LPN #1 said she did not tell anyone else about this incident but thought that LPN #2 should have reported it because she was the one observing it. LPN #1 said she was just as responsible as LPN #2 for not reporting it once she was aware. She said that if there was an order for [REDACTED]. c. At 12:45 p.m., the DON said she was notified of the incident on 9/18/18 by the RN Manager. She said that there was an accusation that LPN #3 had not performed BGs as ordered, she suspended LPN #3 and started an investigation on 9/18/18. The DON said she found three residents that did not have BGs done and LPN #3 was the nurse. She said LPN #3 was terminated for falsification of records on 9/25/18. The DON said she was not sure when the RN Manager was notified. She said the investigation documentation revealed she was notified on 9/11/18. The DON said that she did not know what happened between 9/11/18 and 9/18/18. The DON said that if she had been notified sooner about the allegation, she might have suspended LPN #3 sooner. The DON said that it was considered neglect for failure to follow physician orders. She said the RN Manager should have reported the allegation to someone else or directly to the NYSDOH herself. When interviewed on 7/24/19 at 8:45 a.m., LPN #2 stated that she was watching LPN #3 for a couple of weeks because she was done with her work early. LPN #2 said that on 9/7/18 she watched LPN #3 carefully and did not see her use the glucometer. At the end of the day, LPN #2 said she checked the glucometer and found that no BG was taken for Resident #2 at lunchtime, but one was recorded in the MAR. LPN #2 said she talked to LPN #1 on 9/8/18 and 9/9/18 and looked at the glucometer history again. LPN #2 said she was off on 9/10/18 but she heard that LPN #1 had shared their suspicions with the RN Manager. LPN #2 said she thought the RN Manager would talk to her on 9/11/18 but she did not and then was gone until 9/16/18. She said the RN Manager talked to her on 9/17/18 and asked her to write a statement which she did on 9/21/18. LPN #2 said she believes that LPN #3 neglected the resident. She said that could have been detrimental or even life threatening to the resident. She said she believes that if there was an allegation of abuse, neglect, or mistreatment, the alleged staff should be suspended. LPN #3 did not respond to the surveyor's attempts to be interviewed by telephone. (10 NYCRR 415.4(b)(2))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 13 (Residents #123, #129, #30, #52, #73, #59, #35, #45, #77, #167, #106, #118, and #78) of 20 residents reviewed for Baseline Care Plans, the facility did not develop a care plan that included the minimum required health care information within 48 hours of admission and/or provide the resident and/or resident representative with a written summary of the resident's Baseline Care Plan in a language and conveyed in a manner that the resident or representative can understand. This is evidenced by, but not limited to, the following: Review of the facility procedure, Baseline Care Plan (BCP), effective 11/8/18, revealed the facility would develop a BCP within 48 hours of admission and or provide a written summary of the care plan to the resident and the representative prior to completion of the Comprehensive Care Plan (CCP). The BCP will reflect goals/objectives and include interventions that address the resident's current needs, and there will be documentation in the electronic health record that the BCP summary was given to the resident and or representative. 1. Resident #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 4/8/19, revealed the resident was cognitively intact and received injections and an anticoagulant for seven days. Review of the admission orders [REDACTED]. The BCP provided by the facility included information, dated 3/12/19 (prior to admission), but did not include current information such as goals, objectives, and/or interventions necessary to address the resident's need for and appropriate monitoring of the anticoagulant medications. When interviewed on 4/23/19 at 12:00 p.m., the Assistant Nurse Manager stated that the BCP was started at the time of admission. She said if a resident had a prior admission, information was repopulated from the care plan associated with the previous admission and additional information pertinent to the current admission should be added. She said a written summary was not necessarily provided. She said the information given to the resident and/or representative included the printed care plan and physician orders. 2. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/15/18, revealed that the resident had severely impaired cognition. Review of the medical record revealed no documented evidence that a BCP was completed within 48 hours of admission or that any summary of the care plan was reviewed or provided to the resident's representative following admission to the facility. When interviewed on 4/19/19 at 1:47 p.m., the Registered Nurse Manager stated that she could not provide a BCP for the resident. She said the facility was not completing BCP at that time despite the regulation going into effect (MONTH) (YEAR). 3. Resident #52 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/8/18, revealed the resident had severely impaired cognition. Review of the medical record revealed that a BCP was not provided to the resident until after she had been transferred from Short-term Rehabilitation to a Long-Term Care unit on 9/4/18 (approximately four weeks after the resident's admission). 4. Resident #129 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/19/19, revealed the resident was cognitively intact. Review of the medical record revealed no documented evidence that a summary of the BCP was reviewed or provided to the resident and/or representative. During an interview on 4/24/19 at 10:37 a.m., the Administrator, Director of Clinical Compliance, and the Director of Nursing stated that the BCP was developed as a team and audits had been completed. They said that they were not sure if the facility completed BCPs at the time the new regulation went into effect.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #143) of three residents reviewed for accidents, the facility did not ensure the implementation of each resident's care plan. Specifically, the resident was not wearing geri sleeves at the time of the 3/18/19 incident, and staff did not instruct the resident to tuck in his arms while going through the doorway. This is evidenced by the following Resident #143 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/22/19, revealed that the resident's cognitive skills for daily decision making were moderately impaired, and the resident required extensive assistance of staff with bed mobility, transfers, dressing, toileting and personal hygiene. The Comprehensive Care Plan, dated 6/25/18, revealed that the resident sustained [REDACTED]. Interventions included to provide geri sleeves when out of bed for protection, and was revised on 3/19/19 to include staff to remind resident to tuck his arms in while going through the doorway. The Certified Nursing Assistant (CNA) Care Card directed geri sleeves to be worn when the resident is out of bed. The Incident and Accident Report, dated 3/18/19, revealed that the resident bumped his arm on the doorway going into the bathroom, causing a 3 centimeter (cm) x 3 cm skin tear. The resident was not wearing a geri-chair sleeve. Measures taken to prevent reinjury included to remind the resident to keep his arms tucked into his body. During an observation on 4/23/19 at 9:00 a.m., the resident was transferred using the Redi-stand. The resident was sitting on the Redi-stand and staff pushed the resident across the room to the bathroom. The CNAs backed the resident's chair into the bathroom. The resident's arms were resting on the armrests, and he was wearing his geri sleeves. There was an approximately 2 inch clearance between the arms of the chair and the bathroom doorway. The staff did not remind the resident to keep his arms inside the wheelchair. When interviewed on 4/23/19 at 10:15 a.m. and 11:12 a.m., the Director of Nursing (DON) and Registered Nurse Manager (RNM) both said that the resident wears geri sleeves all day, every day until he goes to bed. They said that on 3/18/19 the resident was in bed but had to get back up to go to the bathroom. They both said that they would not have expected the CNAs to put the geri sleeves back on just to take the resident to the bathroom. The DON said that the staff should remind the resident to keep his arms/elbows in while going through the doorway. (10 NYCRR 415.11(3)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 931), it was determined that for one (Resident #30) of five residents reviewed for Activities of Daily Living, the facility did not provide the necessary care and services to maintain personal hygiene. The issue involved the lack of incontinence care in a timely manner. This is evidenced by the following: Resident #30 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set, Assessment, dated 4/17/19, revealed that the resident had severely impaired cognition, was frequently incontinent of bladder and bowel, and required the extensive assist of one staff for transfers and toileting. The Certified Nursing Assistant (CNA) Assignment Summary revealed that the resident required one assist for toilet use and stress incontinence was written under bladder continence. During multiple observations throughout the day shift on 4/19/19 from approximately 8:30 a.m. through 1:20 p.m., the resident was up in a geri chair in front of the nurses' station, transferred to coffee hour, and then in the dining room for lunch, and back to the nurses' station after lunch at approximately 1:00 p.m. At no time was the resident observed toileted. At approximately 1:20 p.m., the resident smelled strongly of urine and the surveyor requested an observation of incontinence care. CNA #1 transferred the resident to the toilet using a stand lift. The resident's clothing and wheelchair cushion were soaked with urine. The resident then had a bowel movement in the toilet. When interviewed at that time, CNA #1 stated that the resident was up when she arrived at 7:00 a.m. because the night shift staff got her up and dressed. CNA #1 said that she had not toileted the resident since then as there were only three aides on and she could not get to the resident. CNA #1 said she did not think anyone else toileted the resident. She said that sometimes the resident is continent if staff can get to her in time, but she will not ask to be toileted. In an interview on 4/19/19 at 2:27 p.m., CNA #2 and CNA #3 both stated they did not toilet the resident nor did they know of anyone who did. When interviewed on 4/22/19 at 9:02 a.m, the Licensed Practical Nurse stated he did not provide any care for the resident because no one asked him to. During an interview on 4/23/19 at 3:06 p.m., the Registered Nurse Manager stated that if the resident was not on a specific schedule for toileting, then the standard would be two to three times a shift. She said that if the night shift staff got the resident up and she was not toileted until after 1:00 p.m., that would be too long. She said that CNA #1 should have asked for help but to her knowledge she did not. (10 NYCRR 415.12(a)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #78) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen was free of unnecessary [MEDICAL CONDITION] medications. The issues involved the lack of consistent non-pharmacological interventions prior to multiple doses of an anti-anxiety medication, and the lack of a medical evaluation prior to renewing the [MEDICAL CONDITION] medication every 14 days. This is evidenced by the following: Resident #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/8/19, revealed that the resident was cognitively intact, had no behaviors and scored 7/27 on the PHQ-9 (an interview used to determine signs and/or symptoms of depression). Multiple observations of the resident throughout the day shift over three days revealed the resident in her room watching TV or in the hallway watching TV and conversing with staff and residents. The resident was alert and oriented but pleasantly declined an interview with the surveyor stating she had no complaints. Physician orders, dated 11/2/18 on admission, include [MEDICATION NAME] (anti-anxiety medication) 0.5 milligrams (mg) every evening at 9:00 p.m., for sleep disturbance related to anxiety. On 12/14/18, the [MEDICATION NAME] was changed to 0.5 mg every six hours as needed for anxiety for 14 days. The order was renewed every 14 days from 12/14/18 to 4/10/19. The resident was also on an antidepressant medication throughout. The physician documented on 12/14/18 (the day the [MEDICATION NAME] was changed to every six hours as needed) that the resident had worsening depression following admission to long term care but was handling it much better and was to continue using the anti-depressant for an underlying mood disorder. Review of the Medication Administration Records for the past ten weeks revealed that the resident received 19 doses of the [MEDICATION NAME] in (MONTH) 2019, 37 doses in (MONTH) 2019, and 23 doses for the first 22 days of (MONTH) 2019. The Comprehensive Care Plan, dated 11/8/18, included that the resident is on a [MEDICAL CONDITION] medication with interventions to include assessing for effectiveness and side effects, utilizing non-pharmacologic interventions (did not include specifics), and a gradual dose reduction as indicated. The care plan revealed that the Nurse Practitioner would review the recommendations dated 1/30/19, which included the resident's antidepressant and decreasing or discontinuing the [MEDICATION NAME]. The current Certified Nursing Assistant (CNA) Care Plan does not include any mention of signs or symptoms of anxiety and/or interventions to utilize to address anxiety. Review of the medical team progress notes from 12/14/18 through 4/10/19 revealed approximately 16 medical visits to address acute issues but only three notes addressing to continue use of [MEDICATION NAME] along with changes related to the acute issues. There were no notes addressing that an evaluation was done regarding the resident's anxiety, current use of the anxiolytic medication, and/or need to continue it on an ongoing basis prior to every 14-day renewals. Review of the interdisciplinary progress notes for (MONTH) 2019 and (MONTH) 2019 revealed inconsistent documentation regarding why the [MEDICATION NAME] was administered or what non-pharmacological interventions were used if any prior to the administration. In multiple cases there was no progress note at all related to the administration of the medication. When interviewed on 4/23/19 at 3:01 p.m., the Registered Nurse Manager (RNM) stated that the resident should have a behavior care plan, but does not. The RNM said that when an 'as needed' dose of [MEDICATION NAME] is given, the nurses should write a progress note regarding the use and any interventions attempted prior. Interviews conducted on 4/24/19 included the following: a. At 12:20 p.m. the Licensed Practical Nurse (LPN) stated that they had not seen any behaviors but that the resident can become anxious at times. When asked if the anxiety affected the resident's daily routines, the LPN said, No. b. At 12:23 p.m. the CNA stated that the resident has no behaviors but can get anxious sometimes. She said talking may help or they give her a medication. (10 NYCRR 415.12(l)(1))

Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 304) completed on [DATE], it was determined that for 10 of 14 residents (Residents #1, #6, #7, #8, #9, #10, #11, #12, #13, and #14) reviewed for personal privacy, the facility did not provide care and services to ensure personal privacy was maintained. Specifically, five Certified Nursing Assistants (CNAs) admitted to taking photographs and videos on their cell phones, and some of them were shared via the internet without documented authorization from the resident and/or resident representative. This is evidenced by, but not limited to, the following: The facility policy, Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment, dated [DATE], included that photographing, filming, or recording in any way of patients, visitors, staff or others is prohibited except as described in the policy. In order to preserve the privacy and confidentiality of patients and staff, recordings may only be made for permitted purposes by authorized individuals. Written consent must be obtained from the patient prior to recording any patient image or from the patient's personal representative when the patient is unable to consent. Recordings may never be taken of a patient, or used in any manner, that demeans or humiliates the patient regardless of whether the patient or personal representative consented to the recording. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the resident was rarely or never understood, sometimes understands, and had severely impaired cognition. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative gave permission for the resident to be photographed for social purposes such as films, video tapes, and audio recordings, to be published or broadcast in the Continuing Care Center and/or in the public media. Review of the [DATE] Facility Investigation into unauthorized dissemination of resident photos revealed that CNA #1 admitted to taking and sending a photograph of Resident #1 after he passed away. The copy of the photograph shows the resident's head and part of the chest from the side with a washcloth placed over the mouth area. The resident's eyes are closed and the photograph is captioned he's dead. There is also a copy of a text conversation between CNA #1 and the community member. Review of the [DATE] update report from the Attorney General's office interview with CNA #1 revealed that she admitted to taking and sharing photographs and videos of Residents #7, #8, #9, #10, #11, #12, #13, and #14. When interviewed on [DATE] at 3:05 p.m., the Administrator said that on [DATE] she received a telephone call from a member of the public who reported that CNA #1 had taken a photograph of Resident #1 when he was deceased and had sent it to her. CNA #1 was called and she denied taking the photograph but was suspended pending investigation. When interviewed on [DATE] by the facility, CNA #1 admitted she had taken the photograph because she was upset that the resident had passed away. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident had severely impaired cognition. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative declined permission for the resident to be photographed. Review of the facility investigation included that on [DATE] CNAs #2 and #3 admitted to the Attorney General's office and facility administration that they had received photographs of Resident #12 from CNA #1. On [DATE], CNA #4 admitted to the Attorney General's office and the facility that he had taken a photograph of Resident #12 CNA #4 said he was not sure why he took the photograph. He said that he did not send the photograph to anyone and had deleted it from his cell phone. On [DATE] CNA #3 stated that she believed CNA #1 was taking videos of Resident #12's behaviors. CNA #3 said that CNA #1 said she needed to send the video to CNA #5. On [DATE] in a verbal report from the Attorney General's office to the facility, CNA #1 had admitted to taking five videos of Resident #12 mostly yelling and swearing and sent them to CNA #5. 3. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident has modified independence (difficulty in new situations only) with cognitive skills for daily decision making. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative declined permission for the resident to be photographed. Review of the facility investigation included that on [DATE] CNA #3 admitted to the Attorney General's office and facility administration that she had received several photographs of Resident #11 from CNA #1. She said that everyone on the unit on the evening shift was using their cell phones. Interviews conducted on [DATE] included the following: a. At 9:50 a.m., the Registered Nurse Manager said she was not aware the evening CNAs were using the cell phones to take photographs and videos of residents. She said all staff had been educated on the policy to not take and disseminate photographs previous to these incidents. b. At 12:20 p.m., Resident #4 said she saw staff use their cell phones while they were in her room. She said she was not aware of staff taking photographs or videos but was aware of staff making and receiving phone calls on their cell phones. c. At 12:30 p.m., the family of Resident #5 said they have seen staff using cell phones including in Resident #8's room. She said a male CNA working the evening shift was using his cell phone but she could not tell exactly what he was doing. She said she does not know the CNA's name but knew that he had been terminated. d. At 2:45 p.m., the Director of Nursing (DON) said when she went on rounds on the floors, she did not see staff using cell phones. She said she thinks it was occurring behind closed doors. She said staff are allowed to carry cell phones but not use them. The DON said there have not been any changes made to the policies at that time. e. At 3:05 p.m., the Administrator said that once it was discovered that CNA #1 admitted to taking photographs and videos, several other CNAs were also accused. CNAs #2, #3, #4, and #5 all admitted to taking photographs and videos and distributing many of them to each other and others in the community. The Administrator said staff knew they were doing the wrong thing, and they were hiding what they were doing. The Administrator said the involved CNAs were removed from care and have been terminated. (10 NYCRR 415.3(d))

Based on interviews, and record reviews conducted during the Abbreviated Survey (complaint #NY 304) completed on [DATE], it was determined that for 10 of 14 residents (Residents #1, #6, #7, #8, #9, #10, #11, #12, #13, and #14) reviewed for abuse, neglect, and mistreatment, the facility did not ensure residents were free from abuse. Specifically, five Certified Nursing Assistants (CNAs) admitted to taking photographs and videos on their cell phones, and some of them were shared via the internet without documented authorization from the resident and/or resident representative. This is evidenced by, but not limited to, the following: The facility policy, Photographing, Filming or Recording of Patients, Workforce Members and Medical Center Environment, dated [DATE], included that photographing, filming, or recording in any way of patients, visitors, staff or others is prohibited except as described in the policy. In order to preserve the privacy and confidentiality of patients and staff, recordings may only be made for permitted purposes by authorized individuals. Written consent must be obtained from the patient prior to recording any patient image or from the patient's personal representative when the patient is unable to consent. Recordings may never be taken of a patient, or used in any manner, that demeans or humiliates the patient regardless of whether the patient or personal representative consented to the recording. Review of the CNA education records revealed that abuse training was provided to CNA #1 on [DATE], CNA #2 on [DATE], CNA #3 on [DATE], and CNA #4 on [DATE]. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the resident was rarely or never understood, sometimes understands, and had severely impaired cognition. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative gave permission for the resident to be photographed for social purposes such as films, video tapes, and audio recordings, to be published or broadcast in the Continuing Care Center and/or in the public media. Review of the [DATE] Facility Investigation into unauthorized dissemination of resident photos revealed that CNA #1 admitted to taking and sending a photograph of Resident #1 after he passed away. The copy of the photograph shows the resident's head and part of the chest from the side with a washcloth placed over the mouth area. The resident's eyes are closed and the photograph is captioned he's dead. There is also a copy of a text conversation between CNA #1 and the community member. Review of the [DATE] update report from the Attorney General's office interview with CNA #1 revealed that she admitted to taking and sharing photographs and videos of Residents #7, #8, #9, #10, #11, #12, #13, and #14. When interviewed on [DATE] at 3:05 p.m., the Administrator said that on [DATE] she received a telephone call from a member of the public who reported that CNA #1 had taken a photograph of Resident #1 when he was deceased and had sent it to her. CNA #1 was called and she denied taking the photograph but was suspended pending investigation. When interviewed on [DATE] by the facility, CNA #1 admitted she had taken the photograph because she was upset that the resident had passed away. 2. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident had severely impaired cognition. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative declined permission for the resident to be photographed. Review of the facility investigation included that on [DATE] CNAs #2 and #3 admitted to the Attorney General's office and facility administration that they had received photographs of Resident #12 from CNA #1. On [DATE], CNA #4 admitted to the Attorney General's office and the facility that he had taken a photograph of Resident #12. CNA #4 said he was not sure why he took the photograph. He said that he did not send the photograph to anyone and had deleted it from his cell phone. On [DATE] CNA #3 stated that she believed CNA #1 was taking videos of Resident #12's behaviors. CNA #3 reported that CNA #1 said she needed to send that to CNA #5. On [DATE] in a verbal report from the Attorney General's office to the facility, CNA #1 had admitted to taking five videos of Resident #12 mostly yelling and swearing and sent them to CNA #5. 3. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident has modified independence (difficulty in new situations only) with cognitive skills for daily decision making. Review of the Authorization and Releases form for photo release, signed on [DATE], revealed that the resident's representative declined permission for the resident to be photographed. Review of the facility investigation included that on [DATE] CNA #3 admitted to the Attorney General's office and facility administration that she had received several photographs of Resident #11 from CNA #1. She said that everyone on the unit on the evening shift was using their cell phones. Interviews conducted on [DATE] included the following: a. At 9:50 a.m., the Registered Nurse Manager said she was not aware the evening CNAs were using the cell phones to take photographs and videos of residents. She said all staff had been educated on the policy to not take and disseminate photographs previous to these incidents. b. At 12:20 p.m., Resident #4 said she saw staff use their cell phones while they were in her room. She said she was not aware of staff taking photographs or videos but was aware of staff making and receiving phone calls on their cell phones. c. At 12:30 p.m., the family of Resident #5 said they have seen staff using cell phones including in Resident #8's room. She said a male CNA working the evening shift was using his cell phone but she could not tell exactly what he was doing. She said she does not know the CNA's name but knew that he had been terminated. d. At 2:45 p.m., the Director of Nursing (DON) said when she went on rounds on the floors, she did not see staff using cell phones. She said she thinks it was occurring behind closed doors. She said staff are allowed to carry cell phones but not use them. The DON said there have not been any changes made to the policies at that time. e. At 3:05 p.m., the Administrator said that once it was discovered that CNA #1 admitted to taking photographs and videos, several other CNAs were also accused. CNAs #2, #3, #4, and #5 all admitted to taking photographs and videos and distributing many of them to each other and others in the community. The Administrator said staff knew they were doing the wrong thing, and they were hiding what they were doing. The Administrator said the involved CNAs were removed from care and have been terminated. (10 NYCRR 415.4(b))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #14) of nine residents reviewed for medication administration, the facility did not ensure that each resident was free of a significant medication error. Specifically, the wrong dose of an anti-[MEDICAL CONDITION] medication was poured and about to be administered prior to surveyor intervention. This is evidenced by the following: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of current physician orders [REDACTED]. During an observation of medication pass on 11/15/17 at 12:09 p.m., the Licensed Practical Nurse (LPN) poured 5 ml (250 mg) of [MEDICATION NAME] Acid into a cup and mixed several other medications into the cup with the [MEDICATION NAME] Acid and some water. The LPN set up the supplies at the resident's bedside and began to administer the medication via the feeding tube when the surveyor intervened and asked the LPN to recheck the [MEDICATION NAME] Acid dose in the Medication Administration Record [REDACTED]. When interviewed at that time, the LPN stated she was not sure how she missed pouring the correct dose. The LPN said she was looking at the dose per ml as opposed to the actual dose to be administered. When interviewed on 11/16/17 at 10:33 a.m., the Registered Nurse Manager stated that it is her expectations that staff use the five rights of medication administration, right resident, right medication, right dose, right times and right route to avoid errors. The current facility policy, Techniques for Medication Administration, directed under techniques that nurses must observe the five rights of medication administration: right patient, right medication, right dose, right time and right route. (10 NYCRR 415.12(m)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three observations of resident care and two of five dining room observations, proper infection control techniques were not followed. The issues involved improper incontinence care and lack of glove removal (Resident #100), and bare hand contact with food items (Gardens and Meadows units). This is evidenced by the following: 1. Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/16/17, revealed that the resident had severely impaired cognition, was frequently incontinent of urine, occasionally incontinent of bowel, and required physical assistance with bathing. The Comprehensive Care Plan, dated 7/11/16, for urinary incontinence and the current Certified Nursing Assistant (CNA) Care Guide revealed the resident was incontinent of urine and stool at times and needed assistance with incontinence products. During an observation on 11/15/17 at 10:47 a.m., the CNA donned gloves and washed the resident's rectal area in a back and forth scrubbing motion repeatedly using the same surface of the washcloth. She rinsed the washcloth in the water basin multiple times during cares. The CNA then applied barrier cream to the buttocks. Without removing her gloves, the CNA applied the resident's Attends Briefs and pants. The CNA was about to start to wash the resident's chest and arms with a new washcloth and the same contaminated water, when the surveyor intervened. Interviews conducted on 11/15/17 included the following: a. At 11:13 a.m., the CNA said she should have changed her gloves after washing the rectal area. The CNA said that she should not have put the soiled washcloth in the water basin because that contaminated the water. She said that half of the time she starts washing the resident's lower half and then the upper half. The CNA said she should change the water when she does it that way. b. At 11:39 a.m., the Registered Nurse Manager said she would expect staff to wash the resident from top to bottom, doing the perineal and rectal care at the end. She stated she expects staff to change gloves and wash hands after applying barrier cream and before touching anything else. c. At 3:23 p.m., the Director of Infection Prevention and Emergency Preparedness said she expects staff to change gloves moving from a dirty task to a clean task to prevent cross contamination. She said gloves should be removed after providing peri care and always changed after completing a dirty task. 2. During an observation of the lunch meal served in the second dining room of the Garden Unit on 11/13/17 at 12:20 p.m., a staff member was observed with bare hands, removed a slice of bread from the plastic wrapping, picked up a slice of tomato and placed it on the bread. She then removed the second slice of bread from the plastic wrapping and held it while putting mayonnaise on it, and then placed the slice of bread on the top of the sandwich. Interviews conducted on 11/16/17 included the following: a. At 9:53 a.m., the Director of Nursing stated that the facility does not have a policy regarding glove use during food handling. b. At 9:57 a.m., the Food Service Director said that staff should be washing their hands prior to handling food. He said staff should be wearing gloves with any direct food/hand contact. c. At 10:20 a.m., the staff person said that they should have worn gloves while making the resident's sandwich. 3. During an observation in the Meadows Unit dining room on 11/13/17 at 12:39 p.m., without washing their hands, a staff member was observed handling a resident's bread in order to butter it with their bare hands. When interviewed on 11/15/17 at 3:23 p.m., the Director of Infection Prevention stated that she would expect staff to wash their hands before providing assistance with meal set up. She said staff should wear gloves if actually touching a resident's food. When interviewed on 11/16/17 at 10:33 a.m., the Registered Nurse Manager stated that it is her expectations that staff use utensils to touch a resident's food or wash their hands and wear gloves. She said staff should not touch the resident's food with their bare hands. (10 NYCRR 415.19(b)(4), 415.14(h))

Based on observations, interviews, and record reviews, it was determined that for one (Meadows) of five units reviewed for dining, the facility did not promote a dignified dining experience. Issues included a resident being fed by staff who were facing the another resident (Residetn #66), residents who did not receive assistance to eat for 27 minutes (Residents #66 and #95), and a delay in residents receiving their food for 30 minutes while the food carts sat in the hall within their line of vision (Residents #31, #113, #180 and #211.) This is evidenced by the following: 1. Resident #66 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/29/16, describes the resident with severely impaired cognitive skills. The current Certified Nursing Assistant (CNA) care sheet includes that the resident requires one person physical assistance due to being totally dependent while eating. During an observation on 8/15/16 at the mid-day meal, CNA #1 sat between Resident #66 and another resident, feeding one, and then the other. CNA #1 had her back turned mostly to this resident. She fed the resident with her arm turned backwards, as she did not turn her body to face the resident. Additionally, the food carts arrived on the unit at 12:34 p.m. and 12:40 p.m. This resident was brought into the dining room at 12:46 p.m. The resident sat, calling out, and sucking on her fingers until 1:13 p.m., when staff began to feed her. 2. Resident #95 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/6/16, describes the resident with severely impaired cognitive skills. Documentation on the 7/16/16 Comprehensive Care Plan shows the resident has had significant weight loss. Interventions include to allow the resident sufficient time to complete meals and assist the resident with feeding as needed. Instructions on the current CNA care sheet include to feed the resident, who is totally dependent while eating. During an observation on 8/17/16, food trays were being passed at 12:56 p.m. The resident's tray was set before him and uncovered at 1:03 p.m. At 1:12 p.m., a recreation staff person asked the resident if he needed help. The resident did not reply, looking about the room. At that time, all the other residents in the room were eating. No one assisted the resident to eat until 1:23 p.m. 3. During an observation on 8/17/16, the two food carts were delivered to the Meadows unit at 12:26 p.m. and 12:27 p.m. At 12:47 p.m., the surveyor entered the Dining Room. There were 23 residents present and no staff. Residents #31, #113, #180, and #211 began to shout at the surveyor, asking where was their food, where were the staff, This is awful, and they could see the food carts sitting there, why can't they have it? A recreation staff person came out of the office. During an interview at that time, she said she did not know the protocol for giving the residents food. At 12:49 p.m., the Registered Nurse Assistant Nurse Manager came out of the kitchenette and said they were not allowed to give the resident's any food trays until all residents were present in the dining room. Staff began to pass trays to the residents at 12:56 p.m. Recreation Therapists #1 and #2 assisted passing the trays but did not assist with feeding any of the residents. Resident #113 was observed to receive her tray at 12:57 p.m. on 8/17/16. The CNA asked the resident if she was hungry, and the resident replied, Are you kidding!? During an interview on 8/17/16 at 1:04 p.m., Resident #31 said this has been occurring for awhile, the residents just sit and wait for the food. Interviews conducted on 8/17/16 included the following: a. At 1:18 p.m., Recreational Therapist #2 said she is also a CNA. She said her responsibilities include setting up trays, calling the kitchen for additional food, and on occasion, feeding residents if they need extra help. b. At 1:26 p.m., Recreational Therapist #1 said she is also a CNA, and usually staff are waiting for the carts when they come. She said she did hear the residents yelling about their food, but she was concentrating on doing work in the office. She said Resident #95 did not respond when she asked him if he needed help. She did not think that she could feed him, and was unsure who she could feed. Interviews conducted on 8/18/16 included the following: a. At 9:19 a.m., Licensed Practical Nurse #1 said Residents #31, #113, #180, and #211 are all residents that are able to make their needs known. b. At 1:55 p.m., CNA #1 said it is normal that they feed two residents at the same time. The rule is that all the residents are supposed to be in the dining room before they are allowed to pass out any of the trays. c. At 2:11 p.m., CNA #2 said there are five CNAs that work each day. Two CNAs go to lunch between 11:30 a.m. and noon, and the other three go from noon to 12:30 p.m. The CNAs that are left have to get residents up and bring them to the dining room. Some days they are told to wait for all the residents to be in the dining room, and some days they are told to start to feed residents. She said it was not unusual to have to assist three residents at the same time. This makes her feel very frustrated because it is difficult to do. She also said that in the past year, she has seen the recreation staff help feed residents only twice. There are some nurses that will come and help them feed the residents, but most do not. Interviews conducted on 8/19/16 included the following: a. At 8:33 a.m., CNA #3 said she has never seen any of the recreational therapy staff feed a resident, and only on 8/17/16 has she even seen them pass trays. She said that occasionally a nurse will help them feed residents. She also said she has to feed two residents at the same time and feels like she is neglecting one. Sometimes she feeds a resident who is coherent, and one who is not, and she always feels neglectful to the resident who is not. She said they always have to have at least one CNA to toilet residents and help with trays for residents eating in the hall or their rooms. She said they were told not to serve the trays until all the residents are in the dining room, and they have to get all the residents up to bring to the dining room first. She said she did not realize that Resident #95 was not being fed until she finished feeding Resident #211. b. At 8:51 a.m., CNA #4 said they give out trays to the residents that can feed themselves first, then they sit between two residents and feed them. Some of the nurses help and some do not, and the recreational therapy staff do not normally help at all. She said one of the reasons that they struggle is because they have a lot of residents that require two people to assist them in getting out of bed for lunch. There was a meeting approximately two weeks ago where they were told they could feed residents and not wait for all the other residents, but not all the staff attended that meeting. c. At 9:48 a.m., LPN #2 said nurses are supposed to help with lunch time, pass trays, and feeding. Usually it is just her and the CNAs. They do feed two residents at the same time, and the recreation staff do not help them with the meals. The CNAs toilet residents and get them up, and they are supposed to wait until all the residents are in the dining room before they pass out the trays. She said it is not dignified to feed two residents at the same time and was taught to feed one resident at a time. She said there are 14 residents that require assistance to eat, and 27 residents that require two staff to get them up. d. At 10:57 a.m., the Registered Nurse Manager and Director of Nursing said ideally they would like all the residents in the dining room, as they do not want one eating and others not eating. They do see that the flow is not good, and ideally only one resident should be fed by one staff. However, in order for timeliness and number of residents that need to be fed, you may have to feed two at the same time. They stated that this could be done without compromising each resident's dignity. (10 NYCRR 415.5(a))

Based on observations, interviews, and record reviews, it was determined that for one of three residents reviewed for activities for the cognitively impaired, the facility did not have an ongoing program of activities that addressed the resident's individual interests. Specifically, Resident #49 did not consistently receive preferred activities as specified in the care plan. This is evidenced by the following: Resident #49 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/31/16, includes that the resident has severe impairment of cognitive function and is dependent on staff for all locomotion. Additionally, preferences for daily activities listed on the assessment include listening to music, being around pets, spending time outdoors, participating in religious activities, and doing things with groups of people. Review of the resident's activity log from 5/27/16 to 8/17/16 included a total of one religious event, two outdoor events, one music event, and three massage therapy activities for the 12 week period. Review of the spiritual visit logs for the past two months revealed that the spiritual volunteers visit the unit several times a week spending approximately 1 to 2 hours and visiting approximately 40 residents. Review of the Activity calendars for 7/1/16 through 8/17/16 revealed that there were approximately 11 pet visits scheduled for all units and 12 outdoor activities (most involving music) that were scheduled on Resident #49's specific unit. In multiple observations made throughout the day shift, from 8/15/16 through 8/17/16, the resident was seen either in her recliner geriatric chair in front of the nursing station or resting in bed. A CD player was on her bedside stand but was not turned on over the course of the three days. On 8/17/16 at 11:00 a.m., an outdoor activity was going on in the courtyard right off the nursing station. Resident #49 was sitting in her chair in the hallway indoors during the activity. She did engage with staff when spoken to and was occasionally heard yelling out. When interviewed at that time, Licensed Practical Nurse (LPN) #1 stated that that the resident likes to go outside. LPN #1 said she did not know why the resident was not participating in the outdoor activity. She later stated that the resident's CD player located in her room should be on daily. When interviewed on 8/17/16 at 11:08 a.m., the Recreation Therapist stated that there was no reason why this resident was not included in the outdoor activity. The therapist stated that this resident does get a lot of spiritual visits. Review of the current facility policy, Recreation Therapy Activities, revealed that care plans address activities that are appropriate for each resident based on their comprehensive assessment. (10 NYCRR 415.5(f)(1))

Based on observations, interviews, and record reviews, it was determined that for one (Resident #82) of two residents reviewed for urinary incontinence, the facility did not identify that a resident had a significant change in two or more areas of his physcial and mental condition. The issue involved the lack of a Comprehensive Significant Change Minimum Data Set (MDS) Assessment completed for a resident with multiple documented declines in physical and mental well-being. This is evidenced by the following: Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] following a hospital stay for cardiac complications, and again on 6/27/16 after a hospital stay for a corneal ulceration, new onset hallucinations, and [MEDICAL CONDITION] activity. A Comprehensive Adminission MDS Assessment, dated 4/20/16, included that the resident had a moderate impairment of cognitive function, had moderately impaired vision (limited but able to identify objects), minor symptoms of depression, no history of hallucinations or delusions, was independent with bed mobility, was always continent of bladder function, and had some balance problems during transitions and walking but was able to steady self without assist. Review of several quarterly MDS Assessments (6/15/16 and 7/16/16) following the two hospital stays, revealed that the resident was now severely cognitively impaired, had severe vision loss (no vision or only sees light), suffered increased symptoms of depression, hallucinations, and delusions, required extensive assist from staff to move around in bed, was always incontinent of urine, and was no longer able to steady himself when transitioning with staff assist. In a Physical Therapy evaluation, dated 7/11/16, the therapist wrote that this resident was being evaluated for a decline in ambulation and decreased strength and endurance. He noted that this was the resident baseline function at this time, and due to that and refusals, the resident would not be picked up for physical therapy. In a medical progress note, dated 7/12/16, the physician wrote that the resident is having recurrent cardiac episodes of unresponsiveness, which resolve, but that the resident has not returned to baseline and is most likely terminal. Medications were adjusted as needed for the resident's comfort, and the chaplain was notified. His prognosis is grim. Review of the Occupational Therapy discharge summary, dated 7/19/16, revealed that therapy was being discontinued due to a change in medical status requiring increased level of assistance in all Activities of Daily Living. The resident passed away on 8/7/16. Review of the resident's care plan in place at the time of death revealed that it did not include any goals and/or interventions related to end of life care. Interviews conducted on 8/19/16 included the following: a. At 9:57 a.m., the Registered Nurse (RN) Corporate Compliance, who oversees the MDS Assessments, and the MDS Coordinator, stated that if the resident had two areas of decline, they would qualify for a significant change MDS Assessment. They added that technically this resident would qualify for a significant change, but he was receiving therapy and was making progress. b. At 11:17 a.m., the RN Manager stated that they discuss any changes in morning report with the whole disciplinary team. Then the MDS nurses review those changes and decide if a significant change MDS Assessment should be done. Review of the current Resident Assessment Manual revealed that criteria for significant change included the following: a. a decline in the resident's status that will not normally resolve itself without intervention by staff, b. impacts more than one area of the resident's health status, c. requires interdisciplinary reviews and/or revision of the care plan. When a resident's status changes and it is not clear whether the resident meets the guidelines, the facility may take up to 14 days to determine whether the criteria are met. (10 NYCRR 415.11(a)(3)(ii))

Based on interviews and record reviews, it was determined that for one (Resident #204) of five residents reviewed for unnecessary medications, the facility did not provide services in accordance with professional standards of quality. The issues involved medications not given as per physician orders [REDACTED]. Resident #204 has [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED] a. [MEDICATION NAME] was given after a meal (as opposed to before) from 90 minutes up to 6 hours (10:13 p.m.) after the scheduled dose on 13 of 31 opportunities. b. [MEDICATION NAME] was given 98 minutes up to 5 hours (10:13 p.m.) after the scheduled dose on 14 of 31 opportunities. c. [MEDICATION NAME] was administered on one occasion despite the resident's blood pressure being 98/50. Review of the afternoon and evening nourishment schedule revealed the resident was not scheduled to receive a snack in the evening or before bed. Review of meal cart delivery time to the unit revealed the dinner carts are delivered between 5:00 p.m. to 5:30 p.m. Review of nursing progress notes for the same time period revealed a lack of refusals by the resident for the above identified medications. In an interview on 8/18/16 at 9:30 a.m., the Registered Nurse/Assistant Nurse Manger (RN/ANM) stated that the resident's [MEDICATION NAME] should have been held due to a low blood pressure. Also, if the physician orders [REDACTED]. She said that if a medication is ordered to be given with food, it is usually scheduled around meal times. The RN/ANM said that there is no way to tell if those late doses were given with food and the administration times are too late. She stated that this resident does not get a scheduled snack in the evening. When interviewed on 8/19/16 at 11:11 a.m., the covering Registered Nurse Manager stated that medications need to be given as ordered. She added that if a resident refuses a medication, staff would document it in the progress notes and attempt later. The current facility policy, Techniques for Medication Administration, includes that routine medications shall be given within one hour before and after the time due with the exception of daily, weekly, and monthly medications. (10 NYCRR 415.11(c)(3)(i))

Based on observations, interviews, and record reviews, it was determined that for two (Residents #49 and #204) of three residents reviewed for Activities of Daily Living (ADL), the facility did not provide the necessary care and services to maintain personal hygiene. The issue involved a lack of fingernail care. This is evidenced by the following: 1. Resident #49 has [DIAGNOSES REDACTED]. Review of an activity assessment, dated 5/26/16, revealed that the resident's preferred activities included manicures. The Minimum Data Set (MDS) Assessment, dated 5/31/16, includes that the resident has severe impairment of cognitive function, requires extensive assist by staff for personal hygiene, and total dependence on staff for bathing. Review of the current Comprehensive Care Plan (CCP) and current Certified Nursing Assistant (CNA) Assignment sheet revealed that the resident has a self-care deficit and is totally dependent on staff for all aspects of ADLs. Neither document includes any mention of fingernail care. Review of the current unit shower schedule revealed that the resident receives a shower weekly on Fridays. Observations included the following: a. On Monday, 8/15/16, at 1:23 p.m., the resident was sitting in a reclining geriatric chair in the hallway. Multiple fingernails on both of the resident's hands were untrimmed and filled with black debris. b. On Tuesday, 8/16/16, at 4:18 p.m., the condition of the resident's fingernails had not changed. c. On Wednesday, 8/17/16, at 8:54 a.m. and again at 11:00 a.m. after getting dressed and out of bed, the resident's fingernails were in the same condition. The resident periodically put her hand in her mouth and sucked on her fingers. Licnesed Practical Nurse (LPN) #1 was notified of the condition of the resident's fingernails by the surveyor, stated that they were dirty and needed to be trimmed, and she would do it immediately. LPN #1 reported that the aides should look at the resident's fingernails daily and clean them as needed. LPN #1 described the resident's fingernails as pretty bad. When interviewed on 8/17/16 at 3:16 p.m., the Registered Nurse Assistant Nurse Manager (RN/ANM) stated that the primary aide should check the resident's fingernails daily. 2. Resident #204 has [DIAGNOSES REDACTED]. A MDS Assessment, dated 5/30/16, included that the resident has severe impairment of cognitive function and requires extensive assist of staff for personal hygiene. The current CCP and current CNA Assignment sheet both included that the resident has a self-care deficit related to his need for assist with all ADLs. Documentation on the ADL log included that the resident's last shower was on 8/12/16. During several observations made throughout the day shift from 8/16/16 through 8/18/16 at 9:30 a.m., the resident had multiple fingernails on both hands filled with brown debris. In an interview on 8/18/16 at 9:30 a.m., the RN/ANM stated that the resident's fingernails were dirty and needed to be cleaned. At 10:10 a.m. that day, CNA #1 stated that fingernails are trimmed on shower days but should be checked daily. Also, this resident is very cooperative and does not refuse care as far as she knows. (10 NYCRR 415.5(a))

Based on staff interview and record review, it was determined that for one (Resident #78) of one resident reviewed for hospice care, the facility did not code the Resident Assessment Instrument, including the Minimum Data Set Assessment, correctly. The issue was inaccurate coding regarding hospice care. This is evidenced by the following: Resident #78 has [DIAGNOSES REDACTED]. The resident was first admitted to hospice for advanced dementia, pneumonia, and failure to thrive on 2/26/16. A Minimum Data Set (MDS) Assessment, dated 3/4/16, significant change assessment included that the resident was not receiving any specialized program under Section O. The MDS Assessment, dated 6/4/16, quarterly MDS, does not indicate the resident is receiving specialized services. When interviewed on 8/19/16 at 10:45 a.m., the Nurse Assessment Coordinator stated she knew the resident was on Hospice. She must have missed checking it on the MDS Assessment, and she would send in corrections for the March 2016 and June 2016 assessments. (10 NYCRR 415.11(a)(1))

Based on an observation, interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 747) completed on [DATE], it was determined that for one (Resident #1) of three residents reviewed for accident hazards and adequate supervision and assistive devices to prevent accidents, the facility failed to have effective systems in place to ensure a resident was assessed for safe siderail use and that beds in use did not pose a risk for entrapment. Specifically, a demented resident was discovered entrapped with her head in the left siderail and her body in a sitting position on the floor. Both upper siderails were raised on the bed. The resident was unresponsive and did not have a pulse. Cardiopulmonary resuscitation was unsuccessful, and the resident was pronounced dead. The Facility's Resident Entrapment Assessment Tool form was initiated, but not completed. The entrapment zones were not identified. There was no documentation that the risks and benefits of siderail use were discussed with the family. Additionally, three beds taken out of service in 2008, identified as entrapment risks were found in use. One of these three beds was assigned to this resident. This resulted in actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care to Resident Health and Safety. This is evidenced by the following: The Immediate Jeopardy was removed prior to entrance on [DATE]. Resident #1 was admitted to the facility from the hospital on [DATE] for rehabilitation after surgical repair of a fractured left hip. [DIAGNOSES REDACTED]. The Nursing Admission Assessment, dated [DATE], documented that the resident was alert, oriented to person, and had long and short term memory loss. The fall risk assessment, completed on [DATE] by the admitting Registered Nurse (RN) #1, revealed that the resident was a high risk for falls. The Resident Entrapment Assessment Tool, dated [DATE] initiated by the admitting RN #1, was incomplete, only the first of seven questions was answered. The Comprehensive Care Plan (CCP) developed on admission does not include the resident's high risk for falls or the use of siderails. The undated Care Card (used by caregivers to provide care) included that the resident was a two assist for bed mobility and siderails were being used. The type, locations, and number of siderails in use were not listed on this care card. There is no notation on the Care Card that the resident was a high risk for falls. Documentation on the facility incident report, dated [DATE] completed by the Vice President of Nursing (VPN), revealed that the resident was seen at 1:00 a.m. on [DATE] by the Certified Nursing Assistant (CNA) #1 who was completing rounds. CNA #1 woke the resident up to see if she needed to use the bathroom, and the resident responded, "No." At 1:15 a.m. on [DATE], the night RN #2 found the resident sitting on the floor, with her back to her bed. The resident's face was visible within the lower portion of the siderail. Her chin was positioned over the base of the rail. There was urine on the floor, chux, and the side of the mattress. The resident was unresponsive and pulseless. Cardiopulmonary Resuscitation (CPR) was unsuccessful, and the resident was pronounced dead at 1:42 a.m. The facility's investigation, dated [DATE], concluded that on admission, the staff identified the need for siderails based on the resident's limitations in bed mobility. The siderails were included on the care card. The Entrapment Assessment Tool was initiated by RN #1 but was not completed. The entrapment zones were not identified. The RN Assistant Manager (RN #3) did not initiate bed or chair alarms for fall risk because the resident used the call light appropriately and did not try to get up unassisted. This investigation also discovered that the style of bed the resident occupied was previously removed from the facility due to concerns regarding entrapment risk. Facility staff brought the beds back into the facility without nursing approval. The facility concluded that based on the identified risk of the bed involved and the resident's findings, it appears the siderail entrapment occurred. The Medical Director's note, dated [DATE], revealed that on [DATE] the County Coroner verbally reported that the preliminary autopsy results for this resident showed asphyxiation secondary to accidental strangulation. In a joint observation with the surveyor, VPN, and Nursing Compliance Officer (NCO) on [DATE] at 11:50 a.m., the bed involved in the incident was located in a private room. The door to the room was closed with signage that read, "DO NOT ENTER." The style of the hospital bed was an older Hill-Rohm model, with four half siderails attached to the bed. The siderails had three openings in each rail measuring approximately 7.75 inches in height and width. There was a gap between the siderail and the mattress measuring 3.25 inches. The mattress was 82 inches in length and 34.5 inches wide. There was an overlay air mattress on top of the bed, which measured 75 inches in length and 34.5 inches wide. When interviewed at that time, the VPN said that in 2008 there was an initiative to decrease entrapment, and all mattresses were changed from 82 to 84 inches so that they fit snug on the bed frames. The VPN reported that these beds were all removed from the facility in 2008 and replaced with new beds. The VPN is unsure how these beds were brought back into the facility. Interviews conducted on [DATE] and [DATE] revealed the following: a. At 1:30 p.m. by telephone, CNA #1 said that it was her first night working with this resident. She said at 1:00 a.m. on [DATE], she woke the resident and asked her if she needed to use the bathroom. The resident's response was "No," and she seemed appropriate in her response. CNA #1 said that at approximately 1:15 a.m., RN #4 was rounding and called for assistance. CNA #1 reported that the resident was sitting on the floor, with her back against the bed, her neck was between the bed and siderail, and her chin was resting on the lower section of the siderail. b. At 1:40 p.m. and on [DATE] at 1:30 p.m., RN #3 said that the hospital nurse reported to her that the resident was alert but confused. She said that RN #1 completed the entrapment assessment tool for siderails and the fall risk assessment. RN #3 said that there are no physician orders for the use of siderails. RN #3 stated that she added siderails to the care card because she knew the resident was admitted for rehabilitation and having the siderails would promote bed mobility. RN #3 reported that she did not see the resident and did not know if she used the siderails. Also, she was not aware that the resident was a high risk for falls or that the entrapment assessment tool for siderails was incomplete. RN #3 stated that she expects that the admitting nurse (RN #1 for this resident) would report to her if a resident was a high risk for falls or there was concern regarding the entrapment assessment tool for siderails. She reported that there is no formal report from RN #1 to the nursing managers on the unit. RN #3 said that she does not believe the rehabilitation residents participate in the falling star program. c. At 2:00 p.m. by telephone, RN #4 said that she was making rounds on [DATE] at 1:15 a.m., when she approached the resident's room and pulled back the privacy curtain. She said that the resident was sitting on the floor, with her back to the bed, and her head was wedged in the lower section of the siderail with her chin over the bottom part of the rail. She said CPR was started, but unsuccessful. RN #4 said that since she works nights, she is not involved in completing the entrapment assessment tool. She said that some of the older beds, like this one, have been on the unit for a while. d. At 3:05 p.m. by telephone, the night Licensed Practical Nurse (LPN) said that she worked with the resident on the night of [DATE]. The resident was confused and was asking when her plane was taking off. She said that most of the beds on the unit were new, but there were a few of these older ones. Also, she had never been instructed on how to evaluate the size of the openings in the siderails. e. At 3:45 p.m., the Physical Therapist Coordinator said that nursing completes the Entrapment Assessment form for siderails. He said since this incident, Physical Therapy is assessing all residents to determine the need for siderails. He said that nursing is still assessing for gaps and openings in the siderails. Interviews conducted on [DATE] revealed the following: a. At 8:50 a.m., the Director of Facilities said that there is no routine maintenance for looking at beds and siderails. He said that he is unsure of how many beds were replaced in 2008. He said that individual beds are not tracked for movement in the facility These beds were held in a storage area. b. At 9:00 a.m., the Administrator said that it was her belief that all of these beds had been removed from the facility in 2008. She said if she knew the beds were in the facility, they would have been removed immediately. c. At 9:30 a.m., the VPN said that the entrapment assessment tool should be completed within 24 hours of admission but really within the shift. The VPN explained that siderails are not used for residents identified as a high risk for falls and that the risk and benefits of siderail use should be discussed with the family or resident by the nurse that completes the entrapment assessment tool. Also, verbal instructions should be provided and documented. The VPN said a red star is placed on the name plate of the resident's room if they are identified as a high risk for falls. She said she does not know if this was done for this resident. d. At 1:20 p.m., RN #1 said that she cared for the resident on [DATE] and [DATE]. She said that when she changed the resident's dressing on Friday ([DATE]), the resident was confused and unable to keep her train of thought. RN #1 said that the resident used the siderails when she was directed to use them in care but was unsure if she could use them independently. RN #1 said that she did not complete the Entrapment Assessment Tool for siderails and did not assess the siderails for potential entrapment zones for this resident. Also, she is not aware of what the openings in siderails should be in order to be considered safe. She said there was a laminated reference card, but there were no measurements on the card. RN #1 said that she discussed the risk and benefits with the resident, and stated that was not appropriate, but there was no family present. She said she normally documents on the Entrapment Assessment Tool that the risks and benefits were discussed and with whom. She said it is an RN decision if a resident uses siderail, it is not a team decision. She said she identified the resident as a high risk of falls, but she did not put that information on the care card or put a red star on the resident's room door. She said that she did not pass that information along to any of the managers, nor does she report to them after admitting a resident. e. At 2:15 p.m., CNA #2 cared for the resident on the day shift on [DATE] and [DATE]. She said that she used siderails when directed during morning care. She said that she never saw the resident use siderails independently. CNA #2 said that the resident was confused, asked the same questions repeatedly, and she never remembered her caregiver. She said that the resident kept telling her she was on vacation. f. At 3:00 p.m., the NCO said that all residents, including rehabilitation residents, that meet the criteria for being a fall risk are included in the "Falls Program." g. At 3:30 p.m., the RN Manager on the unit said that the resident was confused and alert to herself only on admission. She said that the fall risk and Entrapment Assessment form should be completed within the admission shift. She said that she met the resident and based on her cognition, there should not have been any siderails on her bed. She said that this resident was identified as a high risk for falls, a care plan should have been developed for falls, and the resident should have been placed in the falling star program. Also, the resident should have had a low bed, bed and chair alarms, and the CNA care card should have identified that she was a high risk for falls. The RN Manager said since this incident, a check list has been developed to track that all admission paperwork is completed. The facility's policy, "Entrapment Assessment," dated [DATE], revealed that each resident will be assessed on admission and annually for their risk for potential entrapment using the Resident Potential Entrapment Assessment Tool. The nurse will assess history of entrapment, predisposing factors, such as cognitive status, pain management, or mental status changes. The nurse will assess if siderails will be used. If siderails are to be used, the nurse will assess whether there is additional risk from the identified seven zones of entrapment. If areas of risk are identified, the care team will reduce the risk and document the intervention on the care plan and care card. The resident/health care agent will be informed of the potential risk or entrapment using the siderails vs. the potential benefits of using the siderails. The Administrator, VPN and NCO, and PT Coordinator presented the following actions taken to remove the immediacy. Two older style beds (Hill-Rohm) were removed from the facility and will be destroyed. The whole house was reassessed for the use of siderails, completion of entrapment assessments and risks, and benefits of siderail use. PT is now involved in assessing residents to determine the need for siderails. Also, there are eight beds with controls in the siderails. The siderails have been zip locked using heavy duty material until new beds arrive to the facility. The VPN said that reeducation has been completed on the revised entrapment policy. The Immediate Jeopardy was past noncompliance and corrected as evidenced by the following: During observations, interviews, and record reviews completed on [DATE], the surveyor verified that facility actions had been implemented. Older style Hill-Rohm beds had been removed from the facility. The siderails have been secured in down position on beds that have controls in rails until new beds are delivered to facility. Re-education regarding the policy and risk assessment tool was confirmed through staff interviews and review of education attendance roster. The plan is to educate the remainder of staff before their next scheduled shift. The interdisciplinary team assessment including evaluation of entrapment zones for any siderail use was completed. There are six residents currently in house with siderails. If the resident is not care planned for siderails, the rails have been removed from the beds. (10 NYCRR 415.12(h)(1)(2))

Based on an observation, staff interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 337) completed on 9/25/12, it was determined that for one (Resident #1) of three residents reviewed for accidents, the facility failed to provide adequate supervision of a wandering resident and a safe environment to prevent an elopement. The issue involved an unsecured dining room door located in the Pines Avenue Unit, through which Resident #1 eloped. The resident was found 40 minutes later in the front of the facility by a staff member. This resulted in no actual harm with potential for serious harm that is immediate jeopardy to resident health or safety and substandard quality of care. This is evidenced by the following: Resident #1 is an [AGE] year-old resident with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment, dated 9/5/12, revealed that the resident's cognitive skills for daily decision making are severely impaired. The Comprehensive Care Plan (CCP), dated 7/2712, and the Unsafe Wandering Elopement Risk Assessment, dated 8/27/12, both described the resident as at high risk for unsafe wandering/elopement. The CCP included that the resident would be monitored in non-supervised areas. According to the facility incident investigation, dated 9/11/12, a facility Certified Occupational Therapy Assistant (COTA) found the resident in the parking lot at 4:00 p.m. on 9/7/12, self-propelling her wheelchair toward the West entrance of the Pines Avenue Unit. The resident stated, "I'm lost, I've gone too far." Also, the resident was last seen by a Certified Nursing Assistant (CNA) on the patio of the Gardens seated with other residents at an unspecified time. The COTA returned the resident to the Pines Avenue Unit nurses' station, and the resident sustained [REDACTED]. On 9/13/12, the facility reported to the New York State Department of Health that on 9/7/12, the resident exited the building undetected and was found in a distant facility parking lot after leaving from the unlocked East dining room door on the Pines Avenue Unit leading into the Gardens. In an observation on 9/24/12 at 2:20 p.m., the resident was observed seated in a wheelchair, self-propelling on the Pines Avenue Unit. The resident was wearing a Wanderguard. At that time, the surveyor walked the route the resident took outside and around the building to the left, an approximately five-minute walk if walking briskly. The direction to the right takes one around the opposite end of the building and down a steep embankment. When interviewed on 9/24/12 at 4:10 p.m. and 4:50 p.m., CNA #1 and CNA #3 both stated that the resident is able to activate the handicap remote pad to open the dining room door leading outside to the Gardens. CNA #3 stated that she has caught and redirected the resident many times from attempts to exit the unit, alerted by the sounding Wanderguard alarm. CNA #3 added that the resident was invited to join a group of other residents in the Gardens for dinner. When she first saw the resident outside at 3:20 p.m. on 9/7/12, she was skeptical, but the resident has never left before and was usually the first resident back in. When interviewed on 9/24/12 at 6:20 p.m., the Vice President (VP) of Nursing, who was acting as Administrator, stated that the dining room door on the Pines Avenue Unit had been kept locked at all times until family members complained about having to go to the nurses' station to have the door unlocked to exit to the Gardens. The VP stated that the door was probably unlocked when the weather was nicer in May 2012 and that it is not Wanderguard alarmed. The VP stated that facility staff did not feel that this exit was a danger to the wanderers on the Pines Avenue Unit, as Resident #1 and two other residents assessed as wanderers living on the Pines Avenue Unit were not considered "outside" elopement risks. The provider failed to adequately assess for environmental hazards prior to allowing access to an unsecured outside area. In addition, the facility failed to implement a back-up system to protect wandering residents. The Immediate Jeopardy and Substandard Quality of Care was past non-compliance and corrected, as evidenced by the following: 1. The resident was placed on one-hour safety checks upon return to the Pines Avenue Unit on 9/7/12 and not allowed in unsupervised areas unattended from 9/7/12 through 9/9/12. Evening staff were educated regarding the care plan changes. 2. The dining room door to the Gardens was locked on 9/10/12 and marked with a sign placed to alert staff, residents, and visitors. 3. Staff education was provided to Nurse Managers via e-mail on 9/10/12, to review and sign off the facility's Unsafe Wandering, Elopement and Wanderguard and Emergency Preparedness policies. Nurse Managers were expected to review with all staff/all shifts. Review of attendance rosters initiated on 9/10/12 and completed by 9/17/12 revealed evidence that staff on all units and all disciplines were reeducated. 4. The resident's care plan was reviewed and revised on 9/10/12 to include "cannot be left outside unattended." 5. A temporary gate was installed to block the exit off the Gardens on 9/11/12. 6. Root cause analysis was completed on 9/11/12. The facility determined that all residents at risk for wandering and elopement need to be in secured areas. 7. Unsafe wandering and elopement policy was revised to emphasize the need for supervision of high-risk residents in non-secure areas. (10 NYCRR 415.12(h)(1)(2))

Based on staff interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 2133), it was determined that for one of seven diabetic residents reviewed for critical laboratory values, the facility failed to provide the necessary care and services to attain or maintain the resident's highest practicable physical well-being in accordance with the plan of care. Specifically, Resident #77 had critically elevated blood glucose levels ranging from 465 to greater than 600 over a two-day period. Nursing staff did not complete physical assessments or contact a physician regarding elevated glucose levels. Subsequently, the resident required hospitalization for acute illness. This resulted in actual harm for Resident #77 and the potential for serious harm for other diabetic residents in the facility, which resulted in IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. This is evidenced by the following: Resident #77 had [DIAGNOSES REDACTED]. On [DATE] physician orders [REDACTED]. Also, the order for [MEDICATION NAME] (medication for diabetes) 2.5 milligram (mg) by mouth every morning was renewed. According to the 24-hour report on [DATE], the night shift Licensed Practical Nurse (LPN) notified the day shift charge nurse that the resident's BGs were 480, 486, and 465, and also wrote it on the provider communication board for Nurse Practitioner (NP) follow-up. On [DATE] at 8:45 a.m., the NP wrote an order for [REDACTED]. Review of the [DATE] Medication Administration Records (MAR) revealed that on ,[DATE] at 4:00 p.m., ,[DATE] at 6:00 a.m. and 4:00 p.m., and [DATE] at 6:00 a.m., BGs were all recorded as high ("HI"). The facility policy entitled, "Blood Glucose Testing Using the Accucheck Inform Meter," effective [DATE], described "HI" as greater than 600. Corresponding readings documented on the 24-hour report (daily communication tool for nursing staff) included on ,[DATE] night shift, BG levels were 480, 486, and 465, and for the evening shift, "HI". On the [DATE] 24-hour report, it was documented as night shift, "HI" and 584; evening shift, no documentation. Review of nursing progress notes, dated ,[DATE] through [DATE], revealed no documentation regarding the resident's elevated BG levels. The only physical assessment documented during this time frame was related to the resident's knee. According to the progress notes, dated [DATE], NP #2 saw the resident that day for redness of the left knee. NP #2's note made no reference to the elevated BG levels. Nursing notes, dated [DATE] at 10:10 a.m., revealed that the resident was having increased respirations. At 10:50 a.m., that same day the Registered Nurse (RN) assessed the resident and notified NP #1. The resident was sent to the hospital at 1:20 p.m. Review of the hospital history and physical, dated [DATE], revealed that the resident had a BG level of 836 with [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:00 a.m., the Medical Director reported that in the hospital the resident's BG levels came down to within the 90 to 180 range, however, the sodium level remained elevated. Information on the Medical Orders for Life Sustaining Treatment (MOLST) directs if intravenous (IV) fluids are not correcting the acute issue after 3 to 4 days, please discontinue. On [DATE], the family made the decision, in the hospital, to discontinue treatment and the resident expired on [DATE]. The facility's policy entitled, "Blood Glucose Testing Using the Accu Check Inform Meter," effective [DATE], directs staff to repeat the test if results of blood glucose level testing is greater than 450. It explains that a "HI" blood glucose level result means the level is greater than 600. Also, the facility expects that staff will report critical values to a physician and that this should be documented in the medical record. The facility's current policy entitled, "Nursing Documentation: 24-Hour Report Sheet," directs staff to include any significant laboratory values and their status pending outcomes. Interviews conducted on [DATE] are as follows: a) At 11:00 a.m., the Administrator, Medical Director, Director of Nursing, and Director of Clinical Compliance reported that their conclusion in the Root Cause Analysis, completed on [DATE], was that staff did not follow facility policy when they failed to report critical laboratory values to the physician. The resident's record was requested by family on [DATE] and, according to the facility, investigation review of the record was initiated at that time. b) At 12:30 p.m., the Registered Nurse (RN), who was the day supervisor on [DATE], stated that she always reviews the 24-hour report sheets for all units. On this shift she would have looked at the day, evening, and night shifts for [DATE]. The RN said she talks with the Charge Nurses and she meets with the NP at least once during the day to share concerns. She remembered speaking to NP #2 regarding the resident's knee and thought she told her about the resident's elevated blood glucose levels. She did not contact a physician. c) At 1:15 p.m., NP #2, who covers every other Saturday from 8:00 a.m. to 12:00 p.m., did recall seeing the resident on [DATE] and writing a progress note. She did not recall hearing about elevated blood glucose levels. d) At 2:30 p.m., the Licensed Practical Nurse (LPN), who works nights, stated that she had taken the resident's blood glucose levels on ,[DATE] and [DATE], and they both read greater than 500 She stated the values were not being confirmed so no one needed to be notified and the resident had high readings in the past. She did not contact the physician. e) At 3:15 p.m., the evening LPN stated that she obtained the blood glucose levels from the resident on [DATE] and documented these in the MAR and 24-hour report. She stated that she questioned the order for blood glucose levels but did not speak to anyone regarding clarification. The LPN also said that BGs were not being confirmed with a blood draw, there was no sliding scale, so she thought there would be no treatment. She did not contact a physician. Review of the facility investigation root cause and analysis report completed on [DATE] and interviews with staff determined that Immediate Jeopardy was removed on [DATE], prior to survey exit. The following interventions were implemented: 1) The nurses involved received written counseling/warnings on [DATE] to [DATE] related to the need to report critical lab values, follow policies at all times, the need for thorough documentation in the medical record, and the need to ask questions if something does not seem right. 2) On [DATE] an audit was conducted on nursing avenues (nursing units) for residents with primary and secondary [DIAGNOSES REDACTED]. 3) BG meter results are being transmitted to a computer in the lab. A report is generated that identifies nurse, time, resident identity number, and BG result. Beginning on [DATE], the results are reviewed daily by the Clinical Compliance Department. Results less than 50 or greater than 450 will be audited daily to assess compliance with the policy and procedure. 4) Mandatory policy/procedure review of the updated policy Blood Glucose Testing Using the Accucheck Information Meter was done on [DATE] for all nurses with read and sign confirmation followed by post testing. The policy remained intact, except for the addition that the meter could also be cleaned with Cavi Wipes. 5) On [DATE] the Medical Director reviewed guidelines with providers regarding expectations on BGs to read: BG monitoring frequency if value less than 50 of greater than 450, repeat BG, if validated order lab confirmation and document provider notification. 6) On [DATE], information was circulated to all nurses in Hot Topics Newsletter regarding need to clarify orders if not clearly understood, check policies if uncertain, ask questions when something doesn't seem right, and document rationale for actions. The survey team interviewed facility staff to verify knowledge of policies and procedures. 7) Review of Advance Care Planning guidelines and definitions with education for families was completed via Family Newsletter. Mandatory educational review of Advance Directives with clarification of comfort measures only was completed for all associates through Hot Topics Newsletter on [DATE]. Read and sign confirmation was required. 8) Beginning on [DATE], nursing supervisors were required to write information on the 24-Hour Report Sheet regarding how issues of concern on the report are addressed. Formal education of the nursing supervisors on [DATE] included the above information, as well as direction that items on the 24-Hour Sheet or provider log will have supporting documentation in the medical record. (10 NYCRR 415.12)