Every finding on record at Nottingham R H C F

Based on observations, record review, and interviews during the recertification survey conducted 9/8/2025 - 9/12/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of one (1) resident (Resident #23) reviewed. Specifically, Resident #23 did not have a positioning device placed as ordered. Findings include:The facility was unable to provide a policy referencing positional devices. Resident #23 had diagnoses including Alzheimer's dementia and pain in the right-hand joints. The 8/7/2025 quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, usually made themself-understood, usually understood others, and required maximum assistance with upper body dressing and personal hygiene.The 3/31/2025 unsigned Therapy Trigger form documented the resident had hand discomfort, and weakness of the right 3rd and 4th fingers. The 4/7/2025-5/4/2025 Occupational Therapist #13 Evaluation and Plan of Treatment documented the resident would increase compliance with orthotic management instructions to prevent contractures. Caregiver goals included to get range of motion and functional use back in the right hand and be able to use the sit to stand mechanical lift again to transfer. The resident was to use a palmar guard for contracture of right-hand 3rd and 4th digits. The resident was dependent for putting on and taking off the device. The 4/15/2025 physician order documented a right-hand palm guard placed by certified nurse aides in the AM and removed at bedtime per occupational therapy recommendations for contracture prevention. The nurse monitored for placement and removal every day and evening shifts for contracture prevention.The 5/22/2025 revised Comprehensive Care Plan documented the resident had activity of daily living self-care performance related to dementia. Interventions included right hand palm guard as resident tolerated. On during day hours, remove during meals, off during night, weekly skin inspections, physical therapy and occupational therapy evaluations and treatments as ordered, maximum assistance with upper body dressing, and anticipate and meet needs. The 9/11/2025 care instructions documented right hand palm guard as tolerated, on during day and removed at mealtimes and night hours. The resident removed the palm guard by themself, and staff were to reapproach.The following observations of Resident #23 were made: -on 9/8/2025 at 6:50 PM, sitting in a Broda (positioning) chair in their room. The resident's right index finger was contracted, and the finger curve resembled a hook. The resident did not have a palm guard on the right hand.-on 9/9/2025 at 9:41 AM, sitting in a Broda chair in their room. The resident was dressed and groomed, the right index finger had a hooked appearance, and there was no palm guard in their right hand. A palm guard was not observed in the room. -on 9/11/2025 at 10:31 AM, sitting in the unit common area in their Broda chair. The resident was dressed and groomed with no palm guard on the right hand. The resident's palm guard was observed on top of the nightstand in the resident's room. The 9/2025 Treatment Administration Record documented right hand palm guard to be placed by certified nurse aides on AM and removed at hour of sleep per occupational therapy recommendations for contracture prevention: nurse to monitor for placement and removal every day and evening shift. Licensed Practical Nurse Supervisor #10 signed the right palm guard was applied during the day from 9/8/202-9/11/2025. During an interview on 9/11/2025 at 1:42 PM, Certified Nurse Aide #11 stated resident specific care was documented in the care instructions and care plan. Resident #23 had a palm guard that was listed in the care instructions. The palm guard was supposed to be put on by the Unit Supervisor. If the palm guard was not on by 10:30 AM, the aide was supposed to remind the nurse to put it on. The palm guard was used to prevent contractures, and the resident sometimes wiggled it off. The aide did not know why it was off on 9/11/2025 and did not remember if they told the Unit Supervisor. The aide noticed it was on the nightstand that day and thought the resident took it off and staff put it on the nightstand.During an interview on 9/11/2025 at 2:00 PM, Licensed Practical Nurse #12 stated resident specific care was in the care plan and care instructions. Any adaptive equipment such as a brace or palm guard should have a physician order, and nurses should sign for its use in the treatment administration record. They stated Resident #23 had a palm guard with a physician order. The treatment nurse should ensure it was on and sign for its use. During an interview on 9/11/2025 at 2:07 PM, Licensed Practical Nurse Supervisor #10 stated they were the daytime supervisor and the day shift treatment nurse. They were aware if a resident had adaptive equipment as it was listed in the treatment administration record and had to be signed for. They wrote out a list each morning of the treatments that needed to be done and tried to complete all the treatments prior to staff getting residents ready in the morning. Resident #23 removed the palm guard themselves at times and ended up in the resident's lap. They stated they should document when the resident removed it themselves but did not. They did not think they put the palm guard on the resident on 9/9/2025 as they had to leave that day for a personal reason and had already signed for it being done. They did not put the palm guard on 9/11/2025 and signed for the treatment. They stated they should only sign for it after they put the guard on. The purpose of the palm guard was to prevent the resident's right index finger contracture from worsening. During an interview on 9/11/2025 at 2:25 PM, Occupational Therapist #13 stated the purpose of palm guard was to prevent further decline of a contracture. The palm guard was listed in the resident's care plan, there was a physician order for it, and it should be signed for by staff in the treatment administration record. The therapist expected the guard to be used as ordered, and a rolled washcloth could be used in place if the guard was soiled and needed cleaning. A progress note should be written if the resident refused it. The resident's right hand was very stiff, the contracture was stable all week, and there would not be changes if the palm guard was not in place for a couple of days. The therapist stated they performed informal audits of its use while rounding the unit and did not notice it was not on, as the resident had a habit of removing it by themselves at times. 10NYCRR 415.12

Based on observation, record review, and interviews during the recertification survey conducted 3/4/2024-3/7/2024, the facility did not ensure residents who needed respiratory care was provided such care consistent with professional standards of practice for 1 of 2 residents (Resident #9) reviewed. Specifically, Resident #9 was not administered oxygen as ordered and did not have a care plan that included oxygen. Findings include: The facility policy, Oxygen Therapy dated 11/2023 documented oxygen could be administered by a licensed nurse and all as needed oxygen use will include the number of hours used on the shift under the supplemental documentation on the treatment administration record. Resident #9 had diagnoses of pleural effusion (a buildup of fluid between the lungs and chest), chronic diastolic congestive heart failure, and hypertensive heart disease with heart failure. The 1/2024 Minimum Data Set documented the resident had moderately impaired cognition, required total assistance for transfers with a mechanical lift, used a wheelchair for mobility, and did not use oxygen. Physician order documented: - on 3/16/2023 apply oxygen as needed to maintain oxygen saturation levels above 92%. - on 10/29/2023 check oxygen saturation every 4 hours while on oxygen. - on 11/12/2023 attempt to wean oxygen but oxygen saturations above 90%. The 1/12/2024 physician #8 progress note documented the resident's oxygen saturation (amount of oxygen in the blood) was 94% on room air on 1/11/2024. The resident was sitting up in their wheelchair and receiving oxygen by a nasal cannula (tube delivering oxygen into the nose). The assessment included chronic hypoxic (low oxygen) respiratory failure, use oxygen as needed to keep saturations above 92%. The 1/2024 medication and treatment administration records did not include oxygen provided or oxygen saturations per physician orders. The 1/18/2024 registered nurse #7 progress note documented the resident expressed they were frustrated they had to wear continuous oxygen and felt they did not need it. The 2/2024 and 3/2024 medication and treatment administration records did not include oxygen provided or oxygen saturations. Nursing progress notes dated 2/7/2024-3/5/2024 did not document oxygen use or attempts to wean the resident from oxygen. The weights and vital signs summary sheet for 2/28/2024-3/6/2024 documented oxygen saturation levels for Resident #9 as follows: - on 2/28/2024-94% - on 2/29/2024-96% - on 3/1/2024-95% - on 3/4/2024-97%. There were no documented oxygen saturations on 3/5/2024 or 3/6/2024. There was no documented evidence oxygen saturation levels were measured every 4 hours while on oxygen. There was no documented evidence the comprehensive care plan and care instructions included oxygen use. During an observation on 3/4/2024 at 6:34 PM, the resident was being assisted into bed and there was an oxygen concentrator at the foot of their bed; the concentrator had oxygen tubing attached to it, was turned on and set to 2 liters per minute. During an observation on 3/6/2024 at 9:29 AM, the resident was sitting in a high back wheelchair in the dining room with a portable oxygen tank attached to the back and set to 2 liters per minute. The resident was receiving oxygen via nasal cannula and was escorted back to their room. Certified nurse aide #6 unhooked the portable oxygen tank's tubing from the resident's face, turned on the oxygen concentrator, and placed oxygen tubing from the concentrator on the resident. The concentrator was set to 2 liters per minute. During an observation on 3/7/2024 at 9:54 AM, the resident was sitting in their high back wheelchair in the television activity room receiving oxygen from a portable oxygen tank attached to the back of their chair set to 2 liters per minute. During an interview on 3/6/2024 at 9:38 AM, certified nurse aide #6 stated they had received oxygen therapy training. Certified nurse aides were allowed to turn on the oxygen concentrators and place the tubing on the resident's face, but they could not adjust the numbers on the machine. They stated Resident #9 used oxygen but did not know if they required oxygen all the time. During an interview on 3/7/2024 at 9:56 AM, licensed practical nurse #4 stated physician orders automatically appeared on their computer screen for the resident's medication records when the physician entered them. They stated if an order was new, it would appear as a red box, and they would review the order to make sure it was correct. Licensed practical nurse #4 stated oxygen should show as a treatment order and treatments were usually administered by registered nurse Unit Manager #3. Licensed practical nurse #4 stated they only administered medications. During an interview on 3/7/2024 at 10:05 AM, registered nurse Unit Manager #3 stated oxygen was a treatment order and was applied via a standing order if a resident needed oxygen. A standing order was in place and nurses could implement when necessary. They stated Resident #9 should not receive continuous oxygen and nurses needed to check oxygen saturation levels (amount of oxygen in their blood measured by a machine) before they administered it. If the resident's oxygen saturation levels were above 92% then they did not need it. Registered nurse Unit Manager #3 stated if the resident wore it continuously, they could become dependent on it. Oxygen should be care planned so staff knew how to care for the resident. During an interview on 3/7/2024 at 10:50 AM, the Director of Nursing stated physicians wrote orders and nurses confirmed them in the resident's electronic medical record. Oxygen was documented as a treatment order and was a batch order in the system, meaning there were several parts to the order. The nurses were responsible to put the batch orders into the resident's record. They stated if the resident had an oxygen order that was on an as needed basis, they should not be wearing it continuously. The resident could become dependent on the oxygen. They stated care planning drove care for the resident and oxygen should be care planned so staff knew how to care for that resident. 10 NYCRR 415.12(k)(6)

Based on observation, record review, and interview during the recertification survey conducted 3/4/2024-3/7/2024, the facility did not ensure the resident environment remained free of accident hazards for 1 of 1 treatment cart. Specifically, the treatment cart was unlocked and contained scissors and potentially hazardous medications in an area accessible to residents. Findings include: The facility policy Storage of Medications, revised 8/2000, documented medications and biologicals were stored safely, securely, and properly, and accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Additionally, medication rooms, carts, and medication supplies were locked when they were not attended by persons with authorized access. During an observation on 3/5/2024 at 1:57 PM the treatment cart was in the hallway between room [ROOM NUMBER] and 140 and was unlocked. The top drawer contained scissors and the remaining drawers contained medicated shampoos, antifungal creams, steroid creams, antibiotic creams, and dressing supplies. During an observation on 3/5/2024 at 1:58 PM Resident #2 was wandering in the hall between room [ROOM NUMBER] and 138. During an interview on 3/6/2024 at 10:35 AM, certified nurse aide #5 stated the unit had residents who wandered and went into other residents' rooms and included Resident #2. During an interview on 3/6/2024 at 2:29 PM, licensed practical nurse #4 stated the medication and treatment carts were always locked when unattended for resident safety. They stated the treatment cart contained scissors, hydrocortisone cream, diclofenac pain cream, estrogen (hormone) creams, and other medications that were dangerous if ingested. They stated that residents wandered, and carts should not be left unlocked for the safety of those residents. During an interview on 3/7/2024 at 8:22 AM registered nurse Unit Manager #3 stated the treatment cart should be always locked when unattended. The treatment cart contained scissors that were dangerous if residents with dementia obtained them. Some of the medications in the treatment cart like Volteran (diclofenac) gel, betamethasone cream (corticosteroid), and antifungals were dangerous if ingested. They stated on 3/5/2024 they removed tape from the treatment cart and did not lock the cart after they removed the tape, and they should have locked the cart. They had residents with dementia that wandered on the unit and in the area where the treatment cart was. During an interview on 3/7/2024 at 10:05 AM, the Director of Nursing stated the treatment cart should always be locked when unattended. The treatment cart contained scissors and topical medications that were dangerous if residents obtained them. They stated the unit had residents with dementia and some residents wandered on the unit. They stated the treatment cart was always locked to prevent wandering residents from getting into medications and for resident safety. Residents could get injured or cut with the scissors and could get sick if they ingested medications. 10 NYCRR 415.12(h)(2)

Based on observation, interview, and record review during the recertification survey conducted 3/04/2024-3/07/2024, the facility did not care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life for 1 of 1 resident (Residents #21) reviewed. Specifically, Resident #21 did not receive regular foot care and their toenails were long and uncomfortable for the resident. Findings include: The facility policy Resident Rights & Notice of Resident Rights and Responsibilities, revised 8/8/2022, documented all residents of the facility had a right to a dignified existence and would be supported by the facility in exercising their rights. The residents also had the right to self-determination and to participate in their care planning and treatment. The facility policy Resident Nail Care, revised 8/8/2022, documented all residents would receive toenail care from licensed staff. If a licensed staff member was unable to provide proper toenail care, the resident would be seen by podiatry (foot care practitioner). Resident #21 had diagnoses including congestive heart failure, atrial fibrillation (abnormal heart rhythm), and chronic kidney disease. The 12/6/2023 Minimum Data Set assessment documented the resident was cognitively intact, utilized a walker and a wheelchair for mobility, and required supervision or touching assistance for most activities of daily living. The comprehensive care plan, revised 12/12/2022, documented the resident had an activities of daily living deficit related to heart failure. Interventions included to check the resident's nail length, trim and clean nails on the resident's bath day and as needed. Any changes were to be reported to the nurse. The resident required supervision/touch assistance to set up for most activities of daily living and required partial assistance of one for bathing and toileting hygiene. The 11/21/2023 podiatrist #9 consult documented the resident's toenails were painful upon palpation, were discolored, and had onychomycosis (fungal infection) on all ten toenails. The plan included a debridement (removal of infected/damaged tissue) of all ten toenails and a follow up in ten weeks. The following interview and observations were made: - On 3/4/2024 at 6:25 PM, the resident's toes were purplish in color with crusty yellow and white toenails. The resident stated the podiatrist had not visited recently and that they needed to be seen as their toes were bad. - On 03/6/24 at 2:28 PM, the resident stated because their toenails were so long their toes curled up in their shoe and it made them ugly. The top of the toes on the resident's right foot were reddish-purple all the way around to the middle of the toes, on the bottom of the toes, and down the side of the last toe. The nails of all five toes were yellow and white with a grooved pattern and were thick. The second toe had white and cracked skin underneath the toenail. The toenail on the second to last toe was long and curved into the side of the middle toe. The top of the toes on the resident's left foot were reddish purple all the way around to middle of the toe, and on the bottom of the toes. All five toes had thickened yellow and white crusty-looking nails with a grooved pattern and the nails of the second and third toe were jagged. There were four small red spots on the second to last toe beneath the bottom of the nail. The second to last toe was also long, met the side of the middle toe, and there were red and flakey marks on the side of the middle toe. During an interview on 3/6/24 at 9:57 AM, unit clerk #10 stated a podiatrist came to the facility on ce a month to meet with residents. Unit clerk #10 stated they kept a running list of who saw the podiatrist and when the resident had a follow-up visit. A resident was usually seen every three months unless the provider documented the resident required a sooner visit. The podiatrist filled out the facility's podiatrist consult form with what was done during the appointment and what the plan for follow up was. If the podiatrist marked on the form a resident needed to be seen in ten weeks, they would put them on the schedule to be seen in ten weeks. The unit clerked was unaware if Resident #21 was designated to have a ten week follow-up from the last time they were seen on 11/21/2023. They reviewed the consult and stated the resident was supposed to have a ten week follow up which they had missed on the consult sheet. During an interview on 3/6/24 at 2:40 PM, registered nurse Unit Manager #3 stated they had input on who needed to be seen by the podiatrist. They stated if an issue came up, they would let the unit clerk know if a resident needed to be added to the podiatry list. They stated feet were checked as part of daily care and if a certified nurse aide saw an issue, they brought it to the attention of the licensed nurse. They stated if there was a concern about nails, they would inform the medical providers. They expected if a podiatry consult recommended the resident should have a ten week follow up, it should be adhered to. They were unaware of any issues or concerns with Resident #21's toenails. During an interview on 3/6/24 at 2:55 PM, podiatrist #9 stated Resident #21 should receive routine foot care. They stated they were available to receive phone calls from the facility if an issue with a resident's toes or toenails came up prior to their next visit. They stated if they were available, they would come see the resident in person prior to the next scheduled visit. It was important to have routine toenail maintenance for general health. Without regular maintenance, it could cause painful toes. During an interview on 03/7/24 at 9:28 AM, licensed practical nurse #4 stated they did head to toe skin checks on a resident's shower day as the resident would already be disrobed for their shower. They would expect the certified nurse aides to inform them of any changes to a resident's skin or nails/toenails noticed during care. They stated toenail maintenance was usually done by the podiatrist, but a licensed nurse could cut a non-diabetic resident's toenails if they were long. They were unaware of any changes to the coloration of Resident #21's toes or that their toenails were long. 10NYCRR 415.5 (a)

Based on record review and interviews during the recertification survey conducted 3/4/2024-3/7/2024, the facility did not ensure the designated Infection Preventionists completed specialized training in infection prevention and control for 2 of 2 Infection Preventionists (Director of Nursing and the Assistant Director of Nursing). Specifically, the Director of Nursing and the Assistant Director of Nursing who shared the role of Infection Preventionist, did not have documented evidence of a certificate of completion or equivalent documentation to meet the requirement for specialized training in infection prevention and control. Findings include: The facility policy Infection Prevention and Control Program dated 10/2023, documented authority for the Infection Prevention and Control Program has been delegated by the Director of Nursing to the Infection Preventionist. The ultimate responsibility for overseeing the Infection Prevention/Control Program is delegated to the Infection Preventionist along with the Quality Assurance Committee. The facility's Infection Preventionist is a registered nurse and has attended the Statewide Program for Infection Prevention and Control APIC I and II. During an interview on 3/7/2024 at 9:47 AM, the Director of Nursing and the Assistant Director of Nursing stated they shared the role of Infection Preventionist and could not find their certificate of completion for the infection prevention and control training. They completed a one-hour Infection Control Training on 1/17/2024. There was no documented evidence the Director of Nursing nor the Assistant Director of Nursing had completed the required specialized training in infection prevention and control. 10NYCRR 415.19 (a)

Based on observation and interview during the recertification survey conducted from 12/1/21-12/3/21, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage rooms reviewed. Specifically, there were two boxes of expired [MEDICATION(S)] (antidiarrheal) 2 milligram (mg) tablets observed in the medication room. This is evidenced by: The facility policy Storage of Medications revised 8/2020 documents outdated medications are to be immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. On 12/1/21 at 2:00 PM the medication storage room was observed with two boxes of [MEDICATION(S)] 2 mg tablets with expiration dates of 10/2021. One of the boxes had been opened. During an interview on 12/1/21 at 2:14 PM, licensed practical nurse (LPN) #11 stated the nurses were responsible for checking the expiration dates on the medications when they were removed from the stock room. During an interview on 12/1/21 at 2:19 PM, unit secretary #12 stated they were responsible for ordering over the counter medications. The unit secretary stated they went into the medication room and would see what needed to be ordered based on par levels. The unit secretary stated they rotated the stock and checked the expiration dates. During an interview on 12/3/21 at 9:17 AM, the Director of Clinical Operations stated the medication LPNs were responsible for checking the expiration dates of medications including the medications in the storage room. The Director stated the LPNs should be checking for expired medications routinely. During an interview on 12/3/21 at 9:23 AM, the Director of Nursing (DON) stated the LPNs were responsible for checking medication storage rooms. Each shift was responsible for checking any medication that came in or went out of the medication room and they were expected to check the storage room whenever they went into the room. Once a month, a pharmacy representative came into the room and checked everything. The nurse managers had started to check the medication storage rooms and they had all done audits. The DON stated during a recent mock survey they had not found the expired [MEDICATION(S)]. 10NYCRR 415.18(e)(4)

Based on observation, interview, and record review during the recertification survey conducted 12/1/21-12/3/21, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 1 resident (Resident #28) reviewed. Specifically, Resident #28 did not receive their care planned contracture device and their hand was observed to be unclean. Additionally, the device was recommended for both hands and the care plan documented placement for one hand. This is evidenced by: The facility policy Range of Motion dated 1/21/20 documents when a resident is observed with decreased ability with range of motion (ROM), a therapy trigger will be generated by the nursing unit. The therapy department will perform an assessment and commend any ROM and/or equipment necessary of the resident and document on the plan of care. The information from the therapy assessments and plan of care will be transcribed by nursing to the certified nurse aide (CNA) assignment sheet for documentation by the CNA once completed. Recommendations for contracture devices such as hand rolls will be transcribed to the CNA assignment sheet by the CNA once completed. Resident #28 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/3/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance or total dependence for all activities of daily living, and had range of motion (ROM) impairment on both upper extremities. The 6/14/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation the resident had a contracture device ordered for their left hand. The 9/3/21 revised comprehensive care plan (CCP) documented the resident had contractures to their bilateral hands; the resident was to receive skin care daily to their hands to keep clean and prevent skin breakdown. The resident was to receive passive range of motion (PROM) to bilateral upper exterminates and hands with daily morning and evening care, and to place rolled disposable wash clothes to bilateral hands on in the morning, off in the evening; staff were to check hand hygiene. The 9/3/21 Occupational Therapy Discharge Summary completed by occupational therapist (OT) #5 documented the resident was seen for OT evaluation/treatment starting 8/12/21 to address bilateral hand contractures. OT tried to provide PROM and prolong stretch techniques to try to loosen muscles and get digits out in extension in order to trial rolled wash clothes and/or palm guards to resident tolerance. The resident, nursing, and the resident's representative were educated on importance of PROM, completing hand hygiene and their limited tolerance for ROM/placing anything in their hands. Wool palm guards were ordered to try to fit in bilateral hands as the blue palm guards were too thick and were unable to get into the resident's palms. The OT and nursing consulted about the use of disposable rolled wash clothes to be in place to resident tolerance to prevent any further contracture or skin breakdown. The OT documented the resident's plan of treatment and treatment services were reviewed with interdisciplinary team members. The 11/29/21 certified nurse aide (CNA) Task entered by registered nurse (RN) Unit Manager #1 documented to apply a disposable washcloth to the resident's right palm in the evening and remove in the morning. The task was documented twice under activities of daily living (ADL) and personal hygiene. Licensed practical nurse (LPN) #7 documented the task was completed on 12/1/21 at 12:33 PM. There was no documentation of application of washcloths to the resident's left palm. The 11/2021 treatment administration record (TAR) documented to apply a disposable washcloth to the resident's right hand in the evening and remove in the morning. There was no documentation the resident had a device ordered for their left hand. The care instructions active on 12/3/21 documented to provide PROM to bilateral upper exterminates and hands with daily morning and evening care, and to place rolled disposable wash clothes to bilateral hands, on in the morning, off in the evening; staff were to check hand hygiene. The 11/4/21 OT #5 progress note documented the resident was seen for a screen per nursing referral. The OT documented to please continue to follow plan of care as indicated; the resident had contractures of their bilateral hands and was to receive skin care daily to keep clean and prevent skin breakdown. The resident was to receive PROM to bilateral upper exterminates and hands with daily morning and evening care, and to place rolled disposable wash clothes to bilateral hands on in the morning, off in the evening; staff were to check hand hygiene. On 12/1/21 at 10:04 AM, the resident was observed in their room. Their left hand was contracted, and no device was in their hand. Their right hand was underneath a blanket and was not be observed at that time. On 12/1/21 at 12:50 PM, the resident was observed in the dining room. Both hands were contracted and there were no devices in their hands. On 12/2/21 at 8:50 AM, the resident was observed in their room with no devices in either hand. The resident's left hand had a dark substance on the palm underneath their fingers. The resident had use of their pointer finger on their left hand and all the other fingers were contracted. The resident was unable to open their fingers when asked. During an interview on 12/2/21 at 1:51 PM, CNA #6 stated contracture devices for residents could be found on the care plan. Contracture devices could be applied by the CNAs or the nurses and they would follow the tasks for instructions. The resident had contractures in both hands and used to have devices in their hands. The CNA was unsure if the resident was supposed to have any current devices. The CNA stated the resident previously had washcloths in their hands though not recently. The CNA provided as much care to the resident's hands as the resident would tolerate. The resident got up on the night shift and was up when the CNA arrived to work most days. The CNA stated the resident's hands had gotten tighter over time. During an interview on 12/2/21 at 2:03 PM, licensed practical nurse (LPN) #5 stated resident's devices were documented on the treatment administrator record (TAR). The CNA task list also documented the order and the LPN sometimes documented devices there. The LPN stated the resident was supposed to have rolled-up wash cloths in their hands and they could not recall if the resident was to have their device put on in the morning or the evening. The CNAs could also place the resident's wash clothes if the LPN did not get to them. The resident had wash clothes to help minimize contractures, keep their fingers stretched, and to protect the skin. The LPN stated they did not arrive to work until 10:00-10:30 AM on 12/1/21 and completed the resident's contracture care and documented in the point of care (CNA Tasks) at that time. At 2:08 PM, the LPN and surveyor observed the resident's hands. There were no devices in the resident's hands. During an interview on 12/2/21 at 4:21 PM, registered nurse supervisor (RNS) #10 stated they put devices on residents themself. The RNS stated they documented when the resident refused. The resident was supposed to have both their hands washed with soap and water and was to have a rolled washcloth in their right hand. During an interview on 12/3/21 at 8:37 AM, OT #5 stated they started working with the resident in 8/2021. The resident had contractures to their hands. Palm guards and wool clothes would not fit in the resident's hands because they were too tight. The former Assistant Nurse Manager had suggested disposable wash clothes which were not as rough as the regular wash clothes. The resident seemed to tolerate the disposable wash clothes the best. The OT recommended to put the disposable washcloths on in the morning instead of the evening to allow for staff to monitor the placement and replace as needed without having to wake the resident up. The resident needed wash clothes in both hands as both hands were contracted. The OT was not aware the order and tasks did not match the OT's recommendations and the care plan. During an interview on 12/3/21 at 8:54 AM, RN Unit Manager #1 stated therapy recommendations were communicated verbally, and they thought therapy put their own orders in the electronic medical record when they updated the care plan. The resident had contracted hands and was to have a washcloth placed in their hands at night. The RN looked at the orders in the electronic record and stated the order documented for a washcloth for the right hand only, to be placed at night and to be removed in the morning. The RN stated the care plan documented disposable washcloths for both hands to be placed in the morning and take off in the evening. The RN stated it appeared as though the OT had recommended something new, and the order had not been put in. The RN stated the resident had a washcloth for skin protection from their fingers folding over and their nails digging into their palm. During an interview on 12/3/21 at 9/16/21 AM, RN Assistant Manager #2 stated the resident's hands were severely contracted and the resident was to have a soft (disposable) washcloth placed in both their hands at night and removed in the morning. The RN stated the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN stated the care plan documented the resident needed rolled disposable washcloths to both hands in the morning and removed in the evening. The care plan contradicted the order. The RN stated the progress notes documented multiple occurrences of the resident refusing placement of the washcloths at night which had not been communicated to the RN. The resident was to have the disposable washcloth to add extra space between their fingers and their hand, so their nails did not dig in. The washcloths were also added hygiene to take away moisture to prevent skin breakdown or infection, and to prevent further contractures. On 12/3/21 at 9:41 AM, the resident's hands were observed with RN Assistant Manager #2. The resident did not have disposable washcloths in either hand. The RN could not open the resident's left hands, there was some darkened areas on the left hand at the palm, right below the pointer finger. 10NYCRR 415.12(e)(2)

Based on observation, record review and interview during the recertification survey conducted 12/1-12/3/21, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 2 of 4 residents (Residents #4 and 7) reviewed. Specifically, Resident #4 was not assisted with timely nail care and facial grooming and Resident #7 was not assisted with timely nail care. The facility policy Resident Nail Care dated 8/2020 documented the facility was to ensure that residents received fingernail and toenail care to prevent potential infection, discomfort and or injury. It was the task of the facility that all residents will have their fingernails trimmed (clipped and shaped) as needed. The facility policy ADLs dated 1/21/20 documented the resident will be given the appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living, to include: Hygiene - bathing, dressing, grooming, and oral care. 1) Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan (CCP) documented staff were to check nail length and trim and clean on bath day and as necessary. The resident was to be showered weekly and as necessary and required the assistance of 1 staff for personal hygiene. The 12/2/21 care instructions documented the resident was showered every Thursday on the 7:00 AM - 3:00 PM shift. Staff were to keep fingernails short, and check nail length and trim as necessary on bath days. There were no specifications for facial grooming (shaving) on the care instructions. The certified nurse aide (CNA) activities of daily living (ADL) record documented the resident was provided personal hygiene on 12/1/21. The resident was observed on 12/1/21 at 10:11 AM, 11:57 AM; and 12/2/21 at 8:20 AM and 8:57 AM with long, untrimmed, and unclean fingernails and long strands of hair on their chin. During an interview with CNA #16 on 12/2/21 at 1:22 PM, they stated personal hygiene would include shaving. The CNA stated the night shift got the resident out of the bed and the day shift would clean the resident's face. The CNA stated they checked to make sure the resident looked presentable which included making sure their hands were clean. The CNA stated they did not ask Resident #4 if they were ok with the hair on their face and they did not shave them. During an interview with CNA #17 on 12/2/21 at 1:37 PM, they stated personal care would include bed baths, hand care, and giving showers. On shower days staff washed, shaved, and trimmed the nails of the resident. The CNA stated they gave the resident a shower on this date. The CNA stated they did not shave the resident or cut their nails, but they did wash their nails. They thought the resident had nail care the day prior. The resident was observed with long, untrimmed, and unclean nails on 12/2/21 at 1:51 PM and on 12/3/21 at 9:01 AM. During an interview with licensed practical nurse (LPN) #11 on 12/2/21 at 2:00 PM, they stated personal hygiene included showers, nail care and shaving. Everyone was responsible for providing personal care to residents. The resident's shower day would be on the care plan and residents were showered once to twice per week. The LPN stated on their shower days the residents would have nail care done. Shaving could be done at any time and if staff saw a resident with long facial hair it needed to be trimmed as it was part of personal care. The LPN stated primarily CNAs shaved and did nail care for residents. The LPN stated staff should have shaved Resident # 4's chin and their fingernails should have been cleaned and cut. During an interview with registered nurse (RN) Assistant Unit Manager #2 on 12/2/21 at 2:13 PM, they stated that personal hygiene included nail care and shaving. CNAs were primarily responsible for personal hygiene. Nail care was to be done as needed by CNAs. The resident ate a lot with their hands, and they had to cleaned more often. Staff should have cut the resident's nails and trimmed their chin even if the resident could not voice their preference. 2) Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/1/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required extensive assistance with personal hygiene. The 6/3/21 comprehensive care plan (CCP) documented the resident had an activities of daily living (ADL) self-care deficit. Staff were to check nail length and trim and clean on bath day and as necessary. There was no documentation from 10/2021-12/2021 the resident had declined or refused nail care. The 12/2/21 care instructions documented the resident was totally dependent on staff for personal hygiene. Staff were to keep the resident's nails short to reduce the risk of scratching or injury from picking at the skin. During an observation on 12/1/21 at 10:26 AM the resident had long fingernails that were unclean on top and underneath the nail. The resident stated they would like their nails cut and cleaned. At 3:35 PM the resident was observed with long, unclean fingernails, with dark build up underneath and remnants of nail polish on some nails. The resident was observed picking at their nails. During an interview with certified nurse aide (CNA) #18 on 12/3/21 at 10:18 AM, they stated they were assigned to the resident. The resident required extensive assistance with personal hygiene and did not have use of one of their arms. The CNA stated they provided care to the resident that morning and did not do nail care. During the interview the CNA observed the resident and the resident's nails were clean and their left hand had long nails and one with jagged edges. The CNA asked the resident if their nails were too long and if they wanted them cut and the resident stated yes. During an interview with CNA #19 on 12/3/21 at 10:23 AM, they stated they were assigned to the resident on 12/1 and 12/2/21. The resident was unable to do their own care and required the assistance of staff with nail care. The residents should always have short nails unless they asked for them to be kept long. The CNA stated the resident should have short nails because the resident picked at areas. The CNAs were responsible for cleaning nails and were able to cut nails when needed. The CNA stated they did clean or cut the resident's nails on 12/1 or 12/2. During an interview with registered nurse (RN) Unit Manager #1 on 12/3/21 at 11:12 AM, they stated the CNAs were responsible for nail care and it should be been done every day. Some residents needed their nails trimmed. Resident #7 would get food under their nails and their nails should be checked daily for build-up. 10NYCRR 415.12(a)(3)

Based on record review, observation, and interview during the recertification survey, the facility did not ensure a resident with limited range of motion (ROM) received the appropriate treatment and services to improve and/or to prevent a decrease in ROM for 1 of 1 resident (Resident #2) reviewed for ROM. Specifically, Resident #2 did not have a contracture device implemented as care planned. Findings include: Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The 6/20/19 occupational therapy (OT) evaluation documented the resident expressed a desire to decrease hand pain. It was recommended the resident would wear a soft palmer splint on her right and left hand at all times, except during bathing and exercising, to improve ROM, reduce pain from muscle tightening and maintain joint integrity. The evaluation documented the resident was issued a right soft palmer splint due to finger contractures. The 8/22/17 physician order [REDACTED]. The 7/17/19 updated comprehensive care plan (CCP) documented the resident had contractures. Interventions included keep skin clean and dry, encourage to keep nails short, total assistance with activities of daily living (ADLs), adaptive/positioning equipment as directed and right-hand soft palmer splint on in the morning and off at bedtime. The 9/25/19 resident care instructions documented right soft palmer splint on in the morning and off at bedtime. The 9/2019 treatment administration record (TAR) documented the resident did not have the soft palmer splint applied on 9/15/19, 9/25/19, and 9/26/19. The TAR documented staff were unable to locate the splint on 9/25/19 and 9/26/19. During an observation on 9/25/19 at 11:58 AM, the resident was sitting in the dining room in her positioning chair, her right and left hands were contracted and there were no splints in either hand. During an observation on 9/25/19 at 12:54 PM, there were no palmar splints located in her dressers or her room. The resident was observed sitting in the dining room with contracted hands and no palm splints in either hand. During observations on 9/26/19 at 10:15 AM, 11:00 AM and 11:32 AM, the resident was in her positioning chair and did not have a soft palmer splint in either hand. When interviewed on 9/26/19 at 2:01 PM, certified nurse aide (CNA) #4 stated staff knew how to provide resident specific care by looking at resident care instructions and the instructions would include any equipment a resident needed. She stated the resident's hand splint was kept in the resident's room or in the treatment cart and only the nurses were to put it on the resident and sign for it. When interviewed on 9/26/19 at 11:47 AM, the resident's family member stated the resident was supposed to have a soft palmer splint in her hand. Sometimes it was in the wrong hand and he had not seen it on her in a couple of weeks. He would visit with the resident at least 4 hours every day. He stated the resident had pain when staff put the splint on initially, but she had no pain once it was on. He stated the resident could not open either hand by herself and her ability to do so had declined since not wearing the soft palmer splint. When interviewed on 9/26/19 at 2:23 PM and 3:37 PM, licensed practical nurse (LPN) Assistant Nurse Manager #5 stated she did not apply the resident's soft palmer splint that morning as she could not find the splint. She stated she checked with laundry and the resident's room and could not find the splint. She went to therapy, told them she could not find the splint and asked if they had another one. She expected staff to put either a rolled towel or washcloth in the resident's palm until a soft palmer splint could be obtained from therapy. The resident could have skin breakdown, or the contractures could worsen if something was not in place. When interviewed on 9/26/19 at 2:29 PM and 3:25 PM, LPN #6 stated she had done treatments on 9/25/19 and she could not find the resident's right-hand splint. She informed LPN Assistant Nurse Manager #5 who told her she would follow up with therapy. Without the hand splint, the resident's nails could dig in to her palm, and the resident could lose more function of her fingers if they became more contracted. LPN #6 stated she should have rolled up a washcloth and placed it in the resident's palm. When interviewed on 9/26/19 at 3:25 PM, occupational therapist (OT) #7 stated a soft palmer splint was used for positioning for finger contractures. Therapy had an extra stock of soft palmer splints. She stated she was just made aware earlier in the day the resident did not have a palmer splint. She stated staff could use a rolled wash cloth or towel in lieu of the splint. 10NYCRR 415.12(e)(2)

Based on observation, record review, and interview during the recertification survey, the facility did not maintain drug and biological storage and labeling in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage room observed for medication storage and labeling. Specifically, one vial of purified protein derivative (PPD, used to determine exposure to [MEDICAL CONDITION]) was opened and undated. Findings include: The ,[DATE] revised Drug and Biological Storage policy documented once an injectable drug is opened the date the vial was opened, the expiration date, and the initials of the nurse, shall be placed on the vial. All injectable drugs shall be discarded after 28 days. During an observation of the medication room on [DATE] at 9:00 AM with licensed practical nurse (LPN) #1, one opened vial of [MEDICATION NAME] protein derivative was not dated or initialed to indicate when it was opened and there was no date or initials on the box the vial was in. During an interview with LPN #1 on [DATE] at 9:10 AM, she stated the PPD vial should have been dated and initialed by the nurse that opened the vial. She stated the night nurse generally looked at the medications in the refrigerator and she did not know why the vial was not dated. She stated the test result could have been incorrect if expired PPD was used. During an interview on [DATE] at 9:30 AM, the Director of Nursing (DON) stated when a vial of any kind was opened, the vial and box should be dated and initialed by the nurse. She stated the medication nurses on evening and night shift inspected the contents of the refrigerator for expiration dates and labeling. 10NYCRR 415.18(d)(e)(,[DATE])

Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure 1 of 10 sampled residents (Resident #3) was free of significant medication errors. Specifically, Resident #3 had a physician order [REDACTED]. Findings include: Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, required extensive assistance for most activities of daily living (ADLs), and did not experience shortness of breath or trouble breathing. A physician order [REDACTED]. The physician order [REDACTED]. The MAR indicated [REDACTED]. The physician orders [REDACTED]. The 7/2016 - 12/2017 MARs documented [MEDICATION NAME] sulfate 2.5 mg/3 ml vial via nebulizer every 4 hours prn. The instructions on the MAR indicated [REDACTED]. A physician order [REDACTED]. During an interview with licensed practical nurse (LPN) #1 on 4/10/2017 at 9:10 AM, she stated the night shift nurse would check all the resident MARs when the new monthly MARs came in, and compare them to the physician orders [REDACTED]. She stated the LPNs on the other shifts were responsible for doing a second check to ensure the MARs correctly reflected the physician orders. The LPN reviewed the resident's [MEDICATION NAME] order on the physician order [REDACTED]. She did not know why the medication was only on the MAR indicated [REDACTED] During an interview with LPN Unit Manager on 4/10/2017 at 9:15 AM, she stated the [MEDICATION NAME] order read as to be administered routinely every 4 hours. She thought the medication was only prn, and that was why it was on the MAR indicated [REDACTED] During an interview with registered nurse (RN) Supervisor on 4/10/2017 at 9:30 AM, she stated the MARs were compared with the physician orders [REDACTED]. She stated the LPN on the night shift did the first check, and the second checks were completed by other LPNs on the other shifts. The RN reviewed the physician order [REDACTED]. The RN reviewed the MAR, and stated she would expect the LPNs to question the order when they noticed the physician order [REDACTED]. 10NYCRR 415.12(m)(2)

Based on record review and interview conducted during the recertification survey, it was determined the facility did not ensure that recommendations made by the pharmacist for the monthly MRR (medication regimen review) were acted upon or addressed by the attending physician in a timely manner for 1 of 10 (Resident #3) medication regimens reviewed. Specifically, Residents #3 had pharmacy recommendations requiring physician intervention and the recommendations were not responded to in a timely manner by the physician. Findings include: Resident #3 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, required extensive assistance for most activities of daily living (ADLs), and did not experience shortness of breath or trouble breathing. A physician order [REDACTED]. Nursing progress notes documented the following: - On 6/14/2016 at 1:06 PM, the resident had wheezing in her lungs, and decreased air exchange in lower lobes. The physician was called, who ordered a chest x-ray, albuterol treatment, and oxygen checks. - On 6/14/2016 at 9:31 PM, the chest x-ray results were negative. Albuterol was administered at 8:00 PM for wheezing in bilateral upper lobes with positive results. - On 6/16/2016 at 1:57 AM, the resident's lungs were clear with no cough. - On 6/16/2016 at 6:45 AM, no respiratory symptoms noted. - On 6/17/2016, the resident's breath sounds were clear, with no cough or congestion noted. Staff were to encourage coughing and deep breathing, and nebulizer treatment per physician order. - On 6/29/2016 at 8:59 AM, the resident was seen by the attending physician for a 30 day renewal and there were no changes made. A pharmacy consultation report dated 9/26/2016 documented the order for albuterol sulfate administered via nebulizer appeared to have been initiated during an acute respiratory illness. The acute symptoms had resolved. The recommendation was to consider discontinuing the medication if the condition had improved. There was no documented response from the physician. A pharmacy consultation report dated 1/20/2017 documented the order for albuterol sulfate administered via nebulizer appeared to have been initiated during an acute respiratory illness. The acute symptoms had resolved. The recommendation was to consider discontinuing the medication if the condition had improved. The physician signed the form on 2/1/2017. A physician order [REDACTED]. During an interview with licensed practical nurse (LPN) Unit Manager on 4/10/2017 at 9:15 AM, she stated the pharmacy recommendations were placed in the physician's box or on the front of the chart for the physician to review when he came to evaluate the resident. She stated the physician would then document his response to the recommendation at that time. She stated she did not know why the recommendation from 9/26/2016 had not been addressed. During an interview with the registered nurse (RN) Supervisor on 4/10/2017 at 9:30 AM, she stated the pharmacist came in to review medication regimens monthly. If any recommendations were made, they were emailed to the Director of Nursing (DON) and then she would bring them to the unit. She stated the recommendations were then placed in the front of the resident's chart and reviewed when the resident was evaluated by the physician at the 60 day evaluation. During an interview with the consulting pharmacist on 4/10/2017 at 10:00 AM, she stated she did medication regimen reviews monthly for every resident. She stated if any irregularities were noted, she would send a recommendation to the physician and the recommendation was sent to the DON to distribute. She stated she would follow up on her next visit to ensure the recommendation was addressed, and she would send the physician another one if it was not. During an interview with the DON on 4/10/2017 at 10:30 AM, she stated approximately one year ago she had identified the MMR recommendations were not getting completed timely. The plan was made to put the recommendations in a weekly folder for the physician to review, and he could not wait for the resident's 60 day evaluation to review it. She stated both the LPN and RN on the unit were aware of that process. 10NYCRR 415.18(c)(1)

Based on observation, interview and record review conducted during the standard survey, it was determined the facility did not assure extensive time lapses between meals was approved by the residents, and did not assure snacks were routinely provided between supper and bedtime for 4 of 5 anonymous residents in attendance at the resident group meeting. Specifically, the mealtimes exceeded 14 hours between a substantial evening meal and breakfast the following day; the residents did not agree to this meal span, and nourishing snacks were not consistently provided as required. Findings include: On 2/17/2016, the supper meal was observed being served to the residents at 5:05 PM in the dining room. On 2/18/2016, residents were observed continuing to be served breakfast in the dining room at 8:25 AM. During the resident group meeting on 2/18/2016 at 10:30 AM, held with 5 anonymous residents present, 4 of those 5 residents stated they were not routinely offered a snack between supper and bedtime. One resident stated staff used to come around and offer each resident something, but now you had to ask if you wanted anything. The residents said the meals were 8 AM, 12 PM and 5 PM. They did not recall attending a Resident Council Meeting, or a food committee meeting, within the past year, that approved the hours of the meals. The Facility Survey Report, signed 2/18/2016, and provided to the surveyors, documented mealtimes were at 8 AM, 12 PM and 5 PM. During an interview with the Director of Dining Services on 2/19/2016 at 12:15 PM, he stated he had not discussed mealtimes with the residents at the food committee meetings. Snacks were brought to the unit once a day at approximately 1:30 PM. He said if staff needed more than what was on the unit, nursing called the kitchen and requested what was needed. Review of the Resident Council Meeting minutes, and the food committee minutes, from January 2015 through January 2016, revealed no documented evidence the residents approved the mealtimes, scheduled over 14 hours between supper and breakfast. 10NYCRR415.14(f)(2)(3)(4)

Based on interview, observation, and record review conducted during the standard survey, it was determined for 3 of 5 anonymous residents at the group meeting, the facility did not make prompt efforts to resolve grievances regarding concerns with the air temperature of the shower rooms. Specifically, 3 of 5 anonymous residents stated their shower room was cold; this same concern was previously identified by the residents without resolution. Findings include: Review of the Resident Council Meeting minutes revealed residents expressed a concern regarding the shower room air temperatures on 1/20/2015, 2/17/2015, 3/17/2015 and 4/21/2015. The action plan on 4/21/2015 was for heat lamps were to be installed with a compliance date of 4-6 weeks. The residents continued to express a concern regarding the shower room being cold on 5/19/2015. During the resident group meeting held on 2/18/2016 at 10:30 AM with 5 anonymous residents in attendance, 3 of the 5 residents stated it was often cold in the shower rooms. They stated they informed staff they were cold when given their showers. The residents said they had discussed this concern at previous Resident Council Meetings, and no changes had been made. On 2/19/2016 between 12:00 and 12:05 PM, a surveyor observed the facility's 2 shower rooms: - there were no heat lamps in the tub/shower room; and - there were no heat lamps in the shower room. The Maintenance Director was unavailable for interview on 2/19/2016. The Housekeeping Supervisor was interviewed on 12/19/2016 at 12:30 PM. She stated she was not aware the residents had complained about the shower rooms being cold; she also was unaware there was a plan to install heat lamps in the 2 bathing rooms. During an interview with the Administrator on 2/19/2016 at 1:25 PM, she stated the maintenance department had started the project, was having trouble getting parts for the heat lamps for the shower room. There was no time frame provided for resolution of the cold shower rooms. During an interview with certified nurse aide (CNA) #8 on 2/19/2016 before the evening meal, he stated residents have complained that the shower room near room [ROOM NUMBER] gets freezing cold, especially once the residents were wet. During an interview with CNA #9 on 2/19/2016 before the evening meal, he stated residents complain of the shower room near room [ROOM NUMBER] being cold, even before they begin their shower. 10NYCRR 415.3(c)(1)(i)

Based on observation, interview and record review conducted during the standard survey, it was determined the facility did not provide the necessary services to maintain personal grooming and hygiene needs for 1 of 9 residents (Resident #5) reviewed for activities of daily living (ADLs). Specifically, Resident #5 did not receive the necessary assistance to meet the resident's toileting needs. THIS IS A REPEAT DEFICIENCY FROM THE 12/30/2014 SURVEY Findings include: Resident #5 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, exhibited behavioral symptoms not directed toward others, and required extensive assistance with transfers, mobility, and toileting. The resident was always incontinent of both urine and bowel. The comprehensive care plan (CCP) updated 1/27/2016 documented the resident required the extensive assistance of one person for toileting, and was to be toileted every 2 to 4 hours and as needed. The resident care assignment sheet (care instructions) dated 2/16/2016 documented the resident required extensive assistance of one person for toileting. There were no further directives related to the resident's toileting needs. The resident was observed on 2/17/2016 seated outside her room in her scoot chair from 2:30 PM through 4:35 PM. At 4:35 PM, CNA #8 was observed transporting the resident from outside her room into the dining room. The resident remained seated in the dining room at her table until 6 PM. At 6 PM, CNA #8 entered the dining room to transport residents back to the unit and informed Resident #5 he would be right back to get her. At 6:10 PM, the resident was observed transported back from the dining room to the hallway outside her room. The resident remained seated in the same location in the corridor at 7 PM. At 7 PM, the social worker brought the resident into her room, and back out of her room at 7:10 PM. During this time period, staff approached the resident to offer her candy and drinks. Staff were not observed approaching the resident to meet her toileting needs. During an interview with CNA #8 on 2/18/2016 at 6:15 PM, the CNA stated the resident usually refused being changed and, if so, it was documented in the computer. The CNA said on the 3 to 11 PM shift, the resident often was not toileted/changed until after the supper meal, when she was assisted with bedtime (HS) care. The computer documentation for toileting and behaviors did not document the resident's refusal of care for 2/18/2016. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interview conducted during the standard survey, it was determined the facility did not ensure abilities in activities of daily living (ADLs) did not diminish unless unavoidable for 2 of 9 residents (Residents #5 and 10) reviewed for ADLs. Specifically, Resident #5 was not positioned in the dining room in a manner that promoted independent eating; and Resident #10 was not ambulated as planned. Findings include: 1) Resident #10 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment and required extensive assistance with all ADLs, including ambulation in her room and in the corridor. The resident used a walker and a wheelchair. On 10/26/2015 at 9:40 PM, a nursing note documented the resident was standing at the bar in the bathroom, when her legs buckled and the resident was lowered to the floor by the certified nurse aide (CNA). The resident was assessed and was assisted to bed with 3 staff members and the use of the Hoyer lift (mechanical lift). The incident report dated 10/26/2015 documented the resident's legs buckled and she was lowered to the floor. Physical Therapy (PT) was contacted to evaluate the resident's transfer status. A PT plan of care, dated 10/27/2015, documented the resident was referred as a result of a decline in her functional abilities for transfers and ambulation, due to sedentary lifestyle and knee pain. The physical therapist documented nursing noticed a decrease in the resident's mobility over the past few days, with a need for increased assistance. The plan was to provide PT to increase the resident's strength and coordination, to improve mobility and return to her previous level of functioning. The resident's prior level for gait distance was 100 feet and the current was documented as unable. The resident previously required contact guard for transfers and current level of functioning was a total assistance. The plan was for skilled PT 5 times a week for 4 weeks, with a goal for the resident to ambulate 10 feet safely with a wheeled walker and moderate assistance. The PT plan of care was updated on 11/23/2015 and documented the resident initially declined in her functional mobility; and just recently, started to improve with transfers and gait. Further PT was recommended. On 12/21/2015, an updated PT plan of care documented the resident was eager to participate in PT treatment to improve her mobility. The resident was showing improvement, and no longer required the sit to stand mechanical lift for transfers; and was walking with the assistance of one. The resident was to continue 5 days a week for 4 weeks as previous treatment demonstrated positive results; the goal was upgraded for improve ambulation, bed mobility and transfers. A PT plan of care updated 1/21/2016 documented the resident was beginning to plateau and the resident was educated on the upcoming discharge, transitioning to a nursing plan of care on the unit. The PT discharge summary dated 1/27/2016 documented the resident showed progress during the course of treatment. She improved from non-ambulatory to being able to walk 10 to 20 feet with minimum assistance; she was discharged from PT and was on an ambulation program. The PT nursing plan of care dated 1/27/2016 documented the resident was to ambulate twice a day with minimum assistance of 1 at least 10 feet, with pedal chair to follow. The resident care assignment sheet (care instructions) dated 2/16/2016 documented the resident was to be ambulated twice a day with extensive assist of 1, using a wheeled walker at least 10 feet with a pedal chair to follow. The resident's ADL documentation from 1/27/2016 through 2/18/2016 documented activity did not occur, pertaining to the resident walking in her room or in the corridor. There was no documented evidence the resident ambulated on the unit following the discharge from physical therapy. The behavior charting for 10/1/2015 through 2/19/2016 documented the resident refused ambulation on one occasion, 2/19/2016 at 11:37 AM. The resident was observed seated in a Broda (positioning) chair on 2/17/2016 in the dining room at 1 PM; on 2/18/2016 at 10:30 AM; and on 2/18/2016 at 2:30 PM, seated at a table in the family room, at a therapeutic recreation program. The resident's family member was interviewed on 2/18/2016 at 2:30 PM. She stated the resident fell at the end of October 2015 and was started back in physical therapy. She stated the resident improved when she was in therapy, and the family member recently observed the resident's strength was decreasing again. She said she spoke to physical therapy and requested the resident return for maintenance therapy. Although informed they would need to pay privately for maintenance therapy, the family (with the resident's approval) agreed to have the resident return to therapy one day a week, to see if it was beneficial. During an interview with the physical therapist on 2/19/2016 at 10:35 AM, he stated the resident was recently reassessed for a maintenance program, per family request. He said when the resident was discharged from therapy, a nursing plan of care was sent to the nursing department. The plan for the resident to ambulate on the unit was added to the certified nurse aide (CNA) assignment sheet. He said if there was a trend of the plan not being followed, he was to be informed by nursing and he then would look into the situation. The physical therapist stated sometimes a resident cooperated for the therapist and did not cooperate with the CNA. The physical therapist was not aware that Resident #10 had not been ambulating on the unit. During an interview with CNA #11 on 2/19/2016 at 10:05 AM, she stated the care plan documented a resident's ambulation plan: how the resident ambulated and how many times. When the care was provided, the CNA documented the activity in the computer, if the resident ambulated in the corridor or in the room. If the resident refused, it was documented in the behavior charting refused ambulation. She stated she was familiar with Resident #10. After reviewing the care assignment sheet, CNA #11 stated the resident was to ambulate 10 feet in the afternoon, with the extensive assistance of 2 with a chair behind her. She stated the resident refused frequently due to her anxiety and re-approaching her was not usually helpful. A policy for the ambulation program was requested of the administrator on 2/19/2016. The surveyor was informed there was no policy for the ambulation program. 2) Resident #5 had [DIAGNOSES REDACTED]. An occupational therapy (OT) evaluation/nursing plan dated 11/10/2015 documented the resident was in a scoot chair and the chair was to be elevated at all meals. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive deficit, required supervision for meals, and required extensive assistance with all other activities of daily living. The resident was in a wheelchair for mobility. The comprehensive care plan (CCP) dated 1/27/2016 documented the resident needs supervision at meals, she was to be encouraged to participate at her optimal level, and her chair was to be elevated for all meals. The certified nurse aide (CNA) care assignment sheet (care instructions) updated 2/16/2016 documented the resident's chair was to be elevated for all meals. The resident was observed seated at the dining room table, at chest height, in her scoot chair on: 2/17/2016, from 12:15 PM to 1 PM, and from 5:05 PM to 6 PM; and on 2/18/2016, from 8:25 AM to 8:33 AM. The resident's intake at 2 out of the 3 meals was minimal. During an interview with the occupational therapist (OT) on 2/19/2016 at 11 AM, she stated she observed positioning at meals all the time ,and provided a detailed plan to nursing and dietary for how residents should be seated. She stated she thought Resident #5 had previously been at a table that was lower and a better height for her; she said this changed approximately a month ago. The OT did not think the resident would cooperate being transferred out of the scoot chair to a dining chair, as the resident was often anxious and resistive to care. She stated she would attempt to transfer her to a regular dining chair during the noon meal, and see if the resident was accepting. As the OT was walking out of the resident dining room on 2/19/2016 at 12 PM, she told the surveyor that she had just transferred the resident to a dining chair; the resident's positioning height was improved, and the resident was happy with the change. 10NYCRR 415.12(a)(1)(iv)

Based on observation, interview, and record review conducted during the standard survey, it was determined the facility did not ensure 1 of 9 sampled resident rooms (Resident #9's room) was maintained in sanitary and orderly condition. Specifically, the floor surface in Resident #9's room had a large unsightly crack in the floor tiles that extended diagonally across the room. Findings include: Resident #9 had [DIAGNOSES REDACTED]. The 2/10/2016 Minimum Data Set (MDS) documented the resident had moderately impaired cognition, did not ambulate, had limited range of motion on one side of her body, and was extensive assist with activities of daily living (ADLs). The updated 2/16/2015 Kardex (care instructions) documented the resident used a mechanical lift for transfers and was non-ambulatory. A surveyor observed a 12 foot long crack in the floor surface on 2/17/2016 between 2:15 and 2:30 PM. The Director of Maintenance was present at the time of the observation and stated he was unaware of the crack in the floor. During another observation of the resident's room on 2/19/2016 at 9:15 AM, there was a crack in the floor tiles running diagonally across the room and was approximately 12 feet long and was 4 inches x 0.8 inches high in 2 areas of the crack. The crack separated the door area from the bed, nightstand, and overbed table. When interviewed on 2/19/2016 at 10:35 AM, certified nurse aide (CNA) #1 stated issues with room conditions were communicated by filling out a work order, and the maintenance work log was at the nursing station. She stated the resident was transferred with a mechanical lift. She stated the crack in the floor had been there for several years, was unsightly, and she was unaware if a work order was initiated to repair the floor. When interviewed on 2/19/2016 at 11 AM, the Housekeeping Supervisor stated she was responsible for directing maintenance issues to the maintenance workers, reviewing work orders, and placing work orders in Facility Dude (an electronic maintenance request system). She was aware of the cracked floor in Resident #9's room; she was unaware of how long the crack had been present, and said a work order was initiated the previous week to repair the floor. The Housekeeping Supervisor stated the facility replaced all the room floor tiles with new floor surfaces on an as needed basis, and usually replaced the floor tiles before a new resident moved into a room. The surveyor received a printed email from the Housekeeping Supervisor on 2/19/2016 at 1 PM, documenting a work order was initiated on 2/17/2016 at 7:58 PM for the floor in Resident #9's room. The email documented the facility needed to schedule repair for the floor/install new flooring. The email was initiated following the observation of the surveyor and the Director of Maintenance on 2/17/2016. 10NYCRR 415.29(j)(1)

Based on record review and interview conducted during the standard survey, it was determined the facility did not ensure all alleged violations involving mistreatment, abuse, and neglect were thoroughly investigated for 1 of 10 residents (Resident #4) reviewed for abuse/neglect and mistreatment. Additionally, for 1 of 4 contract employees (Employee #6), the facility did not ensure required resident abuse prevention orientation was completed. Specifically, there was no documentation a thorough and complete investigation was conducted when Resident #4 was found with bruises of unknown origin. Additionally, there was no documented evidence Employee #6 received resident abuse prevention orientation prior to beginning employment at the facility. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF 12/30/2014 Findings include: 1) Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, exhibited physical behavioral symptoms directed toward others, and rejected care. The resident required limited to extensive assistance with activities of daily living (ADLs). A nursing progress note dated 1/25/2016 documented the resident was uncooperative when approached for care and refused to allow staff to change her brief and gown. The plan was to reapproach the resident later in the shift as attempts to increase the resident's compliance were unsuccessful. The comprehensive care plan (CCP) updated on 1/27/2016 documented the resident required the extensive assistance of 1 person for transfers, dressing and toileting. The resident exhibited inappropriate behaviors as evidenced by hitting staff, and verbal aggression towards staff and family. The CCP documented the resident was resistive to care and would hit, kick, pinch staff. The resident was to be approached in a calm, positive manner, given time to respond, and redirected when demonstrating inappropriate behaviors. When behaviors were present, staff were to make sure the resident was safe and leave and reapproach later. The CCP documented on 1/19/2016, the resident continued to be abusive to staff during care and additional staff interventions included avoiding situations that caused stress, explaining care as it was being provided, and maintain a calm environment. A social work progress note dated 1/29/2016 documented the resident continued to be very resistive to care and physically aggressive with staff when they provided care. On 2/5/2016, a nursing note documented the resident hit and pinched the licensed practical nurse (LPN) during a fingerstick. The resident was yelling and aggressive when the certified nurse aide (CNA) toileted the resident. On 2/7/2016, a nursing progress note documented the resident was pinching, kicking and grabbing at staff during personal care. There were no further nursing behavior notes documented in the resident progress notes. The resident care assignment (care instructions) dated 2/16/2016 did not document any behavior plan for the resident, or specific approaches to use when providing care. The CNA incident behavior documentation for the resident, from 2/8/2016 through 2/17/2016, documented the following: - On 2/8 at 9:52 AM, the resident was hitting/slapping, kicking staff from the wheelchair, pinching, grabbing, scratching, screaming and biting. - On 2/13/2016 at 9:56 AM, the resident was hitting/slapping, kicking staff from the wheelchair, pinching/grabbing, scratching, and screaming/biting. - On 2/14/2016 at 10:11 AM, the resident was hitting/slapping, kicking staff from wheelchair, pinching, and grabbing. - On 2/17/2016 at 10:05 AM, the resident was hitting/slapping, kicking staff from the wheelchair, pinching/grabbing, scratching people, screaming/biting, and banging walls. On 2/17/2016 at 12:15 PM, the resident was observed sitting at the table in the dining room with her family member. The back of the resident's hands were bruised: the top of her right hand was purple, and the top of her left hand was yellowish/purple. The resident and family member stated they did not know how the bruises occurred. During an interview with the Charge licensed practical (LPN) on 2/18/2016 at 5:25 PM, she stated she was unaware of any bruising on Resident #4's hands. She stated if it was reported to any of the nurses by the CNAs, a progress note would have been documented and an incident report would have been initiated. The LPN questioned if it was from laboratory (lab) work and, upon reviewing the resident's chart, stated the resident had not had any lab work since 1/11/2016. The Charge LPN stated there was no documented evidence of the resident's bruising, and no evidence an incident report was initiated related to the resident's bruised hands. During an interview with CNA #10 on 2/19/2016 at 1:30 PM, she stated she observed the resident's bruises earlier in the week and forgot to report it to the supervisor. The CNA stated the resident was frequently combative with care, and she currently requested a second nurse or CNA with her whenever she provided care to the resident. 2) Employee #6 worked at the facility as a contract security guard. On 2/18/2016 at 10 AM, the surveyor requested to review the personnel folder and abuse training for Employee #6. The housekeeping supervisor, who was covering for the Director of Maintenance, informed the surveyor that the employee had undergone a background check through the security company and showed the surveyor a letter documenting the background check was completed on 2/5/2016. The housekeeping supervisor stated the company would not provide the personnel folder to the facility, but did provide documentation the background check was done. On 2/18/2016 at 3:45 PM, the Director of Nursing (DON) stated the facility did not provide abuse orientation to contract security personnel. On 2/19/2016 at 10:50 AM, the Administrator stated the facility could not provide proof the abuse orientation was done for their security employees. She stated the contract security employees should have abuse prevention orientation provided to them by the facility. 10NYCRR 415.4(b)(1)(ii)

Based on observation, record review, and interview conducted during the standard survey, it was determined the facility did not provide the necessary care and services to 1 of 10 residents (Resident #5) reviewed for quality of care, to attain or maintain their highest practicable physical well-being. Specifically, Resident #5 was not weighed for more than 9 months as part of comfort care measures, without documented rationale or timely re-evaluation. Additionally, there was no documented evidence: - it was the resident's wishes not to be weighed; - the resident's surrogate was educated on the rationale for weighing the resident; - the comfort care measures were re-addressed when the resident's medical status stabilized; - the resident's nutritional status was accurately assessed, as nutrient content of her daily intake was not determined and the nutritional assessment was based on a weight from 9 months ago. Findings include: Resident #5 had [DIAGNOSES REDACTED]. A social work progress note dated 5/4/2015 documented the resident was admitted following a hospitalization for a fractured left humerus. The resident's health care proxy (HCP) completed the MOLST (Medical Orders for Life Sustaining Treatment) form and included comfort measures. The social work documented the resident's comfort measures were: Do Not Resuscitate (do not begin cardio-pulmonary resuscitation), Do not intubate (tube inserted in throat to assist breathing), no tube feeding (artificial nutrition), no intravenous (IVs), and no hospitalization . The progress note did not address a request for no vital signs, no weights, or no laboratory (lab) work. The physician's admission history and physical dated 5/6/2016 documented the resident had a left humerus fracture treated conservatively with a sling. The physician spoke to the resident's HCP; she requested comfort measures only; and a MOLST was completed. The comfort measures included no hospitalization s, DNR, no tube feedings, no IVs and medications for her anxiety and pain control only. The physician documented the resident was comfort measures only and no labs were to be done. The additional instruction of no labs was not included/documented in the MOLST orders. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, required extensive assistance with activities of daily living (ADLs), and weighed 104 pounds. A social work progress note dated 5/20/2015 documented an initial team meeting was held and the resident's family members were present via conference call. The discussion included the resident's dietary status, and the resident's need for re-direction to stay for an entire meal. There were no concerns about the resident's weight of 104 pounds. A medical progress note dated 5/27/2015 documented the resident was comfort care including no vitals, and weight was not done due to comfort/palliative care. There was no documented evidence these directives were discussed with the resident's health care proxy. The comprehensive care plan (CCP) updated 12/2/2015 documented the resident had the potential for impaired skin integrity and the plan included providing and encouraging adequate oral intake to meet the resident's estimated needs per the nutritional assessment. The CCP documented the resident was at nutritional risk related to leaving 25% or more uneaten at meals and a [DIAGNOSES REDACTED]. physician progress notes [REDACTED]. There was no documented evidence the HCP was involved in a discussion for no vital signs to be done or for the resident was not to be weighed, due to end of life. A nutrition progress note dated 1/13/2016 documented the resident was not being weighed and her needs were based on her last known weight (May 2015) to maintain that weight. The resident's intake for the previous week averaged 47%. The resident's current intake assessment was documented as her norm and no changes were made since the previous review. The resident was to be monitored at meal rounds and for any changes in nutritional status. The resident was designated to be at moderate nutritional risk. The MDS dated [DATE] documented the resident required supervision for meals, and continued to need extensive assistance with all other ADLs. No weight was documented on the MDS. The physician orders [REDACTED]. The resident was observed on 2/17/2016 seated at the table in the dining room from 12:30 PM to 1 PM. The resident's meal was in front of her and she was observed eating her dessert; she did not eat the entree. When the resident was observed with her eyes closed on 2/18/2016 at 8:25 AM as she sat in the dining room. At 8:26 AM, the resident was served scrambled eggs, toast and bacon. At 8:33 AM, the resident remained with her eyes closed and did not eat the meal in front of her. During an interview with the registered dietitian (RD) on 2/19/2016 at 12:50 PM, she stated the resident had not been weighed since she was admitted to the facility. The RD said she was not involved in the determination for no weights and never pursued it as the resident was not a big nutrition concern. She said she observed her frequently and the resident did not necessarily eat well at meals; she ate between meals. The RD said, per her visual observation, the resident had not changed. During an interview with the social worker on 2/19/2016 at 1:05 PM, she stated she spoke with the resident's family upon admission and discussed comfort care measures with the health care proxy. She said at the time of admission, the resident's condition was fragile and the HCP wanted to keep her comfortable. She said the resident had been stable for some time, and the comfort care measures had not been readdressed with the family since the time of admission. 10NYCRR 415.12

Based on observation and interview conducted during the standard survey, it was determined the facility did not ensure food was stored and served under sanitary conditions for the facility's 1 unit kitchenette (family room). Specifically, outdated food was present in the refrigerator in the family room on the resident unit. Findings include: On 2/19/2016 at 12 PM, the following resident food items were observed in the family room refrigerator: - a tuna fish salad sandwich on white bread dated 2/15/2016; - a tuna fish salad sandwich on wheat bread dated 2/15/2016; - an egg salad sandwich on wheat bread dated 2/15/2016. During an interview with the Director of Dining Services on 2/9/2016 at 12:15 PM, he stated snacks were placed in the refrigerator daily at approximately 1:30 PM and included 3 to 4 sandwiches. The dietary staff person placing the items in the refrigerator was to discard items that were outdated. He said they used the 3 day rule for discarding food; sandwiches dated 2/15/2016 should have been discarded no later than 2/18/2016. The Director of Dining Services said he checked the refrigerators periodically to ensure the items in the refrigerator were dated appropriately. He was not aware of any problem when he checked the refrigerators, and was not informed by his staff of any problem. NYCRR 415.14(h) 10NYCRR 415.14(h)