Every finding on record at N Y S Veterans Home

Based on observations, record review, and interviews during the recertification survey conducted 5/12/2025-5/16/2025, the facility did not provide the necessary services and treatment for indwelling urinary catheter use for one (1) of three (3) residents (Resident #8) reviewed. Specifically, Resident #8 was not receiving staff assistance with changing or emptying their urinary drainage collection bag as planned. Findings include: The facility policy Indwelling Urinary Catheter Care and Management, revised 11/18/2024 documented to monitor for changes in urine output, notify the medical provider of abnormal findings, empty the drainage bag reguarly, inspect the catheter system to ensure it was a sterile continous closed system, and replace the system with a sterile no-touch technique if disconnection occurred. If patient teaching occurred documentation of indwelling catheter care and management should include teaching provided to the patient, understanding of that teaching, and follow up teaching that was needed Resident #8 had diagnoses including obstructive and reflux uropathy (urine obstruction and backflow) and urinary tract infections. The 2/24/2025 Minimum Data Set assessment documented the resident had intact cognition, had an indwelling urinary catheter, and was independent with most activities of daily living. The Comprehensive Care Plan created 3/7/2025 documented the resident required assistance to complete activities of daily living related to obstructive uropathy and the need for an indwelling urinary catheter. Interventions included urinary catheter care with morning and evening care, switch the leg drainage bag to a regular urinary drainage bag at night, and the resident required maximal assistance with the management of their indwelling urinary catheter. The following observations and interviews with Resident #8 were made: - on 5/12/2025 at 2:53 PM, they stated their indwelling urinary catheter caused discomfort and would clog up at times. Their overnight urinary drainage bag was lying in a pink basin next to the bathroom sink with 600 milliliters of dark yellow urine and the end of the connection tubing was not capped. - on 5/13/2025 at 1:26 PM, lying in their reclining chair with a leg drainage bag in place on their lower left leg. Their overnight urinary drainage bag was lying in a pink basin next to the bathroom sink with 400 milliliters of yellow urine and the end of the connection tubing was not capped. They stated they did not receive any training but was able to empty their own urinary drainage bags. They switched out their overnight urinary drainage bag with a leg drainage bag in the morning, put it in the basin during the day, and emptied the urine and cleaned the overnight urinary drainage before reconnecting it at night without any staff assistance. - on 5/14/2025 at 9:26 AM, the overnight urinary drainage bag was lying in a pink basin next to the bathroom sink with 300 milliliters of cloudy yellow urine and the end of the connection tubing was not capped. - on 5/15/2025 at 9:13 AM, lying in their reclining chair with their leg drainage bag attached on their lower left leg. Their overnight urinary drainage bag was lying in a pink basin next to their bathroom sink with 200 milliliters of yellow urine and the end of the connection tubing was not capped. There was no documented evidence the resident received education for management of their indwelling urinary catheter and was able to safely and approrpriately manage their own care. During an interview on 5/16/2025 at 11:01 AM, Certified Nurse Aide #9 stated the care plan included everything regarding the resident's care including their toileting status and if they had an indwelling urinary catheter. They were familiar with Resident #8, and had cared for them that week. Resident #8 was independent with managing their indwelling urinary catheter. The resident changed out their urinary drainage bag for their leg drainage bag in the morning and emptied their leg drainage bag throughout the day. The resident would tell them how much urine they emptied so they could document it. They stated they did not monitor the resident to ensure they were managing it appropriately. The nurses were responsible for providing education to the resident and determining if the resdient could be independent with managing their indwelling urinary catheter. They were not aware the resident's care plan documented the resident required maximal assistance with their catheter management. They stated they should not have assumed the resident was independent. If the resident was not managing their indwelling urinary catheter correctly it could put them at risk for infection. During an interview on 5/16/2025 at 11:17 AM, Certified Nurse Aide #10 stated Resident #8 had an indwelling urinary catheter and could manage it independently. They did not monitor the resident performing their urinary drainage bag changes, and the resident would empty their leg drainage bag throughout the shift and let the staff know the total so they could document it. The Registered Nurse Managers provided all of the education and determined if the resident could independently manage the care for their indwelling urinary catheter. They were not aware the residents care plan documented they required maximal assistance. They stated if Resident #8 was not provided education for completing their indwelling urinary catheter care properly it could put them at risk to get an infection. During an interview on 5/16/2025 at 12:02 PM, Registered Nurse/Charge Nurse #11 stated Resident #8's care plan documented they required maximal assistance with their indwelling urinary catheter management. Maximal assistance meant staff provided hands-on assistance with emptying the urinary drainage bags, monitoring the urine output and color, changing the urinary drainage bag over to a leg drainage bag, and providing a new urinary drainage bag and privacy bag weekly. The therapy team determined if the resident could independently manage their indwelling urinary catheter. The charge nurse or supervisor were responsible for providing the resident with education on caring for the catheter appropriately, documenting education was provided, and the resident was able to perform a return demonstration. Resident #8 should not have completed their own indwelling urinary catheter care. They stated they were not made aware the residnet was doing their own care. The resident was not educated and if they were not doing the care properly it put the resident at a higher risk for a urinary tract infection. During an interview on 5/16/2025 at 12:16 PM, Registered Nurse Supervisor #12 stated Resident #8's care plan documented they required maximal assistance with indwelling urinary catheter management which meant the certified nurse aides should empty the urinary drainage bags, ensure the bag was below the level of the bladder and in a privacy bag. If the resident was not deemed independent or did not receive education, it put them at risk for developing a urinary tract infection. There was no documentation Resident #8 was trained or could complete their indwelling urinary catheter care independently. The certified nurse aides should have followed the care plan and let the nurses know the resident wanted to complete their care independently so they could have followed up with the resident or provided training. 415.12(d)(1)

Based on observations, record review, and interviews during the recertification survey conducted 5/12/2025-5/16/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of three (3) residents (Resident #33) reviewed. Specifically, Resident #33 had poor oral intake with significant weight loss and was not assessed by the registered dietitian and the facility medical providers were not made aware of the weight loss. Findings include: The facility policy Mealtime Monitor and Nourishment Monitor Records, revised 1/27/2025, documented the unit meal and nourishment intakes were recorded by the nursing staff in the electronic medical record which was used for resident clinical assessments. The clinical nutrition staff were to be notified of residents who were eating poorly for several days or not taking nourishments well. The facility policy Nutrition/Nursing-Weight Change, revised 1/28/2025, documented nursing staff were responsible for obtaining a monthly weight for each resident and the charge nurse would review the weights and request reweights as necessary. Dietary reviewed the weights and evaluated if the resident had experienced any undesirable weight losses or gains during the past month and six-month period. If the weight change was not planned change, the physician would be notified. The clinical nutrition staff would review significant weight changes and work with the treatment team to develop a plan to identify the problem and formulate goals and interventions regarding the change. The facility policy Full Nutritional Assessments/Quarterly Notes/Nutrition Risk Notes/Care Plans/Revision of Nutritional Needs, revised 05/02/2025, documented residents at increased nutrition risk were reviewed monthly at a minimum. Risk notes were recorded in the interdisciplinary portion of the resident's medical record by the nutrition practitioner. A revised estimation of nutritional needs may have been required between full assessments or quarterly notes based on significant weight changes, changes in skin integrity, laboratory values, or with diagnosis that affected nutritional needs. Resident #33 had diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease (lung disease). The 3/10/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, had wandering behaviors that occurred daily, was independent with eating, had no swallowing conditions, and had a significant weight loss while not on a physician-prescribed weight loss regimen. The 7/22/2024 Comprehensive Care Plan documented: - the resident required assistance with their activities of daily living due to the diagnosis of Alzheimer's dementia with impaired cognition. Interventions included the resident was independent with eating with set up assistance as needed and required a non-skid placemat. - revised 3/11/2025, the resident was at risk for alterations in nutritional status/needs, oral intakes, and appetite. The resident seldomly attended breakfast, was at risk for weight loss, preferred small portions, and had a 17-pound decline or 10.6% weight loss in six months on 3/11/2025. Interventions included a regular diet with thin liquids; provide fluid and snack of choice in the morning and before bed; provide Boost Breeze (a nutrition supplement) juice twice a day; and monitor weight and intakes via the electronic medical record, direct care staff report, and random meal rounds. The resident's weight record documented: - on 12/5/2025 158.4 pounds; - on 1/8/2025 148.8 pounds (6% weight loss in 1 month) with no documented reweight. - on 2/12/2025 150 pounds, The 3/11/2025 Registered Dietitian #2 quarterly progress documented the resident was on a regular diet with thin liquids. They received small portions and their intakes were poor. Their lunch and supper meals averaged about 38% consumption and the resident skipped breakfast routinely. The resident had a significant weight loss of 17-pounds or 10.6% in 6 months and was down 4.5% or 6.8 pounds in one month. The resident's snacks in the evening and at bedtime had fair acceptance while morning and late-night snack acceptance was poor. The resident had moderate malnutrition was a high nutritional risk. The plan was to trial Boost Breeze juice twice a day between meals at the evening and bedtime snack times. The 3/12/2025 weight record documented the resident weighed 142.6 pounds (4.9% decrease in 1 month) with no documented reweight. The 4/7/2025 Nurse Practitioner #3 progress note documented the resident's intakes were at baseline, their weight was stable, and they had no acute illnesses. The 5/2/2025 Physician #4 progress note documented the resident had chronic abdominal discomfort and was a poor historian due to dementia. There was no documentation of the resident's intakes or weight loss. There was no documented evidence the medical providers were made aware of the resident's weight loss. The 5/7/2025 weight record documented the resident weighed 132.2 pounds, a loss of 7.29 % in one month and a 16.54 % Loss in 6 months. There was no documented evidence of a nutritional assessment and plan after the resident's significant weight loss on 5/7/2025. The resident's meal intake record for 5/2025 documented did not occur for: - breakfast meals on 5/1/2025 to 5/12/2025 and on 5/14/2025. - lunch meals on 5/1/2025 to 5/8/2025, 5/10/2025 to 5/12/2025, and on 5/14/2025. - dinner meal on 5/2/2025 and 5/9/2025. The resident's meal intake record for 5/2025 documented intakes of 50% or less for the following meals: - breakfast meal on 5/13/2025. - lunch meals on 5/9/2025 and 5/13/2025. - dinner meals on 5/3/2025, 5/5/2025 to 5/7/2025, and 5/10/25 to 5/14/2025. The resident's snack intake record for 5/2025 documented did not occur for: - evening shift snacks on 5/1/2024 to 5/2/2025, 5/9/2025 to 5/11/2025, and 5/14/2025. - night shift snacks from 5/1/2025 to 5/11/2025 and 5/13/2025. - day shift snack 2 on 5/1/2025 to 5/2/2025, 5/4/2025, 5/6/2025 to 5/8/2025, and 5/10/2025 to 5/14/2025. - evening shift snack 3 on 5/7/2025 and 5/10/2025. The resident was observed on: - 5/12/2025 at 1:00 PM, curled up in bed with a blanket pulled over their head. They did not come out to the dining room for lunch and there was no lunch tray in the room. - 5/14/2025 at 11:41 AM, lying on their bed facing the door. At 12:28 PM, they were asleep facing the door with their blanket pulled up to their nose. At 12:48 PM, the dining staff were cleaning up the lunch meal, no tray had left the dining room for the resident. At 12:49 PM, the resident was asleep on their bed with no meal tray or alternative meal in their room. During an interview on 5/16/2025 at 10:27 AM, Certified Nurse Aide #5 stated if a resident refused a meal, it was documented as did not occur and they should report it to the nurse. Resident #33 often refused meals but got snacks in-between. The resident was not big on the breakfast meal. They stated it was not concerning for the majority of Resident #33's breakfast and lunch meals to be documented as did not occur for 5/2025 as the resident was not usually up for breakfast and sometimes it was not worth the fight to get the resident to come out to the dining room for lunch. The resident was more of an evening person and staff would give the resident a snack. Weight changes that were plus or minus 5 pounds from the previous weight were reported to the nurse. During an interview on 5/16/2025 at 10:51 AM, Licensed Practical Nurse #6 stated the percentage of meals eaten by residents were documented by the certified nurse aides who tracked the meals on paper and input them into the electronic medical record. If a resident refused a meal, they were notified by the certified nurse aide. If a resident refused both breakfast and lunch, they should notify the charge nurse or the nursing supervisor. They should also write a progress note and pass it along to the next shift. The certified nurse aides reported to the nurse if there were changes in a resident's weight and they would pass the information on to a supervisor. During an interview on 5/16/2025 at 10:56 AM, Registered Nurse Charge #7 stated Resident #33 was mostly up in the afternoon and night eating. They were aware Resident #33 was refusing most of their breakfast, lunch and most of their morning and afternoon snacks. They were unaware the resident's intakes for their supper meals was minimal if they ate at all as it had not been reported to them. They would have notified he medical providers if they had known. The registered dietitian kept track of a resident's weights and received an email if there was a weight change. It was concerning Resident #33 had lost 10 pounds in a month and had been refusing meals. Nutrition had a list of malnourished residents they kept track of. They stated they had not received any emails or notifications regarding Resident #33. Resident #33's health could decline further if they consistently refused meals, had poor intake, and was losing weight. During an interview on 5/16/2025 at 11:15 AM, Registered Dietetic Technician #8 stated they and the registered dietitians followed the residents' weights. If a resident was identified as high risk, they were assessed and followed by the registered dietitians. The residents identified as high risk were followed monthly at a minimum, but it also depended on the resident's needs. If a resident was consistently refusing breakfast, lunch, their morning snack, afternoon snack, they expected to be notified. They checked resident weights weekly at a minimum. Registered Dietitian #2 followed Resident #33. If a resident had a significant weight loss, they would assess the resident, write a report, and then discuss the situation with the medical providers. During an interview on 5/16/2025 at 11:42 AM, Nurse Practitioner #3 stated they were unaware Resident #33 was refusing breakfast, lunch, their snacks, and had poor intakes. The consistent refusals of meals were something they should be notified of. They were unaware the resident had lost 10 pounds in one month or had significant weight loss over six months and they should have been notified. If Resident #33 continued refusing meals, having poor intakes, and losing weight, they could become dehydrated, their lab values could be off and overtime the resident could decline further. They expected a resident identified as a malnutrition risk be followed closely by the registered dietitian. During an interview on 5/16/2025 at 1:07 PM, Physician #4 stated they were made aware when a resident had significant weight loss or was identified as a malnutrition risk. For their 60-day federally mandated visits they reviewed the resident's chart which included the resident's weight. When a resident lost weight, they were usually contacted the same day. If a resident triggered for significant weight loss in six months and was identified as a high risk, they expected to be notified. They stated with Resident #33's dementia they were expected to lose weight as the disease progressed but they still expected to be notified of weight loss so the resident could be assessed. They were unaware of the resident's recent weight loss. During a telephone interview on 5/16/2025 at 2:03 PM, Registered Dietitian #2 stated they should notify the medical providers if a resident had a significant weight loss over six months. The protocol for residents who were on weekly weights was to check the weight every week, but they checked the weights every day. If a resident was weighed on 5/7/2025 they likely looked at the weight on 5/8/2025 or 5/10/2025. They were unsure if they were aware of Resident #33's recent significant weight loss. It had been a while since they assessed Resident #33 as they were only doing the assessments required for the Minimum Data Set which were quarterly. If a resident lost over 5% in a month, they should assess the resident, consider new interventions, and place the resident on the high-risk list. They had not kept up the high-risk list due to being short staffed. They stated currently they were mainly doing quarterly assessments and assessments on the new admissions. They were unaware Resident #33 was not eating their breakfast, lunch, daytime snacks, and their supper intake was variable. They would have alerted the medical providers and tried new interventions. If Resident #33 was not eating and their weight continued to decline the resident's overall health could decline. 10NYCRR415.12(i)(1)

Based on interview, observation, and record review during the abbreviated survey (NY00331758), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were investigated or reported to the New York State Department of Health as required for 1 of 4 resident (Resident #1) reviewed. Specifically, Resident #1 had a bruise and fracture of unknown origin and an investigation to rule out abuse, neglect, or mistreatment was not initiated. In addition, the injuries of unknown origin were not reported to the New York State Department of Health as required. Findings include: The facility policy Abuse, Neglect, Mistreatment dated 11/28/2017, documented the facility was to ensure all residents were free from abuse, neglect, or exploitation. Injuries of unknown origin were any injury not observed or could not be explained by the resident. Incidents of abuse, neglect, mistreatment, and injuries of an unknown source were to be investigated thoroughly and promptly. Resident #1 had diagnosis including stroke with hemiplegia (paralysis on one side), chronic obstructive pulmonary disease (lung disease), and atrial fibrillation (abnormal heartbeat). The 1/4/2024 Minimum Data Set assessment documented the resident had moderate cognitive impairment, was dependent on staff for most activities of daily living, had an indwelling catheter (drains urine from the bladder), received tube feedings (a tube in the stomach that provides nutrition), and did not have falls prior to admission. The 12/29/2023 admission fall risk assessment screen completed by Physical Therapist #12 documented the resident was at medium risk for falls. The 12/29/2023 comprehensive care plan documented Resident #1 had decreased strength and functional mobility related to a stroke. They received physical therapy, was dependent on staff for mobility, and was at medium risk for falls. Interventions included to ensure the resident's call bell was within reach when the resident was in their room. The comprehensive care plan was updated on 1/10/2024 to include the resident had a fall, was at high risk for falls, and staff were to complete frequent monitoring. The 1/10/2024 at 12:17 PM, Registered Nurse #15's progress note documented Resident #1 was observed on the foot pedals in front of their wheelchair at around 12:00 PM. The resident was visibly upset and reported they tried to move to a different, more comfortable chair. No injuries were observed, and range of motion was at baseline. The resident reported they did not hit their head and they had right sided weakness per baseline. The resident was calmed and placed back into the wheelchair for lunch. The 1/10/2024 at 12:00 PM, facility investigation completed by Registered Nurse #15 documented the resident was last observed at 11:50 AM. At 12:00 PM, the resident was observed near the nursing station on the foot pedals in front of their wheelchair. The resident reported they tried to get into the chair next to them as it looked more comfortable. An assessment was completed with no noted injuries. There was no reason to suspect abuse, neglect, or mistreatment occurred. Nursing progress notes from 1/10/2024 at 7:27 PM through 1/15/2024 documented the resident did not have any apparent injury, bruising, or pain from the fall on 1/10/2024. The 1/15/2024 at 10:53 AM progress note by Physician #4 documented Resident #1 was noted by physical therapy to have right ankle bruising. Physical Therapy was reluctant to increase weight bearing at that time and the resident denied symptoms and tenderness. An x-ray was ordered. The 1/15/2024 x-ray report documented the resident had an acute non-displaced right distal fibula fracture (fracture of the lower leg bone). There was no documented evidence the bruising or fibula fracture was investigated to rule out abuse, neglect, or mistreatment. The comprehensive care plan, revised 1/17/2024, documented the resident returned from the hospital with a Controlled Ankle Motion boot (a boot worn to stabilize a fracture) to the right foot that was to be worn at all times. The boot was to be removed for skin checks, hygiene, or range of motion. Circulation, sensation, and movement checks were to be completed. During a telephone interview on 6/10/2024 at 10:19 AM, Registered Nurse #15 stated Resident #1 was admitted to the facility with periods of confusion and forgetfulness. On 1/10/2024, the resident was seated in a wheelchair at the nursing station, slid from the chair onto the foot pedals, and reported they were attempting to move to a more comfortable chair. The resident was assessed with full range of motion and no evidence of pain, injury, or bruising, and the resident offered no complaints. They were off for the following few days, was not aware the resident had bruising to the right ankle and did not know if an investigation was initiated related to the bruising or fracture. During a telephone interview on 6/10/2024 at 10:25 AM, Physical Therapist #12 stated Resident #1 slid from their wheelchair to the floor on 1/10/2024 (Wednesday). The therapy aide worked with the resident the rest of the week. During therapy on 1/15/2024 (Monday), Physical Therapist #12 noted Resident #1 had bruising to the right ankle area. The bruising was in different stages of color with green, yellow, and some purple. They immediately notified the medical provider and requested an x-ray due to concerns of the resident's weight bearing. The x-ray showed a fracture. They reviewed the nursing notes to see if there was any documentation of bruising before that day and did not find any. During a telephone interview on 6/10/2024 at 10:32 AM, Director of Nursing #6 stated Resident #1 slid from their wheelchair on 1/10/2024 (Wednesday), was assessed without injuries, and had no complaints of pain, or bruising. They stated the nursing progress notes did not document the resident had bruising or discomfort after the incident. On 1/15/2024, physical therapy noted the resident had bruising to the right ankle, the medical provider was notified, and an x-ray was ordered that showed a fracture. The Supervisor was responsible for reporting the bruising and fracture, and initiating an investigation to rule out abuse, neglect, or mistreatment. The Director of Nursing stated an investigation was not completed into the resident's bruising or fracture and they were not reported. During a telephone interview on 6/10/2024 at 11:18 AM, Certified Nurse Aide #16 stated they worked during the day shift and took care of Resident #1 when they worked. They were in the area when Resident #1 slid from the wheelchair onto the foot pedals on 1/10/2024 (Wednesday). Registered Nurse #15 assessed the resident and there were no injuries or bruising at the time of the fall. They returned after the weekend and approximately one day later (could not recall exactly when), they noted the resident had some tenderness in the right foot with some swelling and bruising. They reported that to the nurse on duty (could not recall who) and an x-ray was done showing a fracture. They did not recall if they provided any statements about the bruising at that time, did not know if an investigation was completed, and the nurses would have the investigation if one was done. 10NYCRR 415.4(b)(1)(ii)

Based on record review and interview during the recertification survey conducted 10/2/2023-10/6/2023, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment; and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility annual water Legionella (a type of bacteria usually found in water causing Legionnaires' disease) testing was not completed in 2022 through September 2023; and the annual facility risk assessment and environmental assessment of water systems in healthcare settings was not completed in 2022 as required. Findings include: The facility Sampling and Management plan, effective August 2023, documented: - An environmental assessment will be conducted and updated annually; and - Legionella culture analysis will be performed quarterly by a NYS (New York State) Environmental Laboratory Approval Program (ELAP) certified laboratory. There was no documented evidence of Legionella testing for the domestic well water supply in 2022 to September 2023. Additionally, there was no documented evidence of a facility risk assessment and environmental assessment of water systems for 2022. The last documented annual Legionella testing for the facility domestic well water supply was completed on 10/1/2021. During an interview on 10/2/2023 at 10:45 AM, the Maintenance Director stated they could not find any documented Legionella testing for the domestic well water supply in 2022 through September 2023. During an interview on 10/3/2023 at 2:45 PM, the Administrator stated they were unaware that the Legionella testing for the domestic well water supply had not been completed in 2022 through September 2023. During a second interview on 10/3/2023 at 2:50 PM, the Maintenance Director stated that they were aware that Legionella testing of water was required to be done quarterly for the first year and tested annually thereafter if there was no Legionella identified in the sampled water. They assumed the domestic water had been tested as required by the facility's licensed water operator during one of the monthly tests. During an interview at 10/4/2023 at 10:12 AM, maintenance assistant #1 stated that they had taken over the task of completing the water testing in January/February 2022. They stated that they were never told by their predecessor to complete the Legionella testing or to complete the annual assessment requirement. They became aware of the requirements after a previous federal survey completed in April 2023. Maintenance assistant #1 stated that after the April 2023 survey they had reviewed and updated the facility sampling and management plan and had submitted it to the Maintenance Director for approval. They stated that there was no onsite training of what to do or where to sample for Legionella. Maintenance assistant #1 stated that they could not find the 2022 annual water Legionella testing records or the 2022 annual Legionella risk assessment. They were aware that if Legionella was present in the water, it could infect the nursing home residents. During an interview on 10/4/2023 at 12:20 PM, the Administrator stated it was important to test for Legionella because if Legionella was present in the water, it could potentially make someone sick. During an interview on 10/5/2023 at 11:16 AM, Infection Preventionist #5 stated that they were aware the facility was required to do annual Legionella testing and the maintenance department was responsible for completing the testing. They were not made aware of any Legionella updates when hired in June 2023, the facility's quality assurance meeting was completed monthly, and Legionella had never been addressed the meetings since they were hired. Infection Preventionist #5 stated that the Legionella testing of the water within the facility was done to ensure that the water was safe for the residents and staff. 10NYCRR 415.19(a) 48446

Based on observation, record review, and interview during the recertification and abbreviated (NY00317113) surveys conducted 10/2/2023-10/6/2023, the facility did not ensure residents received and the facility provided a diet in a form designed to meet individual needs for 1 of 1 resident (Resident #79) reviewed. Specifically, Resident # 79 was provided food items that were not consistent with their physician ordered diet. Findings include: The facility policy Communication of Dietary Orders and Resident Nutrition revised 7/6/2023 documented that purpose of the policy was to ensure accurately prescribed diets are followed. The medical provider writes the diet order in the activities of daily living (ADL) Optimum Order Entry section of the electronic medical record. The facility Clinical Nutrition Care Manual revised 12/28/2015 documented a Mechanical soft diet had food items modified in texture and consistency. The diet was used for an individual who required ground or very soft foods with swallowing problems that created a potential for aspiration (inhaling food into the lungs). The physician may order any combination of consistencies or textures that meet the residents' needs. A consistency modification could be combined with a diet order. Resident #79 was admitted to the facility with diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD, lung disease), and dysphagia (difficulty swallowing). The 8/11/2023 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, was independent with eating after set up, did not have a swallowing disorder, and was on a mechanically altered diet. The 4/20/2023 medical order by nurse practitioner (NP) #19 documented a mechanical soft diet with nectar thick liquids, no thin liquids, and may have a hot dog split lengthwise. The comprehensive care plan (CCP) initiated and 3/3/2023 and updated 4/20/2023 documented the resident was at nutritional risk related to diagnoses including dysphagia and required altered consistency solids and liquids. Interventions included a mechanical soft diet with nectar thick liquids, may have a whole hot dog split lengthwise, and no thin water. The 5/23/2023 at 8:35 AM Accident/Incident Summary completed by registered nurse Supervisor (RNS) #22 documented: - Resident #79 was observed by social worker #23 with a red face and coughing on coffee. Licensed practical nurse (LPN) #24 noticed the coffee was thin liquid and the diet was mechanical soft with nectar thick liquids. The thin coffee was removed. The resident was assessed the medical director was notified. The care plan was not followed, and staff were to be educated on fluid consistency. - A statement by cook #17 documented they were assisting with eggs to order on 5/23/2023 from 7:00 AM- 8:10 AM and there were no unit assistants. They started to pour drinks so the meal would be served on time. Resident #79 asked for a cup of coffee, and they did check the resident's ticket. The resident was on thickened consistency, and they served the resident thin liquids. - An attendance sheet dated 5/23/2023 documented staff were educated on how to read a meal ticket, and they understood the importance of serving the correct diet and fluid consistency to each resident at each meal. The attendance sheet was signed by cook #17. A three page training outline documented staff were educated from 5/23/2023 until 6/19/2023 on the importance of reading meal tickets before giving residents food or fluids and following dietary recommendations for diet orders and consistency. Documentation included residents on nectar thick diets could not have food that became liquid at room temperature, like ice cream. They could have Magic Cups (frozen nutritional supplements) in place of ice cream. Nectar thick liquids were described as liquids that would coat a fork and quickly sink through the prongs. Staff should not give residents food if they were unsure of their diet. A resident's diet could be found on the meal ticket and in the electronic medical record. An example of where to find information on the meal ticket was included in the training. The 6/12/2023 at 2:15 PM speech language pathologist (SLP) #16 progress note documented Resident #79 was screened for dysphagia secondary to a coughing incident on baked cake as they had a history of dysphagia and COPD. The resident was observed during mealtime intakes and agreed to give up cakes and baked muffins secondary to the dryness of those items. The SLP documented they modified the diet order to the medical provider and discussed with nursing and dietary. The 6/12/2023 medical order by NP #19 documented a mechanical soft diet with nectar thick liquids and extra sauces and gravies, a hot dog split lengthwise, 4 oz of thin milk on oatmeal, no thin water, and no cake or muffins. There was no documented evidence the CCP was updated to include no cake or muffins at the time of the medical order. The 8/3/2023 at 1:15 PM Accident/Incident Summary completed by RN #13 documented they were notified that food service worker #10 gave Resident #79 an ice cream sandwich during lunch. Staff attempted to remove the ice cream sandwich. RN #13 assessed the resident, and the resident had diminished lung fields. A food service staff had asked another employee if the resident could have an ice cream sandwich without communicating food consistency. The resident consumed the sandwich without issue. - An 8/3/2023 (A&I documented 8/3/2023) statement by food service worker #10 documented they went to get an ice cream sandwich for Resident #79 and asked food service worker #9 if it was ok and food service worker #9 said to ask an aide. - An 8/2/2023 (A&I documented 8/3/2023) statement by food service worker #9 documented food service worker #10 asked them if it was ok for Resident #79 to have an ice cream sandwich. Food service worker #9 asked registered dietitian (RD) #11 if it was ok and they said yes. - An 8/31/2023 statement by RD #11 documented a food service worker called out to them and asked if Resident #79 could have an ice cream sandwich. They did not know the resident and the food service worker told them the resident was a mechanical soft. RD #11 replied yes, mechanical soft can have an ice cream sandwich. There was no mention of thickened liquids. The 8/4/2023 at 1:58 PM SLP #16 progress note documented they received a request for a screening secondary to early pneumonia. Resident #79 had a history of repeated pneumonia and was tolerating current textures without overt symptoms of aspiration when evaluated. SLP recommended elevating the head of the bed and keeping upright after meals with the diet remaining the same. The CCP was updated on 8/4/2023 and documented the resident was to have mechanical soft diet with nectar thick liquids and extra sauces and gravies, a hot dog split lengthwise, 4 oz of thin milk on oatmeal, no thin water, and no cake or muffins. The 8/16/2023 quarterly nutrition assessment completed by dietitian student #4, documented the resident received a mechanical soft diet, nectar thick liquids, extra gravies, may have whole hotdogs split lengthwise, no thin water, may have 4 oz thin milk on oatmeal, no cake, and no muffins. The resident received an altered diet consistency due to oropharyngeal dysphagia (swallowing problems that occurred in the mouth and/or throat). The undated certified assistant nursing (CNA) book documented Resident #79 was on a mechanical soft diet with nectar thick liquids, extra sauces/gravies, may have a whole hot dog split lengthwise, no thin water, may have 4 ounces of thin milk on oatmeal, and no cake or muffins or water unless thickened. The following observations of Resident #79 were made on 10/3/2023: - at 3:56 PM at a table in the activities area with a cup of thickened coffee and a piece of cake that was missing a section near their fork. Recreational therapist (RT) #12 stated they gave the cake to the resident. - at 4:03 PM, at the table in the activity area with cake missing two pieces and a fork on a plate in front of them. There was no staff in the area. - at 4:06 PM, Resident #79 remained at the table in the activities area and stated they planned to eat the cake in front of them. - at 4:14 PM in the dining room LPN #6 was observed asking CNA #7 if Resident #79 had any dietary restrictions. After looking at the meal ticket CNA #7 stated Resident #79 was not restricted from cake or muffins. CNA #7 stated they did not know what it meant on the meal ticket no muffins or cakes. LPN #6 asked food service worker #8 why the resident was restricted from cake and muffin and food service worker #8 stated they were not sure but would call a supervisor. Food Service Supervisor #21 returned food service worker #8's call and stated the cake was a choking risk for Resident #79 and they should not have it. - at 4:18 PM, food service worker #8 removed a plate, fork, and cake from the table in front of Resident #79. During an interview on 10/3/2023 at 4:04 PM, recreation therapist (RT) #12 stated Resident #79 was on a restricted diet and required nectar thick liquids. They stated the resident was not restricted from cake or muffins. They stated if the resident was on restrictions from cake and ate cake it could be a safety concern as the resident might choke. During an interview on 10/3/2023 at 4:09 PM, LPN #6 stated they were floated to the unit and were unfamiliar with any dietary restrictions for residents of the unit. They stated if a resident had restrictions, and those restrictions were not maintained, they could choke depending on why the restriction was in place. During an interview on 10/5/2023 at 8:23 AM, RN #13 stated when there was a new order the unit nurse was alerted by the electronic record in the ADL section and advised staff that an order required review. The new order would be noted by the nurse with the date and time recorded and was double checked every 24 hours by the Unit Manager or Nurse Supervisor for every resident to make sure all orders were properly addressed. The nurse updated the care plan if required and the CNA book was updated if appropriate. The CNA book was reviewed every shift by all CNAs prior to working with the residents. When there was a change in the diet order staff that served food and drinks were notified for safety issues. CNAs were trained in new employee orientation about altered diets, food consistencies, and how to read the meal ticket. Diet orders were located on the meal tickets and in nourishment binders that were in the dining room. CNAs and RTs were trained to look in the nourishment binders before serving food to residents for safety reasons. If the diet orders were not followed, residents could choke, develop aspiration pneumonia, or have an allergic reaction. Resident #79 had at least one choking incident. During an interview on 10/5/2023 at 9:02 AM, RD #14 stated every resident was screened on admission by speech therapy who recommended the diet order. The order was reviewed and approved by the physician and sent to dietary who put the order in the computer. The meal ticket was printed by dietary and brought to the kitchens on each unit. The RD or dietary technician entered nutritional information in the care plan which was placed in the door of every room and in the nourishment binder in the kitchen and nurse's station. For safety reasons no one could eat without a diet order, to avoid choking or reaction to a food allergy. They stated it was policy for every staff to look at the meal ticket before they gave any resident food or fluids. Resident #79 should not have had cake because it was on the care plan. They were not sure why the resident could not have cake. During an interview on 10/5/2023 at 9:41 AM, SLP #16 stated they assessed every resident on admission and made a draft recommendation for a diet order. A nectar thickened liquid was ordered when a resident had dysphagia to limit the potential for aspiration pneumonia and was recommended for Resident #79. The order was reviewed by the physician, was an active order, and sent to dietary. Dietary entered the diet order in the care plan, made the ticket, and updated the CNA directives on the unit in rooms and in the nourishment book. The book was located at the nurse's station and in the dining room. No one could eat without an active order because of safety reasons which could include aspiration. The SLP communicated to nursing staff on multiple occasions never to feed a resident without reviewing the dining ticket, because there could be a change in the diet order made between meals. If tickets were not checked before every meal residents could get the wrong texture or consistency. Resident #79 was a high risk for choking and had several episodes of aspiration pneumonia. During an interview on 10/5/2023 at 1:30 PM, RD #11stated they had in-service education about food textures over the years. In 8/2023 when working on an unfamiliar unit they told a food service worker Resident #79 could have an ice cream sandwich after the food service worker stated the resident was on a mechanical soft diet. They were not told the resident was also on nectar thickened liquids which did allow the ice cream sandwich. They resident should have had the ice cream sandwich replaced with a Magic Cup because the ice cream was too thin and could cause aspiration pneumonia. They recalled being re- trained after the incident and would not recommend food or fluids to staff without looking in the nutrition book again. During an interview on 10/5/2023 at 2:00 PM, cook #17 stated they gave Resident #79 thin coffee on 5/23/2023 when the order was nectar thick. The nectar thick was ordered for residents to prevent choking. They stated they were educated following the incident on the importance of reading the meal ticket and following diet orders and was counseled by the Administrator. During an interview on 10/5/2023 at 2:21 PM, the Director of Nursing (DON) stated they were aware Resident #79 received the wrong food and fluid consistencies on three separate occasions. They were not sure why RT #12 was not educated in May on food textures and reading a menu, however they should have been included in the training because they gave food and fluids to residents. They stated staff was educated many times about the importance of reading the meal ticket every time before giving residents food or fluid. During an interview on 10/5/2023 at 2:47 PM, RT #12 stated they did not remember being educated about meal tickets or diet consistencies in May. They stated Resident #79 should not have had cake and was given pumpkin spice cake. They stated they did not follow the physician order and the resident had swallowing and breathing difficulties, and aspiration pneumonia in the past. During a phone interview on 10/5/2023 at 5:00 PM, food service worker #9 stated that they were working with food service worker #10 serving ice cream sandwiches to residents after the meal on 8/2/2023. Neither staff was sure if Resident #79 could have the ice cream so food service worker #9 asked RD #11 and was given permission to offer the resident an ice cream sandwich. The resident was given the ice cream sandwich by FS #10. The resident had completely eaten the ice cream sandwich when one of the nursing staff stated the resident was restricted from eating ice cream. During an interview on 10/6/2023 at 9:31 AM, RT #12 stated Resident #79 did not require supervision when eating and on 10/3/2023 ate at least two bites of the cake before it was removed. During an interview on 10/6/2023 at 10:06 AM, RN #18 stated they were responsible for new employee orientation. Food service was discussed with all new employees, and included dining room services, adaptive equipment, allergies, food consistencies, and how to read a meal ticket. Each new employee was given a copy of a meal ticket for an example. They remembered an incident in 5/2023 when Resident #79 choked, and training was completed the following days. The staff educator believed all staff had been trained but did not have signed training sheets available. They stated the DON had all training sheets. If there was a name missing from the sign in sheets it meant they were not trained. 10NYCRR 415.14(d)(3)

Based on observation, interview, and record review during the abbreviated survey (NY 793) the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #1), reviewed for quality of care. Specifically, when Resident #1 had increased weeping of his right leg and his Juzo compression liner became saturated: - The registered nurse Supervisor (RNS) did not ensure a new Juzo compression liner was provided; and - The licensed practical nurse (LPN) did not ensure the resident received the correct Juzo compression liner as ordered and did not document or relay the information to the oncoming nurses to ensure the resident received the appropriate care and services. This resulted in maceration (softening of tissue from increased moisture), swelling and an open area to the resident's right ankle. Findings include: Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, required assistance from two people with dressing and personal care, was at risk for developing pressure injury, did not have pressure, venous or arterial ulcers and had pressure relieving devices in place. The nurse practitioner (NP) order dated 6/6/2019, documented ReadyWrap (outer wraps for the legs that provide compression) to be on at all times, except for hygiene, to both legs. The resident was to have compression liners underneath the ReadyWraps and his skin was to be monitored with morning and evening care. Wound Care registered nurse (RN) #8's progress note dated 9/6/2019 at 9:46 AM, documented the resident's right lower lateral leg had small blood colored excoriation that looked like broken blood blisters from [MEDICAL CONDITION]. The resident had weeping of serous (clear) fluid without signs of infection or pain. The resident had a new order to cleanse the area with [MEDICATION NAME] (topical antiseptic) and apply [MEDICATION NAME] foam (dressing used for draining wounds) daily. The NP order dated 9/6/2019 documented the new treatment of [REDACTED]. There was no documentation the NP made changes to the order for the compression liners or ReadyWraps at that time. RNS #2's progress note dated 9/7/2019 at 11:15 AM, documented Resident #1's right lower leg was very macerated. The Juzo compression liners were soaked with no obvious open areas. The resident had 3 plus [MEDICAL CONDITION] (when pressure is applied an indentation remains in the skin for up to 30 seconds after removing pressure), medical was notified, the Juzo compression liner was removed, and a dressing was placed on the resident's ankle per order. An Allevyn heel cup (an absorbent dressing for the heel) was added to the resident's heel under the compression liner and staff were attempting to elevate the resident's feet. The ReadyWrap was to be left off the resident's right leg and they were to place a foot/ankle liner if tolerated by the resident. There was no documentation a physician order [REDACTED].#2's progress note. There was no order for the Allevyn heel cup or to leave the ReadyWraps off the resident. The 9/2019 Treatment Administration Record (TAR) documented: - On 9/7/2019, on the 7:00 AM - 3:00 PM shift, licensed practical nurse (LPN) #4 applied the physician ordered ReadyWraps and compression liners. - On 9/7/2019, on the 3:00 PM to 11 PM shift, LPN #4 documented she monitored the resident's right leg. - On 9/7/2019, on the 11:00 PM to 7:00 AM shift, LPN #6 documented she monitored the resident's skin and identified the resident did not have the correct treatment or compression liner in place per the physician order. She documented she found a tan Juzo compression anklet on the resident's right foot. The facility investigation report dated 9/8/2019 at 3:30 AM, documented: - LPN #6 found that the wrong treatment was in place to the resident's right leg. The resident had 4 plus [MEDICAL CONDITION] (indentation from applied pressure lasts greater than 30 seconds) and maceration near the right ankle. A treatment of [REDACTED]. LPN #6's progress note dated 9/8/2019 at 4:41 AM, documented the resident had a Juzo compression anklet on his right foot and he did not have on the Juzo compression liner and ready wrap to the right leg and foot. The resident's right lower extremity had increased [MEDICAL CONDITION], redness, and increased excoriation. The Supervisor was made aware. [MEDICATION NAME] foam dressing and an Allevyn heel were applied. A single layer [MEDICATION NAME] (looser compression stocking) was applied to the right lower extremity and medical was made aware. RNS #2's progress note dated 9/8/2019 at 9:56 AM, documented the resident's right lower foot and leg were improved since the previous day. The resident had two plus [MEDICAL CONDITION] (slight indentation when pressure applied [MEDICATION NAME] less than 15 seconds) and the resident's skin surface was much softer with less shine. The plantar aspect (bottom of foot) and heel remained macerated with a crusted layer on the heel. The outer ankle dressing had serous drainage on the dressing and heel cup. The skin was weeping with no obvious trauma or open areas. The resident's lower calf remained red, warm, and tender to touch. Medical was updated and new orders were obtained for a venous Doppler (ultrasound), oral antibiotics, dressing orders, and Juzo compression stockings. RNS #2's progress note dated 9/8/2019 at 12:57 PM, documented the resident started his antibiotic for right leg [MEDICAL CONDITION] (infection of the skin and soft tissue underneath). The initial dose of Keflex (antibiotic)500 milligrams (mg) was started. The redness extended from his toes to mid-calf. The physician orders [REDACTED]. A [MEDICATION NAME] was to be applied to the right leg from the toes to the knee as tolerated. A venous Doppler was ordered. The NP's progress note dated 9/9/2019 documented the resident had worsening of the right outer ankle over the weekend with increased [DIAGNOSES REDACTED] (redness) and warmth that extended to the foot and part way up the calf. The ReadyWraps were removed on Saturday (9/7/2019) per medical order and [MEDICATION NAME] was ordered for compression. A Doppler was ordered and was negative for a [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot). The assessment documented the resident had right lower leg [MEDICAL CONDITION] and Keflex was changed to [MEDICATION NAME]. The NP was interviewed on 10/9/2019 at 10:48 AM. She stated on 9/6/2019, Resident #1 was noted to have mild excoriation and blisters on his right lateral ankle. The weeping and [MEDICAL CONDITION] caused the blisters and he had problems with this for a few months. The resident was non-compliant and would not elevate his feet. A few of the blisters were open and clear drainage was present. A new treatment was initiated of [MEDICATION NAME] foam dressing on the open blisters, and continue Juzo compression liners and ReadyWraps. There was no order for the resident to have a compression anklet on his right ankle. On 9/9/2019, she saw the resident and he had 4 plus [MEDICAL CONDITION] in his right foot. His entire leg and foot were shiny, the lateral ankle was open and macerated and extended to the outer aspect of the foot. His foot was dusky, discolored and was warm. Due to the swelling she was unable to determine if a pulse was present. The resident had [MEDICAL CONDITION]. She stated the compression anklet contributed to the deterioration of the areas. On (Sunday) 9/8/2019, the resident was put on Keflex and the antibiotic was changed on (Monday) 9/9/2019 to an intramuscular injection of [MEDICATION NAME]. The area had shown improvement since the new treatment was administered. LPN #4 was interviewed on 10/9/2019 at 12:53 PM, and stated she worked on 9/7/2019 from 7:00 AM to 7:00 PM and: - She noticed the resident's Juzo compression liner and RreadyWraps were saturated and RNS #2 was called. - LPN #4 went to get another compression liner for the resident, could not find one, and brought back a Juzo compression anklet. RNS #2 told her to complete the same treatment to the resident and apply the Juzo compression anklet in place of the compression liner and ReadyWrap. RNS #2 stated she would obtain an order and a new compression liner. - LPN #4 did as instructed by RNS #2 and applied [MEDICATION NAME] foam, Kerlix (gauze wrap), and the compression anklet to the resident. - During the 3:00 PM - 7:00 PM time frame, LPN #4 was scheduled to monitor the resident's skin. She stated that included identifying changes and ensuring the resident's treatment was in place. She documented she completed the monitoring for that shift, but she did not know if the resident's [MEDICAL CONDITION] had changed, if the treatment was updated, if the compression anklet was still in place, or if the new compression liner had been applied to the resident at that time. - When she documented she did the check on the evening shift, she did not reach out to the evening RNS for assistance and did not document the information in the resident's medical record, progress note or on the shift to shift report. - She did not recall if she relayed any information about the resident in the verbal change of shift report to the oncoming nurse. LPN #5 was interviewed on 10/9/2019 at 2:57 PM, and stated he took over care of the resident from LPN #4 on 9/7/2019 at 7 PM and did not receive any information from LPN #4 about the resident's condition or change to his right ankle. LPN #4 documented she completed the skin monitoring for that shift, so he did not do the monitoring. LPN #6 was interviewed on 10/10/2019 at 8:40 AM, and stated she worked on 9/7/2019 on the 11:00 PM - 7:30 AM shift. She was made aware by the certified nurse aide (CNA) that the resident's dressing was not on properly and his leg had increased [MEDICAL CONDITION]. She observed his right foot was red with deep indentations and 4 plus [MEDICAL CONDITION] where the Juzo compression anklet was in place. She reported his foot looked like a balloon from the top of the instep to his toes. She stated she notified the Supervisor. The resident was observed on 10/10/2019 at 11:00 AM, in his room in bed. His ReadyWraps and compression liners were removed from both legs. The right leg/ankle had Kerlix under the liner with a treatment in place. The area on the right outer ankle was the approximate size of a 50-cent piece. There was no open skin or redness and there was a small amount of clear drainage. Both legs had severe [MEDICAL CONDITION] and RN #8 reported that was usual for this resident as his did not keep his feet elevated. She reported she had never seen his [MEDICAL CONDITION] less than what was present at that time. RNS #2 was not available for interview after attempts to reach her by phone or mail. 10NYCRR 415.12

Based on interview and record review during the abbreviated survey (NY 865) the facility did not ensure residents had the right to be free from abuse for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, Resident #1 was hit in the face and called profane names by certified nurse aide (CNA) #1. Findings include: The facility's policy and procedure for abuse prevention dated 3/19/2019, documented all residents had the right to be free from abuse. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 5/2/2019 documented the resident had cognitive impairment and was unable to participate in making choices. He required extensive assistance of 2 staff for his toileting needs, was frequently incontinent of bowel and bladder and was to be checked and changed every 2 hours for incontinence. His behaviors were unpredictable, he was at risk to be a victim of abuse due to having no insight and was not able to report accurately. He had periods of [MEDICAL CONDITION] and often resisted care. The facility's accident/ incident report dated 6/6/2019 at 4:45 PM, documented CNA #1 was observed by CNAs #3 and 4 hitting Resident #1 in the left side of his face, with a closed fist. CNA #1 also called the resident profane names while she hit him. The force of the blow caused the resident's head to move to the side. The incident was reported by CNAs #3 and 4 immediately after it occurred. CNA #1 was suspended during the facility's investigation and the resident was assessed and did not have an injury. CNA #3 was interviewed on 6/10/2019 at 9:56 AM and stated CNA #4 and she assisted Resident#1 in the bathroom with incontinence care on 6/6/2019. The resident became a little anxious and CNA #4 called for assistance. CNA #1 arrived in the bathroom and grabbed the resident's hand. The resident attempted to push her hand away swinging in a backward motion and did not make contact with CNA #1. CNA #1 then hit Resident #1 with a closed fist to the left side of his face. CNA #3 recalled the resident was hit so hard his head moved. CNAs #3 and 4 both stated to CNA #1 that she could not do that. CNA #1 responded with foul language and called the resident profane names. CNA #1 left the bathroom while CNAs #3 and 4 finished care. CNA #3 left the room and helped another resident and then reported the incident. CNA #4 was interviewed on 6/10/2019 at 12:06 PM and stated both she and CNA #3 were assigned to Resident #1 on 6/6/2019. They were in the bathroom providing incontinence care to the resident prior to the incident. The resident started to become agitated and CNA #4 called for assistance and CNA #1 responded. CNA #1 grabbed the resident's hand and the resident swung his hand back and did not make contact with CNA #1. CNA #1 then struck Resident #1 on the left side of his face with a closed fist and called him profane names. CNA #4 stated the blow was hard enough to make the resident's head move and she recalled the resident said ouch at the time of the punch. She stated she and CNA #3 told CNA #1 she could not do that, and CNA #1 responded to them with foul language. CNA #4 stated they completed care and reported the incident to the nurse. CNA #1 was interviewed on 6/13/2019 at 10:08 AM and stated when assisting CNAs #3 and 4 with incontinence care on Resident #1, the resident became combative and hit her in the face and the upper stomach. She did not report the issue as the resident did not really hurt her. She stated she did hit the resident in the face with a closed fist and did call him profane names. The Assistant Director of Nursing (ADON) was interviewed on 8/30/2019 at 9:04 AM, and stated since the incident, the facility reviewed the abuse policy and no changes were made. All facility staff were re-educated on abuse and CNA #1 was no longer employed at the facility. 10NYCRR 415.4(b)(2)(3)

Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure food was palatable for 2 of 2 meal observations, and for 3 anonymous residents at the resident group meeting. Specifically, cold food items were not served at palatable tastes and temperatures, and 3 anonymous residents reported food was often served out of temperature. Findings include: During the resident group meeting on 6/13/2017 at 3:00 PM, 3 residents stated food and drinks were often served out of temperature. During a meal observation on 6/13/2017, the following was found: - At 5:12 PM, Resident #1 was served chocolate milk. The resident sat with his head down, not drinking, through 5:32 PM. - At 5:37 PM, Resident #1's tray was removed from the table and a replacement tray was requested. - At 5:39 PM, Resident #1 received a replacement tray. - At 5:40 PM, the following temperatures were taken on Resident #1's meal tray: salad, 55 degrees Fahrenheit (F); chicken salad, 51 degrees F; chocolate milk, 55 degrees F; and pasta salad, 53 degrees F. The milk had not been consumed by the resident. During a meal observation on 6/14/2017, the following was found: - At 7:40 AM, Resident #20's fluids were sitting at the dining table and the resident had not yet arrived. The milk temperature was 50 degrees F. A nurse recognized the milk at the table and asked for a replacement. The replacement milk was served and the temperature was 52 degrees F. - At 7:51 AM, Resident #20 arrived to the dining area. - At 7:53 AM, Resident #20 received his meal tray and agreed to the surveyor taking the temperatures of the items on the tray. - At 7:55 AM, the scrambled eggs' temperature was 120 degrees F and tasted bland. An anonymous resident stated to a surveyor on 6/14/2017 at 8:00 AM, the scrambled eggs were bland and not flavorful. At 8:04 AM on 6/14/2017, the surveyor took a temperature of the eggs at the steam table with facility staff. The staff plated the eggs. The facility thermometer temperature of the the eggs at 8:06 AM was 112 degrees F and the surveyor's thermometer temperature was 110 degrees F. During an interview with the Food Service Director on 6/14/2017 at 8:18 AM, he stated milk should not be placed on the table more than 15 minutes prior to the meal being served. During an interview with the cook on 6/14/2017 at 8:30 AM, she stated the goal was to serve all hot food over 140 degrees F. During an interview with unit assistant #6 on 6/14/2017 at 8:45 AM, she stated she started serving milk to the dining room at 7:20 AM on that date. 10NYCRR 415.14(d)(1)(2)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure residents with pressure ulcers received the necessary treatment and services needed to promote healing for 1 of 2 residents (Resident #5) reviewed for pressure ulcers. Specifically, Resident #5 had a pressure ulcer and the wheelchair's pressure-reducing device was not functioning for 3 days of survey. Findings include: Resident #5 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 5/3/2017 Minimum Data Set (MDS) assessment documented the resident's cognition was intact, she required extensive assistance with most activities of daily living, and she had a Stage IV pressure ulcer. The comprehensive care plan dated 1/5/2017 documented an air cushion was added to the resident's wheelchair and was set to float setting. The 6/5/2017 physician order, initially ordered on [DATE], documented the resident required an air cushion in the wheelchair set to float setting. The 6/7/2017 Weekly Pressure Ulcer Tracking Record documented the resident had a Stage IV pressure ulcer on the left buttock that measured 5.0 cm (centimeters) x 2.6 cm x 3.2 cm (length x width x depth). The nursing progress note dated 6/9/2017 at 12:00 PM documented the resident had a new pressure injury to the left medial (toward the center) buttock that measured 0.7 cm x 1 cm x 0 cm and was dark purple in color. The 6/14/2017 Weekly Pressure Ulcer Tracking Record documented the resident's Stage IV pressure ulcer on the left buttock measured 5 cm x 2 cm x 2.6 cm, and the DTI (deep tissue injury) on the left medial buttock measured 1 cm x 1 cm x 0 cm. The resident was observed: - On 6/13/2017 at 5:59 PM, seated in her wheelchair in the dining room. The wheelchair air cushion control box, hanging on the back of the wheelchair, did not show a digital display indicating the unit was turned on. - On 6/14/2017 at 9:12 AM, in bed on her right side during a pressure ulcer dressing change. The wound bed was dark pink, the surrounding skin was intact, and the wound measured 5.0 cm x 2.0 cm x 2.6 cm. The DTI was now a Stage II, it measured 1.0 cm x 1.0 cm x 0 cm, and the wound bed was light pink. - On 6/14/2017 from 11:45 AM - 12:21 PM, seated in her wheelchair in the dining room. The wheelchair air cushion control box display was dark without a digital display. - On 6/15/2017 at 12:17 PM, seated in her wheelchair in the dining room. The wheelchair air cushion control box display was dark without a digital display. At 12:50 PM, the resident wheeled down the hallway after leaving the dining room. The digital display was not visible and was dark. During an interview on 6/16/2017 at 9:10 AM, certified nurse aide (CNA) #7 stated the resident had an inflating air cushion in her wheelchair that was turned on whenever she was in her chair. She stated, after the resident laid down for a nap, the unit was plugged in for charging. On 6/16/2017 at 9:15 AM, nurse Administrator (NA) #3 stated in an interview the resident had the alternating air cushion in her wheelchair to prevent pressure and it was supposed to be turned on when she was in the wheelchair. He stated the unit went into a power save mode and the digital display shut down after a few seconds to preserve the battery. He stated the unit still functioned when in power save mode. At 10:44 PM, NA #3 accompanied the surveyor to the resident's room and observed the digital display to be darkened. He turned the unit off and then on. The digital display illuminated and appeared operational as the numbers were increasing/decreasing showing the alternating pressure. The digital display then dimmed and the numbers disappeared. NA #3 stated in the past he could still read the digital display after the unit dimmed and it appeared the unit was not working. He stated maintenance assistant #8 was more familiar with the unit and could offer more information. On 6/16/2016 at 10:30 AM, the surveyor received operating instructions for the resident's air cushion. The instructions read the light switch illuminates the display and stays on approximately 10 seconds and will automatically shut down (this saves the battery life). During an interview on 6/16/2017 at 11:31 AM, maintenance assistant #8 stated the inflating air cushion had not been used for the last 5 years and the facility recently started using them again. At 11:33 AM, maintenance assistant #8 turned the resident's air cushion off and then on. The unit illuminated, dimmed and then went completely dark without a display. He stated the unit was not working and he was not aware it had not been working. On 6/16/2017 at 1:15 PM, the acting Director of Nursing (DON) accompanied the surveyor to the resident's room. The resident was in bed, her wheelchair was across the room, and the air cushion digital display was dark. The DON pressed on the air cushion and stated it was deflated and not working. 10NYCRR 415.12(c)(1)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not provide the care and services to maintain good nutrition for 1 of 21 residents (Resident #20) reviewed for activities of daily living (ADLs). Specifically, Resident #20 was not assisted out of bed timely. Findings include: Resident #20 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 2/7/2017 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, was totally dependent on staff for transferring, required extensive assistance for bed mobility and locomotion on the unit, and was independent with eating. The 4/27/2017 comprehensive care plan (CCP) documented the resident was at risk for decline in ADLs self performance, and for decreased social interactions. The resident required the use of a ceiling lift for transfers, extensive assistance for hygiene, and was independent with eating. The resident was able to participate in decision making, direct his daily routine, and preferred to get up in the morning around 6:00 AM. The 6/2017 ADL record documented the resident was assisted with toileting at 6:00 AM on 6/14 and 6/15/2017. The surveyor arrived to the unit dining room at 7:35 AM on 6/14/2017. The resident's fluids were sitting at the table and the resident was in his room receiving care. The resident arrived to the dining area at 7:51 AM. The resident's tablemate was already seated at the dining table eating his breakfast meal. The resident's meal arrived at 7:53 AM. The resident was observed arriving to the dining table on 6/15/2017 at 8:00 AM. The resident's tablemate was seated at the table and had consumed half of his breakfast meal. The dining room had already been served and most residents had started and consumed some of their breakfast meal. The resident was observed at 8:42 AM, still eating his breakfast meal. Most of the residents in the dining room had been removed or left the dining room and only 5 independent residents at other tables remained. The resident's tablemate had left the dining area. During an interview with the resident on 6/15/2017 at 11:20 AM, he stated in his day-to-day life prior to nursing home placement, he would get up at 5:00 AM. He stated it stemmed from his previous employment and military background and he was used to it. He stated if anything, he preferred to be up by 6:30 AM. He stated he was sometimes late to breakfast when the staff were not able to get him up in time. During an interview with certified nurse aide (CNA) #1 on 6/15/2017 at 11:35 AM, she stated the resident required the use of a ceiling lift for transfers. She stated he required full assistance with care including assistance with transportation to the dining room. She stated when a resident was admitted at the facility, the staff asked what time they preferred to wake in the morning. CNA #1 stated they were not always able to assist all residents at their preferred wake time and it depended on if the shift prior was able to finish their work. She stated on this date they saved the resident's care for last as he now required 35 minutes to get ready. She stated the unit the resident resides on had a lot of residents that required the use of lifts and assistance with care. During an interview with CNA #2 on 6/15/2017 at 11:53 AM, he stated the resident required the use of two staff with a ceiling lift for transfers and care. He stated recently the resident was not able to bring himself to the dining room and required the assistance of staff. He stated the resident was usually awake when he arrived for the start of his shift at 6:00 AM. CNA #2 stated the resident liked to get up at the start of the shift. He stated the resident now required 20 minutes to get up in the morning. He stated the prior shift assists some residents on the unit before 6:00 AM, and if this did not happen it sometimes put the 6:00 AM - 2:30 PM shift behind. During an interview with registered nurse (RN) #3 on 6/15/2017 at 1:45 PM, he stated resident preferences were gathered on admission by nursing. He stated staff did they best they could to get residents up at their preferred time. He stated it had been an issue at the facility. RN #3 stated staff should try to get the residents up at their preferred time they as best they could. 10NYCRR 415.12(a)(3)

Based on interview and record review conducted during the abbreviated surveys (NY 126 and NY 022), it was determined for 2 of 6 residents (Residents #1 and 4) reviewed for abuse, neglect, and mistreatment, the facility did not ensure all alleged violations involving abuse, neglect, and mistreatment were completely investigated. Specifically, complete and thorough investigations were not performed when Resident #1 had a physical altercation with a staff member, and Resident #4 had misappropriation of funds. Findings include: 1) Resident #1 had [DIAGNOSES REDACTED]. The facility investigative summary dated 9/16/2016 documented Resident #1 was in bed in his room when certified nurse aide (CNA) #2 witnessed CNA #5 throwing a glass of water on the resident. The summary documented the resident was upset and crying and stated, Don't do that again, I am an old man of [AGE] years. The summary documented CNA #5 was suspended when the nursing Supervisor was notified of the incident, and the NYS Police were notified of the incident. The facility investigation did not include statements from all the staff involved in the incident. The statements obtained at the time of the incident on 9/16/2016 did not document when the incident occurred or when it was reported. The Patient Care Assignment sheet dated 9/15/2016 for the 11 PM to 7 AM shift documented CNA #5 was assigned to a group of 18 residents. There was no documented evidence that after the incident with Resident #1, all residents assigned to CNA #5's care were assessed or interviewed for abuse, neglect, or mistreatment. The nursing progress notes dated 9/15/2016 and 9/16/2016 did not document the incident or that a registered nurse (RN) assessment was completed on the resident at the time of the incident or following the incident. There was no documentation the resident was monitored by nursing staff after the incident per summary report. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. He had visual impairment and required extensive assistance with most activities of daily living (ADLs). The comprehensive care plan (CCP) updated 11/2/2016 documented the resident had cognitive impairment, impaired communication related to a hearing deficit, and had poor insight. The CCP did not document the resident had the potential to be a victim of abuse and the CCP was not updated after the incident. When interviewed on 12/13/2016 at 2:14 PM, the Assistant Director of Nursing (ADON) stated at the time the incident was reported to the RN on the unit on 9/16/2016, she sent CNA #5 home until the investigation was completed. She stated the facility protocol was to obtain statements from the staff involved, the witness, and other CNAs on the unit. When an incident/accident form was requested by the surveyor, she stated she completed one last night. When interviewed on 12/14/2016 at 7:30 AM, CNA #2 stated she witnessed CNA #5 throw a cup of water on Resident #1 when he was in bed. She stated the incident occurred on 9/16/2016 between 1:00 AM and 1:30 AM. She stated she did not report the incident at that time and went to assist CNA #3 with another resident and did not see the nurse to report the information. She stated she discussed the incident with CNA #3 between 3:00 AM and 3:30 AM and he encouraged her to contact the nurse. She was unable to recall when she told the nurse of the incident. She stated prior to the incident, she had observed residents freaking out and some residents appeared afraid around CNA #5. She stated some residents heard CNA #5's voice and became upset. She stated that had been going on since she began to work at the facility in 5/2016, and did not report that information to anyone. She stated she had not been counseled or re-educated since 5/2016 upon hire on abuse, neglect, or mistreatment reporting. Review of the personnel file for CNA #2 did not reveal documented evidence the CNA was counseled or re-educated for the delayed reporting that occurred when CNA #2 did not report the 9/16/2016 incident involving Resident #1 at the time of occurrence and did not tell another peer for approximately 2 hours. The last documented evidence of education on timely reporting of incidents was dated 5/2016. When interviewed on 12/14/2016 at 8:10 AM, CNA #3 stated he worked on the night of the incident on 9/16/2016 and no one requested he document a statement of the incident. He stated he was approached by CNA #2 between 4:30 AM and 5:00 PM, and CNA #2 informed him of the incident with Resident #1. He stated he told her to report the incident to the nurse. He stated some residents did not want CNA #5 to provide care to them and the residents seemed more alert when CNA #5 was around. He stated he did not receive any re-education after the incident. When interviewed on 12/14/2016 at 8:33 AM, RN Supervisor #4 stated she was responsible to provide assessments on residents who had physical or emotional concerns. She stated she was present on the night of the incident, and was expected to document on a resident involved in an incident every shift for at least 24 hours after the incident. She stated she did not know what time CNA #2 approached her on 9/16/2016 to report she had concerns about CNA #5's behavior. CNA #2 stated when CNA #5 turned and positioned residents, he jerked the residents' linens and frightened them into feeling they would fall. She stated she did not ask CNA #2 how long this behavior toward other residents had been going on. She stated CNA #2 then reported the incident, and she escorted CNA #5 out of the building. She stated she went to see 3 residents during the 11 PM - 7 AM shift and they reported they had problems with CNA #5. She stated by that time, the day shift staff arrived. She stated she was unable to recall if she completed an assessment on the resident, documented the incident on an incident/accident form, or documented the information in the nursing progress notes. She stated the expectation would be for the assessment to be completed and documented in the nursing progress notes. When re-interviewed on 12/14/2016 at 12:33 PM, the ADON stated she expected the 9/16/2016 incident to have been reported immediately, and statements to be obtained from any staff involved in the incident. She expected an RN assessment to have been completed on Resident #1 and documented in the nursing progress notes, and all other residents assessed and interviewed if possible that CNA #5 provided care for. She stated she did not obtain a statement from CNAs #3 or 5, and did not investigate how long or how CNA #5's behavior affected other residents. The ADON stated the investigation was not thorough or complete. When interviewed on 12/14/2016 at 1:15 PM, the Administrator stated he reviewed all investigations at the facility. He stated he discussed this incident with the DON and directed her to contact the authorities. He stated he would expect an assessment to have been completed on Resident #1, and the care plan updated if necessary. He stated he expected CNA #2 to have reported the incident immediately, and stated he thought the facility could have done a better job in places regarding the investigation. 2) Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and he required extensive assistance with most activities of daily living (ADLs). The facility summary dated 11/6/2016 at 8:45 AM documented Resident #4 reported to certified nurse aide (CNA) #8 on 11/6/2016 that his bifold wallet containing money, a debit card, and personal identification cards was missing from his room. Resident #4 reported he last saw his wallet the previous week. The summary documented the resident had observed a particular CNA (#7) going through his belongings. The summary documented CNA #7 was placed on administrative leave pending the outcome of the investigation. The family reported the debit card had been used at various locations, and notified the New York State (NYS) Police Department. A statement was obtained from the resident, and the resident was to be seen by social services and monitored for his psychological well-being. The facility data collection form (security record) dated 11/6/2016 at 8:45 AM documented CNA #8 reported the missing wallet to facility security. The report documented the wallet contained money, a debit card, and personal identification cards for Resident #4. The wallet was last seen in his reclining chair in his room. The report documented the resident's room was searched and the wallet was unable to be found. There was no documented evidence staff were interviewed regarding the incident, or that statements were obtained from staff and other residents assigned to CNA #7's care. When interviewed on 12/13/2016 at 9:28 AM, the Associate Director of Nursing (ADON) stated security at the facility were notified of the missing item and an investigation was initiated immediately. She stated the nursing department was not involved in a misappropriation investigation unless requested by security. She stated security completes an investigation and the facility does not complete an internal investigation. When interviewed on 12/14/2016 at 11:12 AM, the security department employee stated he was alerted to the incident by staff and he interviewed the involved resident. He stated he did not question staff assigned to the resident or interview any other residents. He stated he reported the information to the social worker. When interviewed on 12/14/2016 at 1:30 PM, the Administrator stated the misappropriation of funds process consisted of security being notified, the resident interviewed, search of missing property, resident assessment if needed, and statements obtained from staff as a part of the investigation. He stated he was not sure if the facility interviewed other residents for issues at the time of the investigation; he would have to check. No further information was presented to the survey. 10NYCRR 415.4(b)(1)(ii)

Based on record review and interview conducted during the abbreviated survey (NY 126), it was determined the facility did not provide medically-related social services to attain or maintain the highest practicable psychosocial well-being for 1 for 6 residents (Resident #4) reviewed for social services. Specifically, the facility did not implement a plan or monitoring for Resident #4, who had a loss of finances and personal documents. Findings include: Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact and he required extensive assistance with most activities of daily living (ADLs). The facility investigative summary dated 11/6/2016 at 8:45 AM documented on 11/6/2016, Resident #4 reported his wallet was missing from his room. The summary documented the facility conducted an investigation of the incident and was unable to locate the wallet. The summary documented facility security and the police were notified of the incident. The resident provided a statement identifying the wallet contained approximately $100.00 in cash, an ATM debit card, his social security card, his veteran's ID card, and his driver's license. The summary documented the resident was seen by the social services department worker and would be monitored for his psychological well-being. The nursing progress note dated 11/6/2016 at 11:39 AM documented the resident reported his wallet was missing and the social worker was made aware of the incident. The interdisciplinary progress notes dated 11/7/2016 - 11/14/2016 did not document the resident was seen or monitored by the social worker. The comprehensive care plan (CCP) dated 8/18/2016 and updated 11/17/2016 documented the resident was alert and oriented, and had a [DIAGNOSES REDACTED]. The CCP did not identify the resident's psychological well-being or monitoring needs, as documented in the facility investigative summary. During interview on 12/13/2016 at 9:28 AM, the Associate Director of Nursing (ADON) stated when an incident involving misappropriation of funds occurred, social services was notified of the issues and the expectations were the social worker would follow up with the resident, monitor the resident, notify the family, and document on the resident's psychological well-being in the progress notes and on the care plan. When interviewed on 12/14/2016, the security department employee stated he reported the information regarding the misappropriation of funds to social worker #10, who was assigned to the resident's care. During an interview on 12/14/2016 at 11:36 AM, the social worker stated she was assigned to the resident's care at the time of the incident on 11/6/2016. She stated the incident occurred on the weekend, Sunday 11/6/2016, and she was notified on Monday 11/7/2016 via e-mail. The social worker stated she did not document the conversation she had with the resident, as the investigation was ongoing. She stated she was expected to documented conversations in the medical record. The social worker stated she did not document the resident's assessment or monitoring for his psychological well-being, and did not update the resident's plan of care. When interviewed on 12/14/2016 at 1:30 PM, the Administrator stated the social services role regarding the misappropriation incident was to assist with the issue, document emotional support for the resident if necessary, update the care plan if needed, and notify the family. He stated he was aware there was no documentation in the resident's medical record regarding the misappropriation of funds and personal identification. 10NYCRR 415.4(b)(1)(ii)

Based on record review and interview conducted during the recertification survey, it was determined for 16 of 30 residents (Residents #1 - 4, 6, 8, 12 - 16, 21 - 23, 26, and 27) reviewed for abuse and neglect, the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated. Specifically, the facility did not complete thorough investigations to rule out abuse, neglect, or mistreatment when Residents #1, 4, 12, 13, 15, 26, and 27 each sustained a fall; when Residents #2, 16, 21, and 22 experienced multiple falls; when Residents #2, 12, 14, 15, 16, 23, and 27 sustained bruises of unknown origin; and when Residents #3 and 6 sustained skin tears. In addition, when Resident #8 was found with a new onset of rib pain and posterior rib fractures, an investigation was not completed to rule out possible abuse, neglect, or mistreatment. Findings include: 1) Resident #8 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired and he required extensive assistance with most activities of daily living (ADLs), including bed mobility. The comprehensive care plan (CCP) dated 11/2/2015 documented the resident had a history of [REDACTED]. Interventions included reorientation when his confusion worsened and reapproach when resistive to care. An accident and incident report dated 12/22/2015 documented the resident fell out of his wheelchair, striking his face on the floor. He was sent to the hospital Emergency Department. A Computed Tomography (CT) scan of the chest dated 12/22/2015 documented the bones were unremarkable. No acute fracture. A nursing progress note dated 12/23/2015 at 2:24 AM documented a verbal report was received from the Emergency Department. The resident had fractures to the nasal, sinus, and orbital bones (facial bones). X-rays to the back, pelvis, legs and ribs were all negative for fractures. At 3:23 AM, the resident returned to the facility. A nurse practitioner (NP) progress note dated 12/23/2015 at 8:21 AM documented the resident was seen for a follow up after the fall. The NP documented the resident denied any pain and he was resting in bed. A physical therapy (PT) note dated 12/23/2015 at 2:41 PM documented a PT screen was requested secondary to a fall. The resident's wheelchair brakes were in good working order and the wheelchair appeared to be a good fit. A NP progress note dated 12/23/2015 at 3:41 PM documented the resident's X-rays from the hospital were reviewed and no changes were made to his plan of care. The resident had a usual day with no complaints of pain. Nursing progress notes documented dated 12/23/2015 at 5:43 PM through 12/24/2015 at 12:38 PM documented the resident denied pain and propelled himself in the wheelchair. On 12/24/2015 at 10:25 PM, nursing notes documented the resident returned from an outing with his daughter and he was in a good mood. A NP progress note dated 12/26/2015 documented the resident was complaining of left sided chest pain with breathing, and noted the resident was slightly short of breath. A nursing progress note dated 12/26/2015 documented when the resident was asked about pain, he pointed to his left rib and abdominal area. The resident was transported to the hospital. A CT scan of the chest radiology report dated 12/26/2015 documented the resident had non-displaced fractures of the left 3rd, 4th and 5th anterolateral (in front and to the side) ribs and the right 11th posterior (back) rib. A NP progress note dated 12/28/2015 documented the resident had a fall on 12/22/2015 and the chest CT at that time did not indicate any rib fractures. On 12/26/2015, the resident complained of rib pain and shortness of breath. He was sent back to the emergency room and was found with 3rd, 4th, and 5th left rib fractures and a right sided rib fracture. There was no documented evidence how the facility concluded the rib fractures were related to the fall on 12/22/2015. An incident summary, dated 1/1/2016 and attached to the 12/22/2015 incident and accident report, documented the resident sustained [REDACTED]. There was no documented evidence in the incident report and the incident summary regarding the resident having sustained rib fractures from the fall. The Director of Nursing (DON) was interviewed on 3/9/2016 at 2:00 PM and she stated the 12/22/2015 accident and incident report was the only one completed for Resident #8 for December 2015. During a follow up interview with the DON on 3/10/2016 at 1:45 PM, she stated an accident and incident investigation was not initiated to identify the cause of the resident's rib fractures as she believed nothing happened with the resident following the fall on 12/22/2015. There was no documented evidence the facility did an investigation to determine the cause of the rib fractures, or to ensure an incident did not occur for Resident #8 between 12/22/2015 and 12/26/2015. 2) Resident #6 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 11/2/2015 documented the resident had a history of [REDACTED]. Interventions included to approach the resident in a calm, pleasant manner, identifying themselves upon approach, and providing explanation of care to be provided. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive deficits, rejected care 1 to 3 days a week, required extensive assistance with most activities of daily living, and had received injections 7 of the last 7 days. A physician order [REDACTED]. A physician order [REDACTED]. A nursing progress note dated 2/16/2016 at 6:05 PM documented the resident was given 8 units of [MEDICATION NAME]one time SQ. A nursing progress note dated 2/17/2016 at 3:30 AM documented the resident refused a skin check. The 2/2016 Medication Administration Record [REDACTED]. The nurse's initials were illegible. A nursing progress note on 2/17/2016 at 10:21 AM documented the skin team (SIMS) assessed the resident's bilateral heels. A Resident Accident/Incident Summary dated 2/17/2016 at 11:30 AM documented the licensed practical nurse (LPN) discovered a 2 centimeter skin tear on the resident's left second finger over an ecchymotic area (bruise) during the medication pass. The resident stated he had cut it on that man's badge this morning when he was giving me that hyperdermic needle, I told him I didn't want it. The area had not been present during skin rounds (SIMS) assessment at 10:00 AM. The investigation summary documented the resident was often confused with daily routine and was a poor historian. The summary documented the resident did not receive any injections and no male staff was on duty this morning. The summary concluded the resident most likely bumped his finger on the dining table. An unwitnessed injury questionnaire, completed by a certified nurse aide (CNA) dated 2/19/2016, and attached with the Resident Accident/Incident Summary dated 2/17/2016, documented the male LPN told her the resident was resistive with his blood sugar and it happened at that time. There was no documentation the male LPN was interviewed regarding the skin tear to rule out possible abuse or neglect. During an interview with the registered nurse (RN) #1 on 3/11/2016 at 8:20 AM, she stated when a skin tear or bruise was discovered, the resident would be assessed. The resident would be questioned if they were able to provide information and the environment would be checked for any possible causes. She stated any staff who had contact with the resident in the previous 24 hours to the discovery of the injury should be interviewed to determine possible causes of the injury. During an interview with RN #22 on 3/11/2016 at 10:50 AM, she stated she was responsible for signing off that an investigation was complete. She stated the team that reviewed investigations had determined the resident was not a credible source, as they felt a male staff member had not worked on the unit on the date the resident stated. RN #22 stated she entrusted in the staff completing the report to interview the appropriate employees to rule out abuse or neglect. She stated the statement completed by staff reporting that a male LPN worked on the unit may not have been accurate. During an interview with the Human Resources Director on 3/10/2016 at 8:20 AM, she stated the male LPN who worked the evening of 2/16/2016 was no longer employed at the facility and his last day of work was 2/19/2016. During an interview with RN #11 on 3/11/2016 at 12:20 PM, she stated she conducted the interviews for the unwitnessed injury questionnaire for the resident's injury. She had not interviewed the male LPN as he was not on duty when she was completing the statements and interviewing him would have been a good choice. 3) Resident #2 had [DIAGNOSES REDACTED]. The 12/24/2015 Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired, required extensive assistance with transfers and bed mobility, and had 2 or more falls with and without injury. MULTIPLE FALLS: The 11/30/2015 comprehensive care plan (CCP) documented the resident had a history of [REDACTED]. The CCP documented the resident required the assistance of 2 staff for transfers and toileting, and experienced [MEDICAL CONDITION] and nightmares. Interventions included the bed in the lowest position, fall mats to the left and right of the bed, a tab alarm on at all times, and to check and change the resident every 2 hours and as needed. Staff were to ensure the call bell was in reach; provide redirection; were to reassure the resident during nightmares; continue safety checks, and to place the resident in a highly visible area in his Posey sitter (chair alarm) when out of bed. The CCP was updated between 12/1/2015 and 12/4/2015 and documented the resident was to be placed in highly visible areas, the tab alarm was discontinued, a laser alarm was implemented while in bed, and a Posey alarm was in the chair. An undated update documented to place Dycem (non-slip material) on top of the Posey alarm pad. The resident sustained [REDACTED]. The reports documented the resident sustained [REDACTED]. The facility's Accident/Incident summary reports for the above dated incidents of falls lacked documentation to rule out abuse, neglect, and mistreatment when the facility did not consistently document: - the names of the staff reporting or witnessing the events; - the names of the staff interviewed to determine if the care plan was followed prior to the falls; - statements by potentially involved staff, or staff that provided direct care to the resident; - when the resident was awake and what the resident was last seen doing, how he was acting, or what position he was in; - when the resident was awake and reaching for items, if items were within his reach prior to the falls; - what care was provided at the time the resident was last seen, assisted with care, or toileted; - if the resident was in a high visibility area of staff at the time of the fall as visibility areas may vary by shift; and - consistent information of when the resident was last seen if care had been provided at that time or if the resident was only visualized at that time. There was no additional information found in the 12/1/2015 - 2/28/2016 nursing progress notes to support the facility ruled out abuse, neglect, or mistreatment. During an interview with registered nurse (RN) Manager #21 on 3/11/2016 at 10:05 AM, she stated it could be stated the resident probably was not in the same spot for 2 hours. She stated they checked the resident's environment to rule out potential causes of resident falls, and determined if planned safety measures were in place prior to the falls occuring. During an interview with RN #22 on 3/11/2016 at 10:50 AM, she stated she was responsible for signing off that an investigation was complete. She stated if there was not an injury from the event there was no need to interview anyone other than the person who found the resident. She stated the nurse completing the report would document information from that staff member. She stated that staff person would be interviewed to determine the resident's environment, and what occurred at the time of the fall. During an interview with the Director of Nursing (DON) on 3/11/2016 at 12:00 PM, she stated the facility used to document the name of the staff that found the resident following or witnessing a fall and no longer did this. She stated she trusted the staff completing the report were interviewing the appropriate staff to determine the care plan was followed. This would have included the aide who was responsible for the resident at the time of the fall. The DON stated the staff should have answered questions that would include information as to when the resident was last toileted, last seen, and if the resident was reaching prior to the fall. She stated when the resident fell twice in the same day, for example the 2/20/2016 reports, she could not see whether an intervention was implemented after the first fall, only after the second fall. BRUISES OF UNKNOWN ORIGIN: The 1/29/2016 and 2/19/2016 CCP documented the resident was at risk for skin break down and nurses were to check the areas with the goal to have them resolved in 14 days. An Accident/Incident Summary dated 1/29/2016 at 6:50 AM documented the resident was found with a small bruise to the lower lip while at bedside. The report documented the resident was last seen at 2:00 AM, and staff did not look at the resident's lips at that time. The resident stated he received the area from kissing his spouse roughly. The report documented 5 potential causes of the resident's bruise including declining medications; taking medications that have increased risk of bruising; flailing arms during a nightmare; missing upper denture; and tremors related to his [MEDICAL CONDITION]. The RN statement of summary documented the area was not present at 2:00 AM rounds by staff and the resident denied anyone hitting him. A final summary completed by an RN documented the resident was observed with a discolored area on his right lower lip. There is no reason to believe abuse or neglect occurred. The report documented it did not happen during staff assist and the care plan was followed. The area was not noted earlier in the shift and it was reasonable to conclude that the resident acquired the area by biting or striking his lip while lying on his bed. The 1/29/2016 incident report lacked documentation to rule out abuse, neglect, or mistreatment when: - there was no documentation of what staff member reported the bruise; - no documentation of any direct care staff that were on the unit or provided care to the resident; and - there were no statements by staff to determine if the care plan was followed to rule out if the bruise occurred during staff care; to determine when the bruise was originated, as the 2:00 AM staff had stated they did not look at the resident's lips; or if the resident was having tremors when observed in bed on safety checks. An Accident/Incident Summary dated 2/19/2016 at 4:00 AM documented the resident was found with a bruise to the 3rd digit of his left hand during morning care. There was a statement attached to the report that had conflicting information documenting the right hand. The investigation documented the resident was often self propelling around the unit quickly, wandered off the unit, and the area was under dry patchy skin and the resident could have scratched it. The resident had decreased safety awareness and frequently became restless. The summary documented the area did not occur during staff assist and the care plan was followed. The RN documented the resident was frequently observed wheeling himself rapidly around the unit and there is no reason to believe abuse or neglect occurred. The 2/19/2016 incident report lacked documentation to rule out abuse, neglect, or mistreatment occurred when: - there was no documentation of what staff member reported/found the bruise; - no documentation if the resident was observed bumping in to anything or anyone while he was wheeling himself around; - no documentation by involved staff as one statement documented night staff observed the resident and did not document names of staff; - one certified nurse aide (CNA) statement did not document the time, if she saw the bruise, or how care was provided when she assisted the resident to rule out what caused the bruise; and there was not a statement by the CNA who was documented as assisting with the 2 person assist for toileting; and - not all statements documented what the resident was doing the last time he was seen, as staff on different shifts had different areas listed. During an interview with RN Manager #21 on 3/11/2016 at 10:05 AM, she stated for injuries of unknown origin, there was a 24 hour look back period. She stated the facility interviewed one staff on each shift until someone saw or did not see the area, then they would no longer have to conduct interviews. During an interview with RN #22 on 3/11/2016 at 10:50 AM, she stated she was responsible for signing off that an investigation was complete. She stated when a resident sustained [REDACTED]. She stated even if the resident required the use of 2 staff during care, they only interviewed the staff person assigned to the resident. She stated if the staff member from a previous shift did not see the bruise, they did not need to conduct any further interviews. She stated they assessed the bruise and determined if the size and shape of the bruise appeared to be finger print marks, irregular bruising, or from an area that could rub against a lift or chair, in order to rule out if abuse occurred. During an interview with the DON on 3/11/2016 at 12:00 PM, she stated when the resident was found with a bruise of unknown origin, the facility was looking to determine if there was a reason the resident had a bruise. By doing this they looked back on the last 3 shifts as to who had responsibility of the resident. She stated if the shift prior to the finding of the bruise did not see the bruise, they could stop their interviews. 10NYCRR 415.4(b)(3)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not provide special eating equipment for residents who need them for 1 of 7 residents (Resident #5) reviewed for assistive devices. Specifically, Resident #5 was not provided with a scoop bowl (a bowl with a suction cup base that keeps the bowl in place and reduces spilling) at meals as planned. Findings include: Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment and required supervision and physical assistance of one person with eating. The occupational therapy (OT) screen dated 12/22/2015 documented the resident was able to independently feed herself and used a blue scoop bowl. The comprehensive care plan (CCP) dated 12/30/2015 documented the resident required increased assistance to complete care routines and her ability to participate in activities of daily living (ADLs) fluctuated related to her cooperativeness and her ability to direct her care needs. Interventions included set-up assistance with eating, may need extensive assistance to complete as needed. Adaptive equipment included a scoop bowl. An undated nursing directives guide (care instructions) documented the resident was to receive a scoop bowl for breakfast, lunch, and supper. The resident was observed in the dining room without her scoop bowl: - on 3/8/2016 at 5:29 PM during supper; - on 3/9/2016 at 12:05 PM during lunch; - on 3/10/2016 at 8:00 AM during breakfast; and - on 3/11/2016 at 8:10 AM during breakfast. During an interview with certified nurse aide (CNA) #2 on 3/11/2016 at 8:10 AM, she stated the food service worker would put the scoop bowl at the resident's place at the table when she was setting the table. She stated nursing staff were also supposed to check the meal ticket to make sure everything the resident needed was there. She was not sure why the resident did not receive her scoop bowl. During an interview with registered nurse (RN) #1 on 3/11/2016 at 8:20 AM she stated all staff were responsible for making sure adaptive equipment was present at meal times. The person setting the table or the drink pourer was the first staff to make sure the equipment was available. When the meal was served, the person assisting the resident was also to ensure the resident had the appropriate equipment; she stated it was a team effort. She stated the resident likely did not use the scoop bowl for the past several days because she was acutely ill and was receiving more assistance from staff. The food service worker would have been notified about the resident's status and would not have given the scoop dish. During an interview with the occupational therapist (OT) on 3/11/2016 at 11:00 AM, she stated the resident required the scoop bowl to ensure her food did not spill, and not all of the resident's food needed to be in the scoop bowl. Items such as cereal and creamy type foods were placed in the bowl. The resident was often inconsistent with her feeding abilities. If the plan of care included a scoop bowl, she expected it would be provided to the resident at all meals. 10NYCRR 415.14(g)

Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not ensure food was stored under sanitary conditions in 1 of 7 kitchens (the Pine Unit kitchen), and prepared under sanitary conditions in 1 of 7 kitchens (the main kitchen). Specifically, potentially hazardous foods were above 45 degrees Fahrenheit (F) in the Pine Unit refrigerator, and kitchen pans were not washed by a sanitary method in the main kitchen. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF 1/8/2015 Findings include: Inadequate Refrigeration 1) A surveyor observed the Pine Unit kitchen refrigerator on 3/8/2016; the air temperature, per the refrigerator temperature displayed on the outside of the refrigerator was 53 degrees F at 4:40 PM, and 54 degrees F at 4:49 PM. The surveyor determined the temperature of potentially hazardous food items in the refrigerator at 4:43 PM, as follows: - tuna salad dated 3/7 was 49 degrees F; - egg salad dated 3/7 was 49 degrees F; - ham salad was 49 degrees F; and - a 4 ounce container of blueberry yogurt was 50 degrees F. Food temperatures from the Pine Unit kitchen refrigerator were re-checked on 3/8/2016 at 4:55 PM with Cook/Supervisor #7, and the temperatures of tuna salad, egg salad, ham salad, and blueberry yogurt were determined to be 51 to 53 degrees F. During an interview with Cook/Supervisor #7 on 3/8/2016 at 5 PM, he stated the facility's standard for refrigeration was food should be 40 degrees F or below. The Pine Unit kitchen refrigerator had malfunctioned in the recent past and had been repaired. During an interview with Food Service Worker #6 on 3/8/2016 at 5:10 PM, she stated she had checked the refrigerator temperature soon after she began work, around 3:00 PM. The refrigerator Temperature Log form (form dated 9/8/2014) for March 2016 documented the refrigerator temperature should be 34 to 40 degrees F; the refrigerator temperature for 3/1/2016 - 3/8/2016 measured 38 to 42 degrees F. Unsanitary Dishwashing 2) A surveyor observed Food Service Worker #8 washing pans in the dishroom on 3/10/2016 between 8:45 AM and 9:00 AM with ungloved hands. The surveyor observed Food Service Worker #8 not washing his hands 4 times between loading soiled pans into the dishwasher and unloading the clean pans on the clean side of the dishwasher. Food Service Worker #8 handled pans with her fingers grasping the inside surface of the pans during handling. During an interview with Food Service Worker #8 on 3/10/2016 at 9:00 AM, she stated she usually worked in the dishroom with 1 other employee who washed dishes in the 3 bay sink, she did not usually wear gloves, and she was educated about handwashing. During an interview with the Food Service Director on 3/10/2016 at 9:05 AM, she stated routinely 1 person worked at the dishwasher washing dishes; occasionally there were 2 staff. The Ware-Washing Procedure policy dated 2/16/2016 and other dishwashing policies (Cleaning & Sanitizing Resident's Personal Dishware & Utensils and Deliming, both dated 2/2016) did not address handwashing when one staff person was both loading and unloading the dishwasher. 10NYCRR 415.14(h), 14-1.40(a), 14-1.110

Based on interview, observation, and record review conducted during the recertification survey, it was determined the facility did not ensure food served was palatable and served at the proper temperature for 1 of 2 meals (breakfast) observed during the survey, and for 7 of 11 anonymous residents in attendance at the group meeting. Specifically, the hot foods on the test tray at breakfast were not hot and the pureed scrambled eggs were unpalatable. Findings include: During the resident group meeting held on 3/9/2016 at 2:30 PM, 7 of 11 anonymous residents stated the food was sometimes served cold, did not always have good flavor, and did not think the food quality was as good as it had been in the past. Specifically, the residents stated the scrambled eggs and fried eggs were often cold and overcooked. On 3/11/2016 at 7:45 AM, hot items from the steam table in the Pine Cottage were tasted and temperature obtained. The regular scrambled eggs were 122 degrees Fahrenheit (F); the fried eggs were 118 degrees F, and the pureed scrambled eggs were 110 degrees F. The 3 items were all lukewarm to cool to taste and the pureed scrambled eggs lacked flavor and were unpalatable. During an interview with the dietary server on 3/11/2016 at 7:45 AM, she stated when she checked the temperatures before serving the items to the residents, they were all over 150 degrees F. She said she had never tasted the pureed scrambled eggs before. Salt and pepper were available for the staff to season the eggs for the residents in the Pine Cottage. She stated the other cottages all had the seasoning on the tables for residents to add themselves. A recipe was obtained for the pureed scrambled eggs on 2/11/2016 at 2:30 PM from the food service supervisor. The undated recipe included the addition of thickener (powder) to the egg mixture, and included 2 cups of milk; the recipe was unclear regarding the milk ingredient, as in one place in the recipe it was listed as milk, and in the other it was listed as powdered milk. 10NYCRR 415.14((d)(2)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not provide adequate supervision to prevent accidents for 1 of 5 residents (Resident #2) reviewed for falls. Specifically, Resident #2 had multiple falls, and timely changes were not made to the resident's plan of care to prevent further falls for all shifts. Findings include: Resident #2 had [DIAGNOSES REDACTED]. The 10/7/2015 comprehensive care plan (CCP) documented the resident had a history of [REDACTED]. The resident preferred to go to bed between 10:00 PM and 11:00 PM and wished to be up between 7:00 and 8:00 AM. The CCP documented the resident required the assistance of 2 staff for transfers and toileting, and experienced insomnia. The resident was to have a bed in the lowest position, fall mats to the left and right of the bed, a tab alarm on at all times, and was to be checked and changed every 2 hours and as needed. Staff were to ensure the call bell was within reach and were to provide the resident with redirection to find his room or other locations on the unit. The CCP was updated between 10/20/2015 and 11/30/2015 and documented the resident had a history of [REDACTED]. The resident did not have serious falls and the goal was to prevent injury with further falls. Staff attempted a busy box with the resident that was unsuccessful. Staff were to reassure the resident during nightmares, continue safety checks, reminders, and place the resident in a highly visible area in his Posey sitter (chair alarm in wheelchair) when out of bed. Nursing progress notes documented the resident sustained [REDACTED]. The CCP was updated between 12/1/2015 and 12/4/2015 and documented the tab alarm was discontinued, a laser alarm was implemented while in bed, and a Posey alarm was in the chair. An undated update documented to place Dycem (non-slip pad) on top of the Posey alarm pad. A 12/4/2015 investigation report included a summary of the investigation, dated 12/11/2015, and documented the resident's periods of restlessness/agitation needs to be identified so staff can provide distraction in an effort to decrease his falls. Nursing progress notes documented the resident sustained [REDACTED]. The accident/incident summary investigations for the 3 falls between 12/10/2015 - 12/11/2015 documented no changes were needed to the resident's plan of care. Nursing progress notes documented the resident sustained [REDACTED]. The accident/incident summary investigations between 12/12/2015 - 12/20/2015 documented the care plan was reviewed and remained appropriate. The CCP was updated on 12/20/2015 and documented the resident continued to fall frequently, there were no serious injuries, the goal was to prevent the resident from sustaining further injuries, and there were no changes made to the resident's plan of care. Nursing progress notes documented 2 falls on 12/24/15. The 12/24/2015 at 1:40 PM accident/incident report documented the care plan addressed the plan to anticipate the resident's needs and to monitor him closely to prevent falls without injury. There was no documentation that a plan was implemented on how to monitor the resident closely, when the resident's plan of care documented to keep him in highly visible areas, and the resident continued to sustain falls. The 12/24/2015 Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired, and required extensive assistance with transferring, bed mobility, and ambulation on the unit. The resident experienced 2 or more falls with and without injury during the assessment period. Nursing progress notes documented documented 5 falls between 12/25/2015 and 2/16/2016. The CCP was updated on 2/17/2016. There was no documentation the resident's current plan for falls remained appropriate when the resident continued to sustain falls on 2 to 10 PM and 10 PM to 6 AM shifts. Nursing progress notes documented 2 falls on 2/20/16 and 2/26/16. A 3/2/2016 social work note documented the resident's sleep patterns were altered, he refused to go to bed or stay in bed several times that quarter. The resident had periods of weepiness that was not always redirected; and had 8 episodes of sliding out of his chair or rolling out of bed, all without pattern or predictability. There was no documentation in the CCP the facility implemented a plan to address the resident's altered sleep pattern, or that a plan was implemented when the resident declined current interventions including snack and a drink. Nursing progress notes documented: - On 3/2/2016 at 3:10 PM, the resident was on the floor in front of his chair in his room; stating he was reaching for a newspaper and there was not one seen in the room; and - On 3/8/2016 at 2:13 AM, the resident refused to lie in bed despite several approaches. Fluids were offered, he declined, continued to call out, was at the nursing station, and staff continued to offer care, snack, and fluids. The 3/11/2016 certified nurse aide (CNA) Directives (care instructions) documented the resident required a stand lift with extensive assistance of 2 for transfers. The resident was not to be left alone in the bathroom, had a low bed, bilateral fall mats, and a laser alarm when in bed. The resident's preferred bed time was 10:00 PM - 11:00 PM and wake time was 7:00 AM - 8:00 AM. There was no documentation on the Directives regarding a plan for staff to address the resident's restfulness or weepiness during hours of wake. The resident was observed on 3/9/2016 at 1:12 PM, seated in the television lounge area alone, and at 1:15 PM, a registered nurse (RN) approached the resident and sat with him discussing pets. During a phone interview with licensed practical nurse (LPN) #16 on 3/10/2016 at 12:46 PM, she stated she primarily worked the 2 PM to 10 PM shift, and the resident was usually awake during most of her shift. She stated sometimes she could give the resident a snack to settle him and he would lie down about midnight. She stated some days the resident started yelling at 4:00 AM and made attempts to get up on his own. She stated he would often sit by the desk and would be quite social if staff were present. During an interview with the 2:00 PM to 12:30 AM RN Supervisor #16 on 3/10/2016 at 3:05 PM, she stated the resident was usually found on the fall mat. She stated his falls usually occurred when he was attempting to reach for something. She stated the resident was often awake on her shift. She stated they would have him call a family member, and offer him snacks or drinks. RN Supervisor #16 stated they added more tasks to the unit helpers so that they were now able to talk or read to the resident. She stated the resident was to be kept in a high visibility area and that was sometimes hard to do. During an interview with CNA #18 on 3/10/2016 at 5:10 PM, who worked primarily 2:00 PM to 10:30 PM, she stated the resident's mood fluctuated from day to day. She stated the resident liked to have company. She stated he would try to get out of bed and she had been present when the resident was found on the floor. She stated the resident was up for most of her shifts. She stated effectiveness of interventions varied dependent on the resident's day, as sometimes he was up and down the hallway frequently. During an interview with CNA #20 on 3/11/2016 at 9:06 AM, who worked primarily on the 10 PM to 6 AM shift, she stated the resident's mood varied by day. She stated sometimes the resident would climb out of his bed around midnight and some days he slept until 5:00 AM. She stated the resident wanted to be up in his chair and out of his bed. She stated she had been working a few times when the resident tried to get out of his bed/had a fall out of his bed. CNA #20 stated the resident wanted to get to his wife or felt like he was missing out on something. She stated they had to do frequent checks on several residents on the unit, including Resident #2. She stated she would try to see if he needed to be toileted, or wanted a drink or snack. During an interview with RN Manager #21 on 3/11/2016 at 10:05 AM, she stated the resident's movement varied, sometimes he was up and down the hallway and the next minute he would be sitting still. She stated they could not prevent him from falling and he did not sustain injuries from his falls, other than a couple bruises and a recent X-ray of his shoulder. She stated they made multiple changes including implementing alarms, changing the type of alarms, and using fall mats. RN Manager #21 stated they had 5 unit helpers (resident care aides - RCAs) in the building at various times, and staff could contact a supervisor to see if an RCA could come to the unit. She stated the RCA's job description changed over the last few months, and not all of them knew and/or were comfortable talking with residents who may become weepy or have behavioral issues. She stated one RCA assigned to Resident #2 did not know how to assist or visit with the resident when he started crying. She stated the resident's falls had been reduced, as they had been having an assigned unit helper to the afternoon. 10NYCRR 415.12(h)(2)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not provide the necessary services to maintain personal grooming and hygiene needs for 1 of 16 residents (Resident #16) reviewed for activities of daily living (ADLs). Specifically, Resident #16 did not receive the necessary assistance to meet his toileting needs. Findings include: Resident #16 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and rejected care 4 to 6 days out of 7. The resident required extensive assistance of 2 persons for bed mobility, transfers, locomotion and toileting. The resident was continent of bowel and frequently incontinent of bladder. The resident had an unhealed unstageable pressure ulcer, was on a turn and position program, and received pressure ulcer care. The comprehensive care plan (CCP) updated by the interdisciplinary team on 1/28/2016 documented the resident had a Stage II pressure ulcer on his buttocks. On 3/9/2016, the CCP documented the area was healed and preventative interventions remained in place. The resident required extensive assistance of 2 people using the mechanical lift for toileting needs, and the resident was to be toileted as a result of the resident's skin breakdown and his risk for falls. The current certified nurse aide (CNA) Directives (care instructions) for the day and evening shifts documented the resident was to be checked and changed every 2 hours and as needed. The resident was observed on 3/9/2016 at 8:30 AM in bed, dressed in a tee-shirt and gray sweatpants. The resident stated he felt like it was biting and he removed his blanket. The resident's pants were observed wet from his right groin, extending up toward his waistband and around toward his back. At 8:56 AM on 3/9/2016 CNA #24 entered the resident's room with another CNA to provide care (including checking and changing) to the resident. On 3/9/2016, the activities of daily living (ADL) form documented for the day shift, the resident was toileted at 9:50 AM. The previous documented time the resident was toileted was on the night shift at 11:41 PM. During an interview with CNA #24 on 3/9/2016 at 9:05 AM, she stated the resident refused to get out of bed for breakfast and it was not unusual behavior for him. She said she changed him and dressed him at 6:00 AM and said he was a heavy wetter and was suppose to be checked hourly. On 3/10/2016, the resident was observed in bed on his back from 8:00 AM through 8:40 AM. At 1:20 PM on 3/10/2016, the resident was observed seated in the outer dining room area with his family member watching television. The family member stated she arrived at the facility at 11:00 AM and the resident was assisted out of bed by staff at that time. She stated he had not been taken back to his room since that time for toileting needs and she was going to take him to the activity program after talking to the surveyor. The resident was observed seated in the living room /activity room on 3/10/2016 at 2:50 PM, after his family member left. The resident remained in the room through 4:56 PM when he was transported by CNA #23 into the dining area. The resident ate supper and remained in the dining area until 6:07 PM when CNA #23 transported him back to the living room/ activity room. The resident was in the living room when last observed at 6:30 PM. The resident was observed for greater than 3.5 hours without being checked, and changed as needed. During an interview with CNA #23 on 3/10/2016 at 6:07 PM, she stated Resident #16 was on her assignment and she knew him well. She said the resident's family member was at the facility several days a week and on those days, the resident usually attended an activity with the family member and went from the activity into the supper meal. After the supper meal, the resident was taken back into the living room, received his medication and preferred to go to bed between 8:30 PM and 9:00 PM. She said she checked and changed the resident today about 2:30 PM when the resident's family member was still at the facility. She stated she routinely started toileting all residents after the supper meal, and Resident #16 was almost always wet when she provided his toileting needs. If the resident refused to be changed, she stated the aides reported it to the nurses and the nurses documented it in the resident record. The aides were supposed to document at the time they provided care to the residents, but sometimes they documented later in the shift. CNA #23 said she was aware the resident was supposed to be checked and changed every 2 hours and she did not have the chance to do so as planned on this date. 10NYCRR 415.12(a)(3)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure appropriate care and services were provided to attain or maintain the highest practicable physical well-being for 1 of 4 residents (Resident #16) reviewed for skin breakdown. Specifically, the facility did not ensure interventions were in place to prevent further skin impairment when Resident #16 continued to develop moisture blisters to his lower extremities (legs). THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF 1/8/2015. Findings include: Resident #16 had [DIAGNOSES REDACTED]. On 1/11/2016, a nursing (skin) progress note documented the resident was found to have an open blister with serosanguinous (yellowish with small amounts of blood) drainage on his left heel, diagnosed as a moisture blister. Treatment was ordered for the area. A nurse practitioner (NP) progress note dated 1/11/2016 documented the resident had [MEDICAL CONDITION] and stasis [MEDICAL CONDITION], was in bed less and less over the past couple of weeks, increasing his [MEDICAL CONDITION] in his lower extremities. The plan was to provide treatment to the resident's blister and entire left heel to prevent skin breakdown. On 1/12/2016, an NP progress note documented the resident was seen for a small open area on his right shin, which appeared to be a moisture blister that popped. [MEDICATION NAME] (antiseptic) was to be used to the area for 7 days. An NP progress note dated 1/13/2016 documented the resident was seen by the skin team and a few scattered blisters were observed on his left shin. The resident was going to be monitored for [MEDICAL CONDITION] to his lower legs and nursing was going to attempt to encourage the resident to lie in bed a couple times throughout the day to assist with elevating his legs and reducing [MEDICAL CONDITION]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive loss, exhibited physical and verbal behavior symptoms directed toward others, rejected care, and required extensive assistance of 2 persons, with bed mobility, transfers, locomotion and personal hygiene. The resident was at risk for developing pressure ulcers, had 1 unstageable pressure ulcer with suspected deep tissue injury, skin tears and moisture associated skin damage (MASD). The treatments included a pressure reducing device for the chair and the bed, a turning and positioning program, nutrition or hydration interventions, pressure ulcer care, application of nonsurgical dressings and applications of ointments/medications. On 1/14/2016, a nursing progress note documented the resident had a small open area on the back of his right leg. An NP progress note dated 1/14/2016 documented the resident's open area to the right calf was likely a moisture blister that opened. A nursing progress note dated 1/14/2016 documented the resident was assessed as having moisture blisters to both sides of his lower legs: two on the front of his left shin and one lateral to the other ones; one on the right side. A physician order [REDACTED]. A nursing (skin) progress note dated 1/19/2016 documented the resident's moisture blisters on his left calf area remained open and continued to be treated. The right calf area blisters were closed and the treatment was to be applied per nursing judgment. On 1/20/2016, a registered nurse (RN) documented in the skin note that the resident's blister to the back of his right lower leg area remained red with a small amount of serosanguinous drainage. On 1/22/2016, the NP documented the resident's left heel blister related to moisture secondary to [MEDICAL CONDITION] was now dry and the treatment was changed. The resident's open blisters to his left shin were resolved and the treatment was changed to preventative. A nursing progress note dated 1/26/2016 documented the resident's bilateral shins remained red and rashy. The comprehensive care plan (CCP) reviewed by the team on 1/28/2016 documented the resident had deep tissue injury to his bilateral buttocks, improved to a Stage II as of 1/20/2016. The CCP documented the resident was at risk for further skin breakdown due to his dementia with possible decreased awareness of the need to make position changes, [MEDICAL CONDITION], diabetes, contractures, need for assistance with care routines, episodes of incontinence and use of [MEDICAL CONDITION] medications. Nursing staff were to provide treatments as ordered and staff were to be aware of his risk for skin breakdown. The resident had developed moisture blisters to his right and left shins. The resident was to have treatment as ordered, was monitored during treatment for [REDACTED]. On 2/17/2016, the CCP documented the areas were resolved. The CCP did not include a plan related to the [MEDICAL CONDITION] and possible cause of the moisture blisters. On 2/3/2016, the NP documented the resident's left heel moisture blister was greatly improved and treatment was to continue to the area. The resident had a fungal rash to both ankles and lower shins, with pinpoint rash. A new order was obtained for treatment to the areas. On 2/3/2016, the CCP documented the resident developed a non-pressure skin impairment on his bilateral shins and ankles due to a fungal rash. Treatment was to be provided as ordered, the resident was to be monitored for infection or deterioration, and observed for signs and symptoms of pain. On 2/17/2016, the RN progress note documented the resident's fungal rash to his bilateral shins and ankles had improved and some red irritated areas remained. The right shin blisters had healed. An NP progress note dated 2/18/2016 documented treatment was to continue for the resident's bilateral ankles and lower shins as the rash remained, although improved. On 2/23/2016, a nursing progress note documented the right shin was moist and there was bloody drainage on the old dressing. On 2/25/2016, a nursing treatment progress note documented the resident's lower legs remained red with [MEDICAL CONDITION], greater on the right leg. On 2/29/2016, an NP's progress note documented the resident had small open area to the right anterior shin. The area was documented as a moisture blister that had now opened secondary to stasis [MEDICAL CONDITION]. On 2/29/2016, the CCP documented the resident developed moisture blisters on his right shin. Treatment was ordered and the resident was to be monitored for signs and symptoms of infection or deterioration, observed for pain and evaluated weekly by the wound care nurse or the designee. There was no plan to prevent the development of the moisture blisters. A medical progress note dated 3/9/2016 documented the resident had 4 new blistered areas to his right lower leg from moisture. On 3/9/2016, the CCP documented the resident developed moisture blisters on his right lower leg. Treatment was to be provided as ordered, the resident was to be monitored for signs and symptoms of infection or deterioration, observed for pain and evaluated by the wound care nurse or registered nurse designee weekly. There was no documentation related to the cause of the moisture blisters. There was no plan to elevate the resident's legs, and the CCP did not document any concern related to the resident's [MEDICAL CONDITION]. The undated current certified nurse aide (CNA) Directives (care instructions) documented the resident was to be turned and positioned every 2 hours when in bed and when seated, had an alternating air mattress, Rooke Boots to be on at all times, a double layer of Tubi grips (elastic tubular bandage) on in the morning and off in the evening, and his heels were to be elevated off the bed as tolerated. There was no plan to encourage the resident to lie in bed a couple of times throughout the day to elevate his legs. The resident was observed seated in a scoot chair on 3/10/2016 from 1:20 PM through 6:25 PM. During an interview with the resident's family on 3/10/2016 at 1:20 PM, a family member stated she had been with the resident since 11:00 AM and he had been up in the chair since that time. During an interview with the RN Manager on 3/10/2016 at 8:10 AM, she stated a moisture blister was caused by excess fluid, from [MEDICAL CONDITION] or circulatory congestion, and usually appeared on a resident's legs or feet. She stated the resident's fungal rash may have been from the resident's refusal to remove the [MEDICATION NAME]. She stated the plan for prevention of the blisters was the use of the [MEDICATION NAME] and said the facility did not like using medications for [MEDICAL CONDITION] due to kidney function concerns. She said staff were to try to encourage the resident to lie down. She said the information probably should have been written on the CCP and she thought it was on the CNA directives. She stated the resident's legs could not be elevated in the current chair and they thought elevating his legs in the chair crated a greater fall risk for the resident. The RN did not provide any information related to a plan to prevent any further development of the moisture blisters. During an interview with CNA #23 on 3/10/2016 at 6:12 PM, she stated the resident was usually up in his chair at the beginning of her shift (2:00 PM to 10:30 PM) when his family member was visiting, and he did not like to go to bed until between 8:30 PM and 9:00 PM. When describing the resident's daily care, the CNA did not identify any specific directives related to elevating the resident's legs. 10NYCRR 415.19(a)(1-3)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection for 2 of 4 residents (Residents #31 and 32) observed for fingerstick blood glucose monitoring, and 1 of 7 residents (Resident #2) observed for urinary catheters. Specifically, the nurse did not disinfect a shared glucometer (device used to measure blood sugar levels) with an approved disinfectant for Residents #31 and 32; Resident #2 was observed with a catheter privacy bag lying directly on the floor. Findings include: 1) Resident #31 had [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The comprehensive care plan (CCP) dated 2/12/2016 documented the resident had diabetes, and the nursing staff were to obtain the resident's blood sugars as ordered. Resident #32 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 1/29/2016 documented the resident had diabetes, and the nursing staff were to obtain the resident's blood sugars as ordered. The physician orders [REDACTED]. During a continuous observation on 3/8/2016 starting at 4:25 PM, licensed practical nurse (LPN) #9 was observed donning gloves, removing a glucometer from the top of the medication cart and entering Resident #32's room. She performed the fingerstick blood glucose reading, exited the room, placed the glucometer on the top of the medication cart, donned a new pair of gloves and wiped the glucometer with an alcohol wipe. LPN #9 then entered Resident #31's room with the glucometer. She performed the blood glucose reading, exited the resident's room, placed the glucometer on the medication cart, donned a new pair of gloves, and wiped the glucometer with an alcohol wipe. During an interview with LPN #9 on 3/8/2016 at 4:40 PM she stated she would generally use a bleach wipe to disinfect the glucometer, but there was none in the cart. During an interview with the Infection Control registered nurse (RN) #1 on 3/11/2016 at 8:45 AM, she stated glucometers were to be disinfected with a bleach wipe after each use. She stated alcohol wipes were not an adequate disinfectant, as alcohol would not kill bloodborne pathogens. 2) Resident #2 had [DIAGNOSES REDACTED]. The 12/24/2015 Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired, and the resident required extensive assistance with most activities of daily living (ADLs). The 12/31/2015 comprehensive care plan (CCP) documented the resident was at risk for a UTI, and had a history of [REDACTED]. Nursing progress notes documented the resident had a Foley catheter (for urinary drainage) placed on 2/17/2016. The CCP was updated on 2/17/2016 and documented the resident required the use of an indwelling Foley catheter (for urinary drainage), and staff were to provide catheter care during morning and before bed care, change the drainage bag and leg securing strap weekly and as needed, and to monitor for signs and symptoms of a UTI. Nursing progress notes documented: - On 2/27/2016 at 12:12 PM, the resident's Foley was showing tea colored urine; - On 3/7/2016 at 3:14 AM, the resident's Foley was draining yellow urine with sediment in tubing; - On 3/7/2016 at 3:24 PM, the resident's Foley was draining hazy amber urine; and - On 3/8/2016 at 3:09 PM, the resident's Foley was draining clear dark yellow urine with sediment. The resident was observed on 3/10/2016: - at 8:30 AM and 8:59 AM, seated in his scoot chair outside the dining area across from the nursing station with his catheter privacy bag directly touching the floor; and - at 4:40 PM, being wheeled by an anonymous staff member from the lounge area located down the hallway, through the hall, and to the dining area. During that time, the catheter privacy bag was directly on the floor under the seat of the chair. The 3/11/2016 certified nurse aide (CNA) Care Directives (instructions) documented the resident had an indwelling Foley catheter; and staff were to maintain his regular drainage bag at all times. The Care Directives documented the resident required extensive assistance of 2 for transfers and he sat in a scoot chair with a wheelchair Posey sitter (alarm attached to the wheelchair) when out of bed. During an interview with CNA #19 on 3/11/2016 at 8:56 AM, she stated the catheter bag was always to be in a cover, and when the bag was placed on the chair, it should have been on a hook to hold it off the floor. She stated positioning of the bag was more difficult on some chairs, and for Resident #2's she would have attached it to two different hooks to get it off the floor. During an interview with registered nurse (RN) Manager #21 on 3/11/2016 at 10:05 AM, she stated the facility had covers made for the catheter bags which were not always the right size; sometimes the bags touched the floor if they were too big. She stated some chairs were difficult, as they were not high enough to place the catheter bag at the right level. During an interview with the Infection Control RN on 3/11/2016 at 2:00 PM, she stated the cloth bags used to cover the drainage bags were permeable (liquids could pass through). She stated she would not want them dragging on the floor, and hooks or Velcro should have been used to keep them off of the floor. 10NYCRR 415.19(b)(1)