Every finding on record at Penfield Place

Based on observations, interviews, and record review conducted during the Recertification Survey from 01/27/2025 to 01/31/2025, for one (Resident #13) of five residents reviewed, the facility did not ensure a resident was clinically appropriate to self-administer medications. Specifically, Resident #13 was observed to have multiple medications left on their bedside table and there was no documented evidence their ability to self-administer medications had been assessed or care planned for. This is evidenced by the following: Review of the facility policy Comprehensive Care Plan, dated November 2016, revealed the Comprehensive Care Plan for each resident would include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that were identified on the comprehensive assessment. The care plan would be reviewed and updated as necessary on a quarterly basis and the ability to self-medicate would be reviewed at each care conference. Resident #13 had diagnoses that included dementia with mood disturbance, depression, and diabetes mellitus. The Minimum Data Set Resident Assessment, dated 10/26/2024, included the resident was cognitively intact and took high risk medications including an antidepressant, diuretic (medications that help the kidneys remove extra water and salt through the urine), and hypoglycemic (a medication that reduces the amount of sugar present in the blood). Review of the current Comprehensive Care Plan, initiated on 12/29/2024, did not include measurable goals or interventions for Resident #13 to self-administer medications. Review of current medical orders, did not include an order for Resident #13 to self-administer medications. Additional review of Resident #13's electronic health record did not include documentation of an interdisciplinary team decision that the resident was clinically appropriate to self-administer medications. During an observation and interview on 01/30/2025 at 10:13 AM, Resident #13 was sitting in their room and an unlabeled undated medicine cup that contained approximately 18 pills, including but not limited to, several Tylenol tablets and a Metformin (an anti-diabetic medication) tablet, was on their bedside table. There was no nurse in the area or in site at that time. Resident #13 stated they did not know all of the medications they were taking and pills were often left for them to take unsupervised depending on the nurse (who administered the medications). Resident #13 stated they were slow to take their pills because they preferred to wait until they had something to eat. During an interview on 01/30/2025 at 10:30 AM, Licensed Practical Nurse #1 stated Resident #13 had not eaten yet and took a long time to take their pills. Licensed Practical Nurse #1 stated they had left pills with the resident before, but knew residents needed to be evaluated and approved by a medical provider before taking their medications unsupervised. During an interview on 01/30/2025 at 12:42 PM, the Director of Nursing stated for residents to have medications left at their bedside unsupervised, they should be alert and oriented, know their medications, and have a care plan in place (to self-administer). During an interview on 01/31/2025 at 10:22 AM, Physician Assistant #1 stated they did not know Resident #13 very well, but the resident previously had a medical order to leave medications at their bedside. Physician Assistant #1 stated following an assessment of Resident #13 earlier in the day, they thought the resident had experienced some changes in their cognition and awareness. During an interview on 01/31/2025 at 12:59 PM, the Director of Nursing stated they were unable to find documentation Resident #13 had been assessed for their ability to self-administer medications. The Director of Nursing stated an assessment should have been completed and a care plan initiated before medications were left at the bedside. 10 NYCRR 415.3(f)(1)(vi)

Based on observations, interviews, and record review conducted during a Recertification Survey from 01/27/2025 to 01/31/2025, for one (Resident #13) of one resident reviewed for oxygen use, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs including resident goals, desired outcomes and preferences. Specifically, there was no comprehensive care plan including goals and interventions for the resident's respiratory disease and oxygen therapy requirements. This is evidenced by the following: Review of the Comprehensive Care Plan Policy, revised November 2016, documented in part, it is the policy of this facility that each resident has an interdisciplinary, comprehensive care plan. The care plan summarizes the team approach to active and /or potential problems or concerns based on the Care Area Assessments as per regulatory requirements. The Comprehensive Care Plan for each resident includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified on the comprehensive assessment. The Certified Nurse Assistant Resident Care Plan is also a part of the Comprehensive Care Plan which includes specific schedules/actions necessary to provide resident care. Resident #13 had diagnoses that included acute respiratory failure with hypoxia (decreased oxygen in the body), pulmonary emboli (blood clot to the lungs), wheezing and anxiety. The Minimum Data Set Resident Assessment, dated 10/26/2024, revealed Resident #13 was cognitively intact and received oxygen therapy. Review of current physician's orders, initiated 05/14/2024, documented oxygen per nasal cannula at two liters for comfort around the clock (nights, days, evenings shifts). Review of Resident #13's current (undated) Comprehensive Care Plan, and the Certified Nurse Assistant Resident Care Plan, did not include any information related to the resident having a respiratory related medical condition or that they were receiving oxygen therapy around the clock. During an observation on 01/27/2025 at 10:24 AM, Resident #13 was sitting in their wheelchair in their room. The resident was receiving oxygen via nasal cannula from an oxygen concentrator at two liters. The humidifier bottle (water bottle that delivers humidified air to the oxygen) attached to the oxygen concentrator was completely empty of water and unclean. During an observation on 01/29/2025 at 1:25 PM, Resident #13 was asleep in bed with their nasal cannula in place receiving oxygen at two liters. During an interview on 01/29/2025 at 3:05 PM, the Director of Nursing stated the facility was in the process of switching electronic health records software and even if the resident's information had not yet switched over, both electronic health records should have the same up to date information. During an interview on 01/30/2025 at 10:30 AM, Licensed Practical Nurse #1 stated Resident #13 always wore oxygen and they should be care planned for it, and their nursing interventions should include their oxygen settings, how often to change the tubing, and if they required humidification. During an interview on 01/30/2025 at 12:42 PM and again at 3:43 PM, the Director of Nursing stated the nurse managers were responsible for initiating the care plans, and afterwards other members of the interdisciplinary team should add to the care plan. Resident #13 should have been care planned for oxygen with interventions to fill the humidifier bottle every shift and change the humidifier bottle and oxygen tubing once weekly. The Director of Nursing stated prior to today, Resident #13 did not appear to be care planned for oxygen, but should have been and it was an oversight. 10 NYCRR 415.11(c)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey completed 5/4/23 to 5/10/23, it was determined that for two (north and east halls) of four resident units, the facility did not ensure that the resident environment remained free of accident hazards. Specifically, hot water temperatures exceeding 120 degrees Fahrenheit ( F) were accessible to residents at point of use. The findings are: Observations, interviews, and record review on 5/4/23 from 11:08 a.m. to 4:06 p.m. included the following: Water temperatures at point of use (sinks, showers, tubs) using a [NAME] model 9842 digital thermometer were as follows: resident room [ROOM NUMBER] - 127.6 F, resident room [ROOM NUMBER] - 127.4 F, resident room [ROOM NUMBER] - 122.2 F, resident room [ROOM NUMBER] - 124.4 F, resident room [ROOM NUMBER] - 127.8 F, resident room [ROOM NUMBER] - 128.7 F, north hall shower room - 131.5 F, east hall shower room - 127.4 F. The [NAME] brand digital thermometers were verified to be accurate using the ice-point method and read between 32 F and 32.2 F after being placed in a cup of ice water. The temperature gauge for water leaving the mixing valve, located in the basement, read 128 F. The Director of Environmental Services (DES) stated that this mixing valve serves the older section of the building, the north and east halls. The DES also stated that the temperatures should not be more than 120 F. The DES stated that the boilers should be 118 F to 120 F and they recalibrated the valve to turn the water temperature down. Certified Nursing Assistant (CNA) #3 stated that the water in one (resident) room was very hot today, so they added cold water. CNA#3 also stated that it is not always like this and is hit or miss but did not tell anyone. Residents #12, #18 and #21 stated that they use their bathrooms to wash their hands. Facility weekly water temperature logs from 12/7/22 through 3/31/23 were reviewed and did not indicate any temperatures exceeding 120 F at points of use accessible to residents. There was no additional documentation provided to show that hot water temperatures were being monitored and or recorded for April 2023 and May 2023. 10NYCRR: 415.12(h)(1), 415.29, 415.29(a), 415.29(f)(6)

Based on observations, interviews and record review conducted during the Recertification Survey 5/4/23 to 5/10/23, it was determined for one (Resident #10) of three residents reviewed for activities of daily living (ADLs) the facility did not ensure that residents who are unable to carry out ADLs received the necessary services to maintain personal hygiene. Specifically, there were issues with incorrect use of a bathing cleanser. The findings are: Resident #10 was admitted to the facility 11/13/20 with diagnoses including knee replacement, broken femur (leg), muscle weakness, and diabetes. The Minimum Data Set Assessment, dated 1/30/23, documented that the resident was cognitively intact, and required extensive assistance with personal hygiene. Review of the resident's comprehensive care plan, dated as reviewed 4/17/23, revealed Resident #10 required total assist 1-2 staff for ADL care, and to use gentle care with positioning as the resident has fragile skin and high risk for skin tears and bruising. During observation of morning care 5/8/23 at 9:17 a.m., Certified Nurse Assistant (CNA) #1 CNA #1 poured Total brand bath skin/hair cleanser into a basin of water. CNA#1 cleansed Resident #10's upper body using a washcloth soaked in the soapy water and without rinsing, cleansed the resident's private areas including around an indwelling catheter. CNA #1 changed the water, added more Total skin/hair cleanser and proceeded to clean the resident's lower body and buttocks (which were smeared with stool) and dressed the resident. At no time did CNA #1 rinse off the cleanser from the resident's skin. Additionally, CNA #1 touched the resident's clean clothes, mechanical lift sling and environmental surfaces without changing their soiled gloves. During an interview on 5/8/23 at 10:07 a.m., CNA #1 stated the product they used to bath the resident was a rinse free soap. When requested at the time to review the bottle of cleanser directions CNA #1 read the directions on the bottle that included For skin apply to washcloth or directly to skin. Massage into lather and rinse. Towel dry. CNA #1 stated they thought they changed their gloves after cleaning the resident's buttocks and should have changed gloves to keep things separate clean from dirty. During interviews on 5/10/23 at 10:47 a.m. and at 11:56 a.m., the Director of Nursing (DON) stated the bath skin/hair cleanser should be used per manufacture directions, if soap is not rinsed off the skin it could contribute to itchy and dry skin. The DON stated that staff should change their gloves after providing peri care (private areas of a resident). 10NYCRR: 415.12(a)(3)

Based on observations, interviews, and record review conducted during a Recertification Survey 5/4/23 to 5/10/23, it was determined that for one (Resident #26) of one resident reviewed for pressure ulcers, the facility did not ensure that the resident received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, the nurse did not change gloves or perform hand hygiene while doing dressing changes on multiple wounds including a pressure ulcer. This was evidenced by the following: The facility policy Aseptic Dressing Change dated 12/3/10, directed the nurse to put on gloves, remove the dressing, place the used dressing in a waste receptacle, remove gloves, cleanse hands, replace gloves, clean the wound, place the used cleaning gauze in waste receptacle, observe wound for complications, cleanse hands, reapply gloves, apply medication, packing, outer dressing and/or wrap as ordered, remove gloves, sanitize hands. Tape and date new dressing in place, double-bag contaminated articles, and wash hands. Resident #26 was admitted on [DATE] with diagnosis including dementia, osteomyelitis (infection in the bone) and malnutrition. The Minimum Data Set assessment dated [DATE] documented that the resident was severely impaired cognitively, was at risk for developing pressure ulcers and had a stage 3 (full thickness tissue loss involving damage of the subcutaneous tissue) pressure ulcer. Physician orders for a right heel pressure ulcer dated 4/26/23 included to wash right heel with soap and water, dry thoroughly, apply Aquacel AG (wound treatment often used for infected wounds) to wound bed only, and cover with Allevyn (wound dressing) every Monday, Wednesday, Friday and PRN (as needed) if soiled, and apply a prevalon boot (cushioned boot that relieves pressure on the heels). Physician orders for left leg wound dated 5/3/23 included to cleanse with normal saline, apply skin prep (a liquid that when applied to the skin forms a protective barrier to prevent skin breakdown) to the area, cover with non-adherent telfa (dressing), wrap with kling (gauze) and secure with tape, daily and PRN. During an observation and interview on 5/9/23 at 9:52 a.m. the Dietician, Director of Nursing (DON) and the Nurse Practitioner (NP), wearing full personal protection equipment (PPE) assisted with wound care for Resident #26. While wearing gloves, the DON removed the soiled right heel dressing and assessed the wound which had a large amount of serous (blood tinged) drainage, granulating (pink-red moist healing tissue), and some eschar (dead tissue). Wearing the same gloves, the DON cleansed the wound stating it measured 3 centimeters (cm) by 2.5 cm, and applied the dressing as ordered. Without removing the soiled gloves, the DON replaced the resident's stocking. With the same gloves the DON removed the other stocking, cleansed another wound on the resident left leg which measured 2 cm by 0.7 cm and applied the dressings as ordered and replaced the sock and prevalon boots. Still wearing the soiled gloves, the DON touched both of the resident's arms that had multiple scabs in various stages of healing from the resident picking and touched multiple items and supplies in the resident's room before removing the soiled gloves and performing hand hygiene. During an immediate interview the DON stated that they did not change gloves or perform hand hygiene during either wound care (or prior to touching clothing and environmental surfaces) and should have to prevent the spread of infection. In an interview on 5/9/23 at 10:43 a.m. the NP stated gloves should be changed and hand hygiene performed between different dressing changes on resident's wounds to prevent cross contamination of wounds. The NP stated Resident #26 tested positive for MRSA (methicillin-resistant staphylococcus aureus-a bacteria resistant to some antibiotics) in the past but had not tested positive in any wounds recently. During an interview on 5/10/23 at 8:47 a.m. The Infection Preventionist (IP)/Staff Educator stated if a resident had more than one wound, each wound should be treated separately and without changing gloves it could cross contaminate one wound to another (potentially slowing down the healing process). The IP/ Staff Educator stated Resident #26 is on enhanced precautions (glown, gloves, masks) due to a history MRSA in their wounds and staff should change gloves and perform hand hygiene for each wound. 10NYCRR: 415.12(c)(2)

Based on observations, interviews, and record review conducted during the Recertification Survey 5/4/23-5/10/23 it was determined that for one (Resident #32) of four residents observed during medication pass, the facility did not ensure that it was free of medication error rate of 5 percent (%) or greater. There were 2 medication errors for 26 opportunities resulting in a 7.69 % medication error rate. The issue involved not mixing a medication in the correct amount of liquid, and not using a spacer nor rinsing the mouth after administering an inhaled medication as ordered by the phusicain. This is evidenced by the following: The facility Medication Administration Policy, revision dated March 2012, documented that medication is administered as ordered by the physician. Resident #32 had diagnoses including constipation, chronic obstructive pulmonary disease (COPD), and asthma. The Minimum Data Set (MDS, a resident assessment tool) dated 2/5/23, documented the resident had severe cognitive impairment. The current physician orders on 5/8/23 included, but were not limited to, the following medications: a. Miralax (polyethylene glycol 3350) powder, 17 gram dose oral twice a day, mix in 8 ounces (oz) of fluid for chronic constipation. b. Pulmicort Flexhaler (budesonide) aerosol powder breath activated 90 mcg (micrograms)/actuation (activation) twice a day, please use with spacer, have patient rinse mouth after use for COPD. During an observation of medication pass on 5/8/23 at 7:38 a.m., Registered Nurse (RN) #1 administered multiple medications (6) to Resident #32 including, but not limited to, Miralax mixed with water in a 5.5 oz cup, and Pulmicort inhaler without a spacer or having Resident #32 rinse their mouth after the administration. The 5/1/23 through 5/10/23 Medication Administration Record (MAR) for Resident #32 documented on 5/8/23, the Miralax was signed as administered in 8 oz of fluid, and the Pulmicort Flexhaler was signed as administered with the use of spacer and have patient rinse mouth after use. During an interview on 5/8/23 at 9:16 a.m. RN #1 stated they did not mix the Miralax in 8 oz fluid secondary to larger cups not available, and they did not use a spacer nor have Resident #32 rinse their mouth after the administration of the inhaler. During an interview on 5/8/23 at 1:01 p.m. the Director of Nursing (DON) stated medications should be administered as per the physician orders. During an interview on 5/9/23 at 2:54 p.m. the Nurse Practitioner (NP) stated medications should be administered as per the written physician orders. 10NYCRR: 415.12(m)(1)

Based on observations, interviews, and record reviews conducted during a Recertification Survey and complaint investigation (#NY 983), completed on 2/10/22, it was determined that for one (Resident #245) of three residents reviewed for accidents, the facility did not thoroughly investigate multiple falls to rule out abuse, neglect, or mistreatment. This is evidenced by: Resident #245 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], documented that the resident had moderately impaired cognitive function, limited mobility and required extensive assist from staff for transfers. The facility policy Fall Precautions, dated 10/10/16, directed that all residents identified at high risk for falls will receive appropriate assessment and interventions to decrease risk for falls and fall related injuries. The facility memorandum Falls, dated 11/21/19, directed Registered Nurses and Licensed Practical Nurses (LPN) to call medical first if there is any loss of consciousness, major injury, acute pain and/or significant change in vital signs after a fall. Neither policy directed staff that after a fall, an investigation should be completed to rule out abuse, neglect, or mistreatment. Review of the current Comprehensive Care Plan (CCP) and the current Certified Nursing Assistant (CNA) Kardex (care plan used by the CNAs for daily care), revealed that Resident #245 required two staff members for transfers, was at risk for falls related to a history of multiple falls, unsteady gait, impulsivity, and failure to comply with requesting assist. Interventions included, but not limited to, encouraging use of assistive devices as recommended, keeping frequently used personal items within reach, changes to the environment, and keeping the bed in low position and against the wall when occupied. Review of nursing progress notes from 9/25/20 through 3/12/21, revealed that Resident #245 was found on the floor on 12/31/20, 1/11/21, 1/12/21 and 1/15/21. No documentation was provided that any investigation had been conducted to rule out abuse, neglect or mistreatment or failure to follow the care plan. In an interview on 2/10/22 9:28 a.m., the LPN, stated that Resident #245 was exit seeking at times and that they would try to redirect. The LPN stated that the resident had motion sensors and when they alarmed, staff would report to the resident's room. The LPN stated they did frequent checks and attempted to keep the resident in highly visible areas but that the resident's dementia was progressing, and they did not always understand what was going on around them. In an interview on 02/10/22 at 10:05 a.m. and at 11:39 a.m., the Director of Nursing stated that after each fall, it was expected that a new incident and accident report would be completed to rule out abuse, neglect (failure to follow the care plan) and mistreatment. [10 NYCRR 415.4(b)(3)]

Based on observations, interviews and record review conducted during the Recertification Survey completed on 2/10/22, it was determined for that for 1 of 16 residents reviewed for care planning, the facility did not develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs and includes the resident's goals, desired outcomes, and preferences. Specifically, Resident #34 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the Tubigrips were not included in the residents Comprehensive Care Plan (CCP) nor the Certified Nursing Assistant (CNA) Kardex (care plan used by the CNAs to drive daily care). The evidence is: 1.Resident #34 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], documented Resident #34 had moderately impaired cognitive function, required extensive assistance of staff for dressing, did not have any rejection of care behaviors and had skin tears at that time. Review of current medical orders included for localized [CONDITION(S)], to apply a double layer of Tubigrips to the resident's legs from knees to toes in the morning at 7:00 a.m., and remove in the evening at 7:00 p.m. Review of the CCP and the CNA Kardex revealed that neither care plan included the need to apply the Tubigrips as ordered. During observations on 2/8/21 at 11:17 a.m. and again on 2/9/22 at 8:43 a.m., Resident #34 was up in their chair and was not wearing Tubigrips. Resident #34 had red and purple skin color changes to both shins, significant peeling of the skin all over their lower legs and swelling to both feet. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of nursing progress notes did not reveal any documentation regarding Tubigrips or the refusal of. In an interview on 2/8/22 at 11:17 a.m., LPN #1 stated Resident #34 may become violent if you try to put on the Tubigrips. In an interview on 2/9/22 at 9:32 a.m., CNA #1 stated Resident #34 wore the Tubigrips every day. In an interview on 2/9/22, at 9:55a.m., LPN #1 stated that if a resident refused treatments, they would reapproach, encourage, and document in the electronic medical record the refusal. LPN#1 stated that if refusals continued to happen, they would notify the physician. In an interview on 2/9/22 at 10:38 a.m., the Director of Nursing (DON) stated that if a treatment was due at 7:00 a.m., it should be completed at that time. If it was not done, then it should be reported to the team leader and the team leader should have reported to myself or the nurse manager. The time or the necessity of the treatment may need to be reevaluated. The DON stated they would expect to see a progress note in the electronic medical record if unable to complete. [10NYCRR 415.11 (c)(1)]

Based on interviews and record reviews conducted during the Recertification Survey, completed on 2/10/22, it was determined for one (Resident #39) of five residents reviewed, the facility did not ensure each resident's drug regimen was free of unnecessary medications. Specifically, the resident's medications were not held despite demonstration of potential adverse side effects and the medical team was not notified of the potential side effects. This is evidenced by the following: Resident #39 is [AGE] years old with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], documented that the resident had severe impairment of cognitive function, was incontinent of bowel function and was totally dependent on staff for toileting and bathing. Physician orders, dated 1/1/22 to 2/8/22, included Senna-S (a [MEDICATION(S)] + stool softener) daily at bedtime and to hold for loose stools and [MEDICATION(S)] (a [MEDICATION(S)]) 17 grams daily for constipation and to hold for loose stools. Review of Resident #39 bowel movements in the electronic medical record, dated 1/20/22 through 2/7/22 revealed that the resident was incontinent of bowel 55 times in that time period. Numerous bowel movements were described as loose and/or tarry black stools. There was no documented evidence that the laxatives or stool softener were ever held or communicated to the medical team. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 2/8/22 at 11:31 a.m., and at 2:47 p.m., the Certified Nursing Assistant (CNA) stated that Resident #39 is incontinent of bowels, goes several times a day and is always loose. The CNA stated that they did not let the nurse know recently because they didn't think it had been too bad lately. In an interview on 2/8/22 at 2:27 p.m., the Licensed Practical Nurse (LPN) stated that they get a report daily on any residents who have not had a bowel movement for three days but not for residents who may be having too many bowel movements or loose stool. The LPN stated that they would expect the CNAs to inform the nurses so the laxatives could be held. In an interview on 2/10/22 at 9:37 a.m., the Director of Nursing stated that the expectation is that for a resident having frequent and loose stools, a medical workup is completed, and the medications reviewed. The DON said that the CNAs should note this on their activities of daily living report and notify the nurse as they have been trained. The DON said that this resident should have been placed on the 24-hour report so staff can hold the [MEDICATION(S)] as ordered and keep an on eye on the resident. [10 NYCRR 415.12(l)(1)]

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 498) it was determined that for two (Residents #1 and #2) of two residents reviewed, the facility did not provide the appropriate liability and appeal notice to Medicare beneficiaries in order to notify them of their appeal rights under the regulations. Specifically, the facility did not provide the beneficiaries with a Notice of Medicare Non-Coverage letter prior to a discharge to the community. This was evidenced by the following: Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] under Medicare Part A benefits and discharged home on[DATE] with Medicare Part A days remaining. There was no documented evidence that the resident or responsible party was provided with the appropriate liability and appeals notice prior to discharge. Resident #2 was admitted to the facility on [DATE] under Medicare Part A benefits and discharged home on[DATE] with Medicare Part A days remaining. There was no documented evidence that the resident or responsible party was provided with the appropriate liability and appeals notice prior to discharge. When interviewed on 12/10/20 at 12:00 p.m., the Administrator stated the Business Office Manager was responsible for providing the beneficiary with the Notice of Medicare Non-Coverage. When interviewed on 12/10/20 at 12:09 p.m., the Business Office Manager stated if a resident is admitted straight Medicare Part A and has a planned discharge, a notice of Medicare Non-Coverage is not required prior to discharge home. The Business Office Manager stated she does not provide any resident or representative a notice of Medicare Non-Coverage when they are being discharged home even if they have Medicare days remaining. (10 NYCRR 415.3(g)(2)(iii))

Based on observations, an interview, and record reviews conducted during the COVID-19 Focused Infection Control Survey (complaint #NY 118) completed on 8/12/20, the facility did not maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not comply with Centers for Disease Control (CDC), Centers for Medicare and Medicaid Services (CMS), and New York State Department of Health (NYSDOH) guidance for visitation. This is evidenced by the following: The facility did not comply with Centers for Medicare and Medicaid Services (CMS) and New York State Department of Health (NYSDOH) visitation guidelines. The CMS Quality, Safety & Oversight Group (QSO-20-14-NH) Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED), dated 3/13/20, documented that all facilities nationwide should, restrict visitation of all visitors and non-essential health care personnel, except for certain [MEDICATION NAME] care situations, such as an end-of-life situation. The NYSDOH Health Advisory: COVID-19 Cases in Nursing Homes and Adult Care Facilities, dated 3/13/20, directed facilities to suspend all visitation except when medically necessary. A NYSDOH Health Advisory: Skilled Nursing Facility Visitation, dated 7/10/20, documented that the Department will now permit outside visitation, and limited indoor visitation and activities, if the Nursing Homes (NH) meet specific benchmarks and develop a reopening plan via the NY Forward Safety Plan. Nursing Homes in Phase 3 regions may resume limited visitation and activities beginning five days after the release of this health advisory and only under ten conditions including, but not limited to the following: (4) The NH has completed the NY Forward Safety Plan and submitted a copy of the completed plan to covidnursinghomeinfo@health.ny.gov., and, (6) The absence of any new onset of COVID-19 among staff or residents as reported to the Department on the HERDS and staff testing surveys and as reported to the National Health Safety Network (NHSN) for a period of no less than 28 days. A review of the HERDS data submitted by the facility revealed the last COVID-19 positive staff member was on 7/31/20. There was no documentation that the facility submitted a NY Forward Safety Plan to resume visitation. In an observation on 8/12/20 at 12:53 p.m., Resident #1 was visiting with a family member approximately outside the main entrance. Further observations revealed the area was setup with a staff member screening area and social distancing for visitation. When interviewed on 8/12/20 from 1:30 p.m. to 1:45 p.m., the Administrator stated the facility's NY Forward Safety Plan was completed shortly after the advisory was released but was not submitted to NYSDOH because that was the direction from corporate. The Administrator stated that outdoor visitation only (no indoor) was resumed about a week ago and that they used their NY Forward Safety Plan for proper social distancing and infection control. He said the decision to resume visitation was made with the Acting Director of Nursing, and since the plan was good from an infection control perspective, they considered it an activity rather than a visit. The Administrator said that resuming visitation has dramatically improved the quality of life for the residents and everyone has been so happy. When asked about a positive COVID-19 test for a staff member reported on 7/31/20, the Administrator stated that they believed the test was a false positive because the person subsequently tested negative three other times. The Administrator said that they have not been able to get anything from the lab confirming that the test was a false positive. (10 NYCRR 415.19(a)(1-3))

Based on interviews and record reviews conducted during the COVID-19 Focused Infection Control Survey (complaint #NY 118), it was determined that the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation and misappropriation of resident property related to screening prospective employees. Specifically, a Nurse Aide Registry abuse screening was not completed prior to hire for four (Employees #2, #3, #4, and #5) of five employee files reviewed. This is evidenced by the following: The facility policy, Abuse, Neglect, and Exploitation Prohibition, Training, Investigation, and Reporting Policy, included all staff that are being considered for hire must also be checked with the NYS Nurse Aide Registry for a history of findings. The printed web screen with verifications of date checked will satisfy the State and Federal requirements. On 8/12/20 at 2:45 p.m., the surveyor was provided with five employee Nurse Aide Registry screens and employee files. The files documented that Employees #2, #3, #4, and #5 were hired for Dietary, CNA (Certified Nursing Aide), Dietary, and Activities, respectively. The files also showed that Employees #2, #3, and #4 were hired on 7/29/20, and Employee #5 was hired on 6/24/20. The Nurse Aide Registry check for all four employees showed a date stamp of 8/12/20 with no findings of abuse. When interviewed on 8/12/20 at 2:45 p.m., the Human Resources Manager said they review the Nurse Aide Registry for abuse before hire, but they do not print them out or otherwise document. (10 NYCRR 415.4(b))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for rehabilitation, the facility did not ensure that each resident received the appropriate treatment and services to improve or maintain ambulation. Specifically, Resident #11 was not ambulated after being discharged from therapy. This is evidenced by the following: Resident #11 was admitted to the facility on [DATE] for rehabilitation, and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/28/19, revealed the resident was cognitively intact and required extensive assistance of two staff to transfer and walk in the room. The current Comprehensive Care Plan and Certified Nursing Assistant (CNA) Care Card both included that the resident transfers with two staff and a mechanical ready stand, and the resident was to be ambulated with therapy only. The last Rehab Recommendations to Nursing sheet, dated 8/7/19 revealed the resident transfered with one assist using a rolling walker and gait belt and ambulated with Physical Therapy only. The Physical Therapy Discharge Summary, dated 8/19/19, revealed that the resident's discharge transfer status was to stand with the platform walker with minimum to moderate assistance of one staff. She no longer required the mechanical ready stand. The ambulation status was documented that the resident was able to walk 60 feet with the platform walker with minimum to moderate assistance of one staff. During an interview on 9/24/19 at 1:46 p.m., the resident and daughter both said the resident has not been walked to the bathroom nor in the room or hall since therapy discharged the resident. Interviews and observations conducted on 9/26/19 included the following: a. At 1:11 p.m., the day CNA said the resident transferred with the mechanical ready stand using two staff. She said nursing staff do not walk the resident, but she has seen therapy walk the resident in the past. b. At 3:41 p.m., the evening CNA was observed removing the mechanical ready stand from over the resident's wheelchair where she had just placed the resident. The evening CNA said the resident was transferred with the mechanical ready stand using two staff and they do not ambulate the resident. The evening CNA showed the surveyor the Care Tracker computer program in the room that instructed staff that the resident ambulates with therapy. It was documented that ambulation did not occur for any of the shifts in the past week. Interviews conducted on 9/27/19 included the following: a. At 9:26 a.m., the Physical Therapist (PT) said that when therapy discharges a resident, the Recommendation to Nursing Form was completed and put in a box by the front desk. She said then someone adds that information to the care plan. She said the resident was using the platform walker, which was what she recommended for both transfers and ambulation. She said that a CNA told her the resident refused to use the platform walker. The PT said she could not remember the name of the CNA, and said she did not document that information. b. At 9:56 a.m., Registered Nurse (RN) #1 said she was not aware the resident had been discharged from therapy. She said she thought therapy was walking the resident. RN #1 said the staff used the mechanical ready stand to transfer the resident. She said that therapy completes a Recommendations to Nursing form when the resident is discharged from therapy. The RN said she does not recall seeing a form for the resident. c. At 9:58 a.m., RN #2 said the nursing staff was not told they could use a platform walker with the resident. She said the staff always used a ready stand for the resident. d. At 10:08 a.m., the Director of Nursing said the latest Recommendation to Nursing Form was dated 8/7/19, and directs staff that the resident ambulates only with therapy. She said nursing has not received any further recommendations from the therapy department. (10 NYCRR 415.12(e)(2))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, two of two in use facility thermometers were not accurate, shell eggs were not heated to the required 145 degrees Fahrenheit (°F) or above, and a ready to use blender had not been air dried. This is evidenced by the following: Review of a facility policy, Thermometer Calibration Log, dated (MONTH) 2007, directs that a thermometer calibration check will be completed and documented on a weekly basis to ensure that food temperature readings are correct so that all food items are served at a safe and palatable level. In an observation and interviews conducted of the Main Kitchen on 7/9/18 at 8:27 a.m., the Director of Food Service (DFS) said an Oster Duralast Classic Blender had been used for food preparation at breakfast and was now ready to use. The blender was set back on the base. When the lid was removed, there was visible water on the sides of the blender as well as standing water on the blades. The DFS unscrewed the base from the container and the gasket was wet. When lifted, there were small white food particles below the gasket. At that time, the Cook said he uses the blender at all three meals to blenderize food for three residents. Observations and interviews conducted on 7/11/18 included the following: a. At 9:18 a.m., the Cook said there were only two residents who requested soft poached eggs and the rest are supposed to get hard poached eggs. He said the facility does not use pasteurized shell eggs. At that time, the Cook and the surveyor observed in-use shell eggs and the eggs lacked a P on the shell, which means pasteurized. A review of resident food trays that were returned to the kitchen revealed remains of bright yellow egg yolk in several dishes, as well as eggs with yolks cut open and draining yellow liquid yolk. At that time, the DFS said he thought that all shell eggs came in pasteurized because that is what he ordered. He checked the order and said he had been ordering the wrong product and would order pasteurized shell eggs from now on. The Cook said he likes to cook the eggs so that residents can dip their toast in them because that is what they like. He said he had cooked 30 poached eggs that day and they had not been hard cooked. b. At 9:31 a.m., the Cook looked at that day's temperature log and said he had not recorded the cooking temperature of the eggs. He said he remembered he had cooked the eggs to 140°F. c. At 10:20 a.m., the Cook said poached eggs are offered twice during the five week menu cycle. He said that if a resident wanted a poached egg as a meal substitute, he would cook them a poached egg. d. At 10:33 a.m., the Registered Nurse/Infection Control said there had not been any outbreaks of gastrointestinal illness that would be related to food borne illness. e. At 10:55 a.m., the Cook said he had just calibrated facility thermometers on Monday, 7/9/18. The surveyor and the Cook reviewed the Thermometer Calibration Logs which revealed calibration was done twice in (MONTH) (YEAR). There was no documentation of any calibration for (MONTH) (YEAR) or (MONTH) (YEAR). f. At 11:01 a.m., two of two(NAME)Bimetallic 6072-1 facility thermometers and the surveyor's Thermo Couple thermometer were calibrated using the ice-bath method. The facility thermometers displayed 22°F and 38°F. The surveyor's thermometer displayed 33.4°F. The DFS and Cook said facility thermometers should have been 32°F. When asked about cooking temperatures for eggs, the DFS said yolks congeal at 138°F, so the eggs should have been cooked to that temperature. The Cook said he would cook the eggs to 165°F to set the yolk. g. At 11:15 a.m., the DFS said he had not been able to find a Thermometer Calibration Log for (MONTH) (YEAR). He said he would be adding that to his quality assurance audit to verify it is put out and used. The DFS reviewed a kitchen policy, Food Temperature Requirements, dated 2/6/18, which revealed shell eggs and egg containing foods are to be cooked to 145°F. (10 NYCRR 415.15(h), 14-1.85, 14-1.82(d), 14-1.116)

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that the facility did not have sufficient staff for one of one residential unit to care for residents' needs as identified through resident assessments and plans of care. Specifically, there were insufficient staff to care for residents' needs in a timely manner, including Activities of Daily Living (ADLs) and/or Resident Council grievances. This is evidenced by the following: The Facility Assessment, dated (YEAR), revealed the overall number of facility staff needed to ensure sufficient number of qualified staff are available to meet each resident's needs is day shift: Director of Nursing (DON), one Nurse Manager, two medication nurses, and five Certified Nursing Assistants (CNA). The evening shift: two nurses and four CNAs, and the night shift one nurse and two CNAs. The Facility Census and Conditions Form, dated 7/9/18, revealed a census of 43 residents. There were 31 residents that were dependent or required the assistance of at least one staff member for transfers. There were 37 residents that were dependent or required the assistance of at least one staff member for eating. There were 40 residents that were dependent or required the assistance of one or two staff members for bathing. The Benefit Improvement and Protection Act (BIPA, current staffing on a given day), dated 7/9/18, documented a census of 43 residents. The staffing for the day shift (7:00 a.m. through 3:00 p.m.) included one Registered Nurse (RN), one Licensed Practical Nurse (LPN), and two CNAs. The evening shift (3:00 p.m. through 11:00 p.m.) had one RN and two CNAs, and the night shift (11:00 p.m. through 7:00 a.m.) had one LPN and two CNAs. 1. During an interview on 7/9/18 at 8:09 a.m., the Dietary Aide said the residents were eating in their rooms that morning because nursing was short staffed. The Dietary Aide said there was a note on the door to serve room trays. She said that happens off and on. She said the food trucks were delivered to the unit about 7:30 a.m. 2. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/25/18, revealed that the resident had moderately impaired cognition, understands, is understood, and requires the assistance of two staff members to transfer. The CNA Care Sheet, dated 9/19/17, revealed that the resident likes to be out of bed in the mornings, between 6:30 a.m. and 7:00 a.m., for breakfast. During an observation on 7/9/18 at 8:07 a.m., the resident was lying in bed, and stated she has been waiting to get up. She said she does not like to be in bed at that hour. The resident said she told the CNA that she wanted to get up as she does not like to eat in bed. The resident was assisted out of bed at 8:20 a.m. During an interview on 7/11/18 at 12:12 p.m., the primary CNA said the resident likes to be up before breakfast and it is documented on her care card. 3. Resident #26 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/17/18, revealed the resident had severely impaired cognition, usually understands and is sometimes understood, required assistance to eat and assistance of two staff members for transfers. The CNA Care Card, dated 3/20/18, revealed the resident likes to be out of bed in the mornings between 5:00 a.m., and 7:00 a.m., and to encourage the resident to eat all meals in the dining room. During an observation on 7/9/18 at 9:03 a.m., the resident was lying in bed and said she had not had breakfast yet. She stated she is usually up around 5:00 a.m. and staff seemed awfully busy that day. She said she was hungry. The resident's tray was observed to be on the food truck. At 9:43 a.m., the resident was observed being washed up. She stated she had not had her breakfast yet and was starving. The resident was assisted out of bed at10:05 a.m. and then received her breakfast. During an interview on 7/11/18 at 12:12 p.m., the primary CNA said the resident likes to up before breakfast. She said the resident is on aspiration precautions and cannot eat lying down. She said the resident is always up before 9:00 a.m. and her breakfast is reheated. 4. Resident #32 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/5/18, revealed that the resident had modified independence (some difficulty in new situations only), was understood, understands others, and choosing the type of bathing was very important to the resident. During an interview on 7/9/18 at 8:35 a.m., the resident stated that she would like a shower that day (her regular day for showers) but was told by staff that they would not have time to give her one because they were short staffed that day. The resident said that it happens frequently and that she would like to shower at least twice weekly but does not even get one shower a week most of the time. Review of the CNA Resident Care Plan, dated as last revised on 7/11/18, revealed the resident receives a shower on Monday day shift. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) CNA ADL Tracking Form revealed that the resident received two showers over the previous five weeks. During an interview on 7/9/18 at 8:40 a.m., the CNA stated she told the resident that she and an orientee were the only aides on that unit (21 residents) that day. She said that 21 residents are difficult to get up with just an orientee and that staffing is a frequent issue. 5. Resident #42 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 6/11/18, revealed the resident had severely impaired cognition and required the assistance of one staff member to eat. During an observation on 7/9/18 at 12:43 p.m., the resident was seated at the dining room table with two other residents who were eating. At 1:02 p.m., the resident was still sitting at the table without any encouragement or assistance to eat. At that time, a family member said the resident's food had been sitting there for 45 minutes and it was cold. The family member said there was not enough staff. 6. During a Resident Council meeting on 7/9/18 at 2:00 p.m., the four residents in attendance said they have complained about not having enough staff, and although some staff have been hired, they have not had any resolution for the staffing and there are still problems. Review of the monthly Resident Council meeting minutes, from (MONTH) (YEAR) through (MONTH) (YEAR), revealed six of the seven months the resident's complained about staff attitudes and the lack of help. Administration replied that all residents are encouraged to address specific events where they may feel that their needs are not being met, they are restructuring some staffing with the renovations, and they are always hiring. Staff interviews included, but were not limited to, the following: a. On 7/9/18 at 8:07 a.m. and 8:33 a.m., Staff #1 said there are only two CNAs working that day and an orientee on her first day. Staff #1 said they used to have six CNAs on the day shift, then five, then four, then three and sometimes it is only two, like now. b. On 7/09/18 at 9:42 a.m., Staff #2 said she often works both the day and evening shift to cover, or works as a CNA. Staff #2 said they are unable to get some things done such as rinsing out a catheter bag. c. On 7/9/18 at 3:32 p.m., Staff #3 and Staff #4 said there are just two CNAs for the evening shift. They said all the residents require assistance to get into bed. They said that frequently they are unable to provide showers and pass that information on to the next shift. d. On 7/10/18 at 8:35 p.m., Staff #5 said it is difficult to get everything done when you have residents that need attention such as frequent fallers and hospice residents. Staff #5 said staff are unable to give residents that extra time. Staff #5 said there are several residents that require the assistance of two staff members, and staff are unable to get everything done such as showers. She said that had been reported to the Director of Nursing (DON). Staff #5 said there are frequently only two CNAs on the day shift. Staff #5 said that when the evening shift starts, incontinent residents are wet and if there is no hospitality aide, the residents do not have any water and it is hot. e. On 7/11/18 at 7:30 a.m., Staff #6 said that there should be two CNAs on the night shift, and sometimes there is only one. Staff #6 said that they try to get everything done, but the residents must wait. Staff #6 said when the evening shift is short, which they frequently are, the night staff come in and the residents are wet, they have not been changed. When interviewed on 7/12/18 at 11:32 a.m., the DON said that staffing is not good. She said they are trying to recruit all the time. She said most applicants have other jobs and do not want full time. She said it was not easy to get the number and quality of staff they need. The DON said they strive to have at least three CNAs on the day and evening shift and one CNA on the night shift. The DON said they will call in nurses to work as CNAs and she helps out, too. She said she had been informed by some staff that showers were not being done. She said that the Human Resource Coordinator completes staffing. When interviewed on 7/12/18 at 1:36 p.m, the Human Resource Coordinator said that she does the scheduling. She said the maximum budget allows for five CNAs on days, four CNAs on evening and two CNAs on nights. She said she feels that goal is met 2/3 of the time. She said the acuity of the residents is not part of the staffing process. The Human Resource Coordinator said the facility has certified staff to assist with feeding, and hospitality aides that can transport or walk with residents. When interviewed on 7/12/18 at 1:44 p.m., the Administrator said she was aware of the staffing issue, and also aware of the Resident Council complaints regarding staffing. She said they are continuously hiring and terminating staff as she feels strongly about having the right people working at the facility. She said they provide incentives for staff that come in and pick up extra shifts, thank the current staff, give gift cards and pizza parties. (10 NYCRR 415.13(a)(1)(i-iii))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #20) of two residents reviewed for pressure ulcers, the facility did not provide the necessary care and services to promote the healing of existing pressure ulcers. The issue involved the lack of notifying the medical team and lack of treatment following identification of a new pressure ulcer. This is evidenced by the following: The current facility policy, Skin Assessment, directed that residents are to have at least weekly skin assessments, complete with documentation on any resident presenting with any alteration in skin integrity including redness, rashes, bruising, etc. The assessment will consist of location, size and drainage of the affected area, as well as current treatment. All assessments will be done by a Registered Nurse. Resident #20 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/14/18, revealed that the resident had moderately impaired cognition, required total assist of staff for personal hygiene and bathing, and had no skin issues. In an interview on 7/9/18 at 1:32 p.m., a visitor stated that the resident sits in his chair all day long (morning to night with no naps) and has sores on his legs from the chair. The visitor said that sometimes cushions are in place, but not always. The Comprehensive Care Plan, dated 5/24/18, included the resident was at risk for skin issues, bruises easily, has fragile skin and interventions included to direct staff to monitor skin daily and be seen during skin care team rounds as needed. Review of the Certified Nursing Assistant (CNA) Resident Care Plan, dated 7/6/18, revealed geri- sleeves (sleeves used to protect arms from skin injuries) to both arms at all times, padded arm rests, and bilateral green bolsters to each side of arm rests on the geri-chair. Observations included the following: a. On 7/9/18 at approximately 1:30 p.m., the resident was sitting in a geri-chair. He had geri-sleeves to both arms and knee-high socks to both legs. There were no visible wounds or dressings noted on his legs. b. On 7/10/18 at 7:35 a.m., the resident was in his geri-chair in front of the nurses' station. There were socks on both legs to the knees and no cushions between either knee and the side of the chair. There was no visible dressing on either leg. At 1:13 p.m., an unsecured piece of gauze pad was observed sticking out of the top of the resident's stocking on the right leg with a small amount of blood tinged drainage visible above the stocking. There was no padding in place. c. On 7/11/18 at 10:11 a.m., there was a blue bolster between the resident's left thigh and the side of the chair, but there was nothing between the outside of the knee and the chair on the right. d. On 7/12/18 at 8:40 a.m. the resident had socks on both legs to the knee, but there was no gauze pad in place. The surveyor, with Registered Nurse (RN) #1, requested to see the resident's legs (under the socks) at that time. The lateral (outside) left knee area revealed a small pencil eraser size scabbed area with surrounding blanchable redness. The right lateral knee area had an approximately 6 centimeter (cm) long by 2 cm wide bloody open area where the knee hits the side of the resident's geri-chair. RN #1stated at that time that she had been working all week and was not aware of these open areas. RN #1 said that the resident wears socks all day so she would not be aware of them unless someone notified her. She said there were no treatment orders for either one. The Physician's Assistant (PA) was notified at that time, assessed the wound, and new orders for treatment to both areas were obtained. The PA stated at that time that she was not aware of the leg sores and she would have expected to be notified. Review of the medical record revealed the following: a. In a Nursing Progress Note, dated 7/3/18, RN #2 documented that she observed a prior abrasion on the right lateral knee that was scabbed and had re-opened. The wound was cleaned and a dressing applied. There was no mention of size, cause or what the wound was cleaned or covered with. b. The 24-hour Report, dated 7/3/18 day shift, included that the resident had an abrasion on the lateral right knee that re-opened. No measurements were listed. Both the evening and night shift documented on the report the word noted, but there was no other information. c. In an Occupational Therapy Progress Note, dated 7/6/18, the Occupational Therapist documented that bolsters were placed between the resident's knees and geri-chair for protection of skin. d. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Treatment Administration Records revealed no treatments related to any leg wounds. e. There were no Skin Round Wound Sheets in the medical record. f. The PA Progress Note, dated 7/12/18, after assessment of the wound, included that the resident had a traumatic skin injury to the right lower extremity where the knee abuts up against the chair. The note included wound treatments, a Physical Therapy and/or Occupational Therapy Evaluation to assess the resident's chair, Tylenol for pain and recommendation to go back to bed for a nap in the afternoon. Interviews conducted on 7/12/18 included the following: a. At 9:02 a.m., the CNA stated that the first time she saw the leg sores that week was on Tuesday (7/10/18) and she did not tell the nurse because she thought she knew about them as they had been there awhile. b. At 11:45 a.m., the RN Charge Nurse stated that the Nurse Manager (NM) and/or Director of Nursing (DON) reviews the 24-hour Report Sheet every morning. She said all skin issues are reviewed on weekly skin rounds with the DON and the provider. She said the provider would decide the treatment. She said skin issues are then monitored weekly and progress notes written. c. At 11:51 a.m., RN #2 stated that when she saw the open area on 7/3/18 she did not measure it as she thought it was old. She said she documented in the Provider's Book, the 24-hour Report, wrote a progress note and covered it with a dressing. She said the 24-hour Report Sheet is reviewed daily in morning report by the DON and the NM, but they have not had a NM in several months. When interviewed on 7/13/18 at 11:35 a.m., the DON stated that when a new skin issue is identified, she expects staff to put a note in the Provider Communication Book. When reviewed at that time, there was no communication regarding the resident's leg sores. The DON said that concerns identified on the 24-hour Report should be followed up on the next day. She said if there is a holiday (7/4/18), then the concern should be addressed the next day. (10 NYCRR 415.12(c)(2))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for two of four residents reviewed for choices, the facility did not allow each resident the right to make choices about aspects of life that were significant to them. Specifically, Resident #23's choice of when to get out of bed in the morning was not consistently honored, and Resident #32 was not consistently showered twice a week. This is evidenced by the following: 1. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/25/18, revealed the resident had moderately impaired cognition, understands, is understood, and required the assistance of two staff to transfer. The Comprehensive Care Plan for a Self-Care Deficit, dated 5/31/18, included the resident required assistance with Activities of Daily Living (ADLs) with a goal to have all care needs met and dignity preserved. Approaches included to offer choices of clothing and activities, and complete the ADLs per the Certified Nursing Assistant (CNA) Resident Care Plan. The CNA Resident Care Plan, dated 9/19/17, revealed the resident likes to be out of bed in the mornings between 6:30 a.m. and 7:00 a.m., and out of bed for breakfast daily. During an observation on 7/9/18 at 8:07 a.m., the resident was lying in bed and stated she has been waiting to get up. She said she does not like to be in bed at that time and had told the CNA that she wanted to get up as she does not like to eat in bed. The breakfast food trucks were observed on the floor at 7:30 a.m. The resident's call light was activated, and at 8:10 a.m. CNA #1 entered the room. The resident told CNA #1 she still wanted to get up. CNA #1 told the resident they were serving breakfast trays at that time. The resident replied that was why she wanted to get up. The CNA told the resident that she always eat in bed. The resident denied that, and the CNA left the room stating she would ask the nurse. CNA #1 returned a few minutes later and said she would get the resident up. When interviewed on 7/10/18 at 11:57 a.m., the resident said she had been asked by facility staff what time she wants to get up each day and she believes she told them 7:00 a.m. During an interview on 7/11/18 at 12:09 p.m., the resident's primary CNA said the resident likes to be up in the chair before breakfast. She said that was documented on the resident's care card. 2. Resident #32 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/5/18, revealed that the resident had modified independence (some difficulty in new situations only), was understood, understands others, choosing the type of bathing was very important to the resident. During an interview on 7/9/18 at 8:35 a.m., the resident stated that she would like a shower that day (her regular day for showers) but was told by staff that they would not have time to give her one because they were short staffed that day. The resident said that it happens frequently and that she would like to shower at least twice weekly but does not even get one shower a week most of the time. Review of the Customary Routine and Activities Interview, dated 3/5/18 and 6/22/18, revealed the resident's choice was a tub bath or shower twice weekly. The Medical Note, dated 6/5/18, documented that the resident was anxious and requesting powder due to increased perspiration associated with summer months and her known obesity and tendency to develop rashes. Review of the CNA Resident Care Plan, dated as last revised on 7/11/18, revealed the resident receives a shower on Monday day shift. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) CNA ADL Tracking Form revealed that the resident received two showers over the previous five weeks. During an interview on 7/9/18 at 8:40 a.m., the CNA stated she told the resident that she and an orientee were the only aides on that unit (21 residents) that day. The CNA said she did not tell the resident that she would not give her a shower. She said that 21 residents are difficult to get up with just an orientee and that staffing is a frequent issue. When interviewed on 7/11/18 at 1:24 p.m., the Director of Activities stated that interviews regarding choices are updated quarterly and reviewed by nursing. The Director of Activities said that nursing makes changes to the residents' care plans. (10 NYCRR 415.5 (d)(1)(3))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #42) of 19 residents reviewed for care planning revisions, the facility did not ensure a resident's plan of care was reviewed or revised to reflect the resident's current condition. The issue involved the lack of care plan revisions for the resident's toileting needs. This is evidenced by the following: Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set Assessment, dated 6/11/18, revealed that the resident had severely impaired cognition, was incontinent of bladder and bowel, required total dependence of one staff for toileting, daily use of a diuretic (a medication to rid the body of excess fluid), and moisture associated skin damage. A physician note, dated 6/8/18, revealed a small red abrasion to the mid and right buttock, and an area of white discoloration in the gluteal folds reflective of candidiasis (fungal infection caused by yeast) are likely related to urinary incontinence and retention of moisture. The plan was for staff to provide meticulous skin care with frequent brief checks and changes, and use of a moisture barrier antifungal cream. A physician order, dated 6/8/18, directed the use of Baza Moisture Barrier Antifungal Cream to the area of candidiasis, on the sacrum, and to both buttocks twice daily and as needed with brief changes. A Certified Nursing Assistant (CNA) Resident Care Card, dated 6/11/18, directed to toilet every four hours and as needed. A CCP for Urinary Incontinence, dated 6/21/18, included approaches to monitor bowel regime, provide incontinence care per facility protocol and toileting schedule. A physician order, dated 7/3/18, directed to continue Baza Cream to buttocks twice daily and as needed after hygiene care for 14 days, then as needed for fungal rash. During an interview on 7/10/18 at 8:01 a.m., a family member said the biggest concern is untimely toileting. The family member said that was discussed with a nurse and a change in the resident's schedule was made to toilet her every two hours. Observations and interviews conducted on 7/11/18 included the following: a. At 8:36 a.m., the CNA said the night shift changed the resident around 6:00 a.m. The CNA said she had not heard that the resident was to be changed every two hours. b. At 10:35 a.m., the CNA said she had changed the resident about 9:50 a.m. The CNA said the resident had been wet, but not drenched, and she had applied cream. The LPN said a family member had requested over a week ago, to change the toileting schedule to every two hours due to a continued rash. The LPN said she had reported that to a Registered Nurse (RN) so the care card could be changed. The CNA looked at the current Care Card and said it had not been updated, it still directs to toilet every four hours. The LPN said she did not know how to update the Care Card and would again ask the RN to do that. c. At 12:08 p.m., the RN reviewed the current Care Card and said the toileting schedule reflected facility protocol, every four hours and as needed, not the requested every two hours. She said the family member had also reported that concern to her and the Care Card should have been changed. d. At 12:20 p.m., the Director of Nursing (DON) said it is her responsibility to update the CNA Care Cards and she maintains them on the computer. The DON displayed the Care Card on the computer screen and said it was last updated 6/11/18. (10 NYCRR 415.11(c)(2)(i-iii))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #2) of two residents reviewed for Activities of Daily Living, the facility did not provide the necessary services to maintain good grooming and personal hygiene. The issue involved the lack of nail care. This is evidenced by the following: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/9/18, revealed that the resident's cognitive skills for daily decision making were moderately impaired, and the resident required extensive assistance of staff for personal hygiene and bathing. Observations and interviews included, but were not limited to, the following: a. On 7/9/18 at 10:10 a.m., the resident had brown debris under all fingernails. b. On 7/10/18 at 9:00 a.m. the resident was eating toast in the main dining room, and her nails remained filled with brown debris. c. On 7/12/18 at 12:06 p.m., the resident's nails remained filled with brown debris. d. On 7/13/18 at 11:35 a.m., the surveyor and Director of Nursing (DON) observed the resident's fingernails. The DON stated that the fingernails were dirty and needed attention. She said that nail care should be done on shower days and the resident's bath was scheduled for Wednesday evening (7/11/18). She said the resident may have refused. The DON said if the resident did refuse, the Certified Nursing Assistant should have reported that to someone. (10 NYCRR 415.12(a)(3))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of seven residents reviewed for pharmacy services, the facility did not ensure that medications were available and provided to meet the needs of each resident. Specifically, eye drops were not available for Resident #27 following medical orders for several days, and a newly ordered high blood pressure medication was not available for Resident #39 following a hospitalization . This is evidenced by the following: Review of the facility policy, Missing Medication Procedure, dated 6/7/17, directed that if unable to find a medication, staff should fax to pharmacy and check to see that it was received. If the medication does not arrive to the facility before the end of the shift, the on-call provider must be notified. If a medication is not given for more than two doses per day or for more than three days total, the Nurse Manager, the Director of Nursing (DON) or Registered Nurse (RN) on call and the medical provider must be notified promptly. 1. Resident #39 was readmitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/15/18, revealed the resident had moderately impaired cognition. Review of the Hospital Discharge Summary, dated 3/7/18, included that the resident was seen for complaints of a headache and nausea, and was diagnosed with [REDACTED]. The resident was prescribed [MEDICATION NAME] (high blood pressure) 5 milligrams (mg) daily in addition to her previous blood pressure medication. The hospital summary included that the [MEDICATION NAME] was started 3/8/18 in the morning. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The [MEDICATION NAME] was documented as first administered on 3/11/18 at 5:00 p.m. The 3/9/18 and 3/10/18 doses were circled and it was documented on the back of the MAR indicated [REDACTED]. Review of the Nursing Progress Note, dated 3/9/18 at 10:30 p.m., revealed that the resident's blood pressure was 177/73. There was no documentation that the medical team was notified. In a Medical Progress Note, dated 3/11/18, the Physician's Assistant documented that [MEDICATION NAME] was unavailable in the building for the resident and directed to give the medication as soon as it arrives from pharmacy. The note included instructions for the staff to order the [MEDICATION NAME] from pharmacy STAT (immediately). In an interview conducted on 7/11/18 at 10:26 a.m., the Registered Nurse (RN) Charge Nurse stated that when they receive a medication order, it is faxed to the pharmacy and transcribed to the MAR. She said if the order is faxed to the pharmacy by 1:00 p.m., it is usually delivered between 3:00 p.m. and 5:00 p.m. The RN Charge Nurse said if the medication is not available by the last pharmacy delivery for that day, then medical should be notified. She said a STAT order should be delivered from the pharmacy immediately. The RN said that she ordered several medications for Resident #39 and other residents the previous day and they still have not arrived. She said that they have had a lot more problems with the pharmacy deliveries recently. In an interview on 7/13/18 at 11:35 a.m., the DON stated that if medications are unavailable, she expects staff to call the pharmacy and follow up, and to notify the medical provider for directions. The DON said that she was not aware of any medication errors for that resident. 2. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/30/18, revealed the resident was cognitively intact, had moderately impaired vision, and used corrective lenses. A Comprehensive Care Plan for Visual Impairment, dated 6/7/18, related to [MEDICAL CONDITION] in the left eye and blurred vision in the right eye, included interventions to use verbal cues to describe location of items and food, keep glasses clean and in good repair, and ophthalmology as needed. A physician order, dated 7/9/18 at 2:15 p.m., directed to discontinue Artificial Tears and start Refresh 0.5 percent eye drops (lubricant eye drops, available over-the-counter (OTC) used to protect against dry eye and to improve visual clarity), two drops to both eyes twice daily for dry eyes, and every four hours as needed. Review of the (MONTH) (YEAR) MAR, revealed that the eye drops were crossed out or circled as not administered from 7/9/18 through 7/12/18. It was documented on the back of the MAR indicated [REDACTED]. In an interview on 7/11/18 at 1:30 p.m., Licensed Practical Nurse (LPN) #1 said the resident's eye drops had been delivered from the pharmacy. LPN #1 said she had documented on her Daily Report Sheet to follow up with pharmacy regarding the eye drops. She said there have been problems with timely deliveries from the pharmacy and she had been told the drops were on back order. LPN #1 said the eye drops were first ordered 7/9/18 and can be purchased over the counter. Interviews conducted on 7/12/18 included the following: a. At 3:24 p.m., LPN #2 said she had not administered eye drops that day because they had not been delivered from the pharmacy. LPN #2 said the pharmacy had been called to ask about delivery of the eye drops. The DON said at that time, she had no idea why these OTC eye drops had not been delivered and she was going to call the pharmacy right now. b. At 3:52 p.m., the resident said she is blind in one eye and the vision in the other is blurry. She said her eyes hurt and itch. The resident said she was supposed to be getting eye drops, but had not received them lately. c. At 4:18 p.m., the DON said she had called the pharmacy and the eye drops were being delivered that evening. She said no reason was given for the delay in delivery. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] In an interview with the Administrator and the DON during the Quality Assurance Review on 7/13/18 at 11:02 a.m., and again at 12:54 p.m., the DON stated that it had not been brought to her attention that medications were not being delivered from pharmacy in a timely manner. The DON said that she was responsible and had been doing audits on missing medications due to previous pharmacy issues, but when asked the Administrator and the DON were unable to produce any audits. (10 NYCRR 415.18(b)(l)(2)(3))