Every finding on record at Sapphire Nursing And Rehab At Goshen

Based on record review and interviews conducted during an abbreviated survey, the facility did not ensure referrals to the New York State Office for People With Developmental Disabilities (OPWDD) for Preadmission Screening and Resident Review (PASRR) Level II evaluations were completed as required prior to admission for two (Residents #3 and #4) of three residents reviewed for Preadmission Screening and Resident Review requirements. Specifically, 1. Resident #3, who was admitted to the facility on [DATE], had a preadmission Level I SCREEN dated 01/12/2026 from the hospital identified an intellectual/developmental disability; however, a referral to the New York State Office for People With Developmental Disabilities for a Preadmission Screening and Resident Review Level II evaluation and determination was not made prior to admission. Review Level II Referral Response Letter documented a referral date of 02/02/2026, 20 days after Resident #3's admission. 2. Resident #4, who was admitted to the facility on [DATE], had a preadmission Level I SCREEN dated 11/25/2025 that identified an intellectual/developmental disability; however, a referral to the New York State Office for People With Developmental Disabilities for a Preadmission Screening and Resident Review Level II evaluation and determination was not made prior to admission. The facility completed another Level I SCREEN on 12/08/2025. The Preadmission Screening and Resident Review Level II Referral Form documented PASARR Level II determination was completed on 12/29/2025, 21 days after admission.The Finding Include:1. Resident #3 was admitted to the facility on [DATE] with diagnoses including, but not limited to, anxiety, schizophrenia, and unspecified intellectual disabilities. Resident #3 was discharged from the facility on 03/31/2026.The 01/20/2026 admission Minimum Data Set documented that Resident #3 had mildly impaired cognition and was not considered by the State Level II Preadmission Screening and Resident Review process to have serious mental illness and/or intellectual disability or a related condition.Review of the New York State Department of Health Level I SCREEN dated 01/12/2026 revealed Item 24, Does this person have a diagnosis or documented history of mental retardation and/or a developmental disability, was marked Yes, and Item 25, Has this person ever been deemed eligible for and/or received MR/DD services, or has this person been referred by an agency that serves persons with MR/DD, was marked Yes. Resident #3 was admitted to the facility the following day, on 01/13/2026.Review of the New York State Department of Health Level I SCREEN completed by Social Worker #1 on 01/29/2026 revealed the facility completed another Level I SCREEN 16 days after Resident #3's admission. Review of the New York State Office for People With Developmental Disabilities (OPWDD) Preadmission Screening and Resident Review (PASRR) Level II Referral Form revealed the nursing facility was identified as the referral organization and Social Worker #1 was identified as the referral contact.Review of the New York State Office for People With Developmental Disabilities Preadmission Screening and Resident Review Level II Referral Response Letter dated 02/02/2026 revealed the referral date was 02/02/2026, 20 days after Resident #3's admission. The response letter documented that an Abbreviated Level II Assessment (Part IV) IS Required and identified the categorical determination as Convalescent Care (not to exceed 120 days).During an interview on 08/06/2026 at 9:46 AM, Complainant #1 stated that the SCREEN is completed prior to admission to a nursing facility and, when a developmental disability is identified, a Level II Preadmission Screening and Resident Review evaluation is required. Complainant #1 stated that when the nursing facility reviews the residents' diagnoses, the facility should determine whether a Level II Preadmission Screening and Resident Review evaluation is required. They stated that the SCREEN is referred to the New York State Office for People with Developmental Disabilities (OPWDD) or the Office of Mental Health, as applicable. Resident #3's Patient Review Instrument was dated 01/12/2026 and the SCREEN was initiated and completed on 01/29/2026. Resident #3 had already been admitted to the facility without a Preadmission Screening and Resident Review determination, and the referral was not completed until 02/02/2026. Complainant #1 stated that 02/02/2026 would have been the date the facility would have received approval to admit Resident #3. Complainant #1 stated that if a resident is admitted to a facility without a Preadmission Screening and Resident Review referral, the resident may not receive specialized services. Complainant #1 stated that when referrals are sent to the New York State Office for People With Developmental Disabilities, they are usually quick with their responses. Complainant #1 stated that the abbreviated Level II Preadmission Screening and Resident Review assessment was completed on 02/02/2026.2. Resident #4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, Down syndrome, hyperlipidemia, and fracture of the right femoral neck.The 12/12/2025 admission Minimum Data Set documented that Resident #4 had severely impaired cognition and was considered by the State Level II Preadmission Screening and Resident Review process to have an intellectual disability or a related condition.Review of the 11/25/2025 New York State Department of Health Level I SCREEN, completed by [NAME], Registered Nurse, Certified Case Manager, revealed Item 22, Does this person have a dementia diagnosis (including Alzheimer's disease), was marked Yes; Item 23, Does this person have a serious mental illness, was marked No; Item 24, Does this person have a diagnosis or documented history of mental retardation and/or a developmental disability, was marked Yes; and Item 25, Has this person ever been deemed eligible for and/or received MR/DD services, or has this person been referred by an agency that serves persons with MR/DD, was marked Yes. Despite the 11/25/2025 Level I SCREEN identifying Resident #4 as having a diagnosis or documented history of mental retardation and/or a developmental disability and as having been deemed eligible for and/or received MR/DD services, Resident #4 was admitted to the facility on [DATE] without a completed Office for People With Developmental Disabilities (OPWDD) Preadmission Screening and Resident Review (PASRR) Level II determination.Review of the 12/08/2025 New York State Department of Health Level I SCREEN, completed by Social Worker #1, revealed Item 23, Does this person have a serious mental illness, was marked Yes; Item 24, Does this person have a diagnosis or documented history of mental retardation and/or a developmental disability, was marked Yes; and Item 25, Has this person ever been deemed eligible for and/or received MR/DD services, or has this person been referred by an agency that serves persons with MR/DD, was marked Yes. Item 33 identified a Level II referral for evaluation by the Office of Mental Retardation and Developmental Disabilities.Review of the 12/08/2025 Office for People With Developmental Disabilities Preadmission Screening and Resident Review Level II Referral Form revealed Resident #4's anticipated nursing facility admission date was 12/08/2025, Social Worker #1 was identified as the nursing facility contact person, and Long-Term Care was selected as the nursing home referral type. A handwritten notation on the form documented, sent out on 12/23 6pm. The referral was sent to the Office for People With Developmental Disabilities on 12/23/2025 at 6:00 PM, 15 days after Resident #4 was admitted to the facility.Review of the 12/29/2025 Office for People with Developmental Disabilities Preadmission Screening and Resident Review Abbreviated Level II Assessment: (Part IV) Determination & Recommendations revealed the Preadmission Screening and Resident Review assessment date was 12/29/2025, 21 days after Resident #4's admission on [DATE].During an interview on 08/06/2026 at 10:26 AM, Complainant #1 stated that Resident #4 was admitted to the facility without a Preadmission Screening and Resident Review (PASRR). They stated that the SCREEN they had was dated 12/08/2025 and was received on 12/23/2025. They stated that on 12/29/2025, the facility sent a referral and that the Preadmission Screening and Resident Review (PASRR) referral response letter was dated 12/29/2025. They stated that residents are not to be admitted without a Preadmission Screening and Resident Review (PASRR). They stated that the facility sends the referral to Office for People with Developmental Disabilities (OPWDD) so that a Level II SCREEN can be initiated and that a Level II evaluation is required for individuals with a developmental disability. They stated that Resident #4 should not have been admitted until the facility received the PASRR Level II referral response letter.During an interview on 08/06/2026 at 10:42 AM, Social Worker #1 stated that the facility receives the SCREEN and Patient Resident Instrument (PRI) upon admission and reviews the information with the interdisciplinary team and family members. Social Worker #1 stated that, to their knowledge, Level II does not have to be completed until after the resident is admitted , then Social Worker #1 completes Level II if one is needed. Social Worker #1 stated that the Patient Resident Instrument (PRI) and SCREEN are reviewed by Admissions, Nursing, and Social Work. Social Worker #1 stated that prior to completing the Level II process, they gather additional information about the resident by speaking with the interdisciplinary team and family. Social Worker #1 stated that Resident #3 was admitted with a SCREEN, Social Worker #1 saw the diagnosis for the resident. Social Worker #1 was aware that Resident #3 required Level II.During an interview on 08/06/2026 at 11:20 AM, the Director of Admissions stated that Admissions receives information from the hospital, including the Patient Review Instrument (PRI), SCREEN, face sheet, and medication information. The Director of Admissions stated that the SCREEN is reviewed to ensure it is completed and that the admission information is provided to Social Work and Nursing for review and discussed by the team. The Director of Admissions stated that residents should have a Preadmission Screening and Resident Review (PASARR) and SCREEN upon admission. The Director of Admissions stated that Admissions does not review or complete the Level I or Level II process. Admissions is responsible for ensuring that the Preadmission Screening and Resident Review (PASARR), the Patient Review Instrument and SCREEN, and other required admission documents are present.Title 10 NYCRR, the New York Codes, Rules and Regulations Section 415.11(e)

Based on record review, and interviews during a Recertification Survey (4/10/2025 - 4/16/2025), the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not ensure an infection surveillance plan based on facility assessment was implemented for identifying, tracking, and monitoring infections, communicable diseases, and outbreaks. The findings include: A facility policy titled Infection Prevention and Control Program dated 12/01/2017 and last reviewed on 3/21/24 documented the elements of the Infection Prevention and Control Program consists of coordination/oversight, surveillance, data analysis, outbreak management, enhanced barrier precautions, prevention of infection, identifying, recording and correcting infection control and prevention incidents, and conducting and annual review of the Infection Prevention and Control Program. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics and detecting unusual pathogens with infection control implications. The infection control reports for March 2025 and April 2025 documented residents on antibiotic therapy for respiratory infection, urinary tract infection, pressure ulcer, bacteremia, and local infection of the skin. The infection reports had no documentation that could be reviewed for infection onset dates, signs and symptoms, laboratory tests/results, isolation, and outbreak potential. During an interview on 04/10/25 at 10:51 AM with the Assistant Director of Nursing Infection Preventionist, they stated they were responsible for tracking infections. They further stated the list of infections for March 2025 and April 2025 was a report of residents that were placed on antibiotic therapy. They stated they did not have line list documentation for infection onset date, signs and symptoms, laboratory tests/results, radiology tests/results, precautions and isolation. During an interview with Director of Nursing on 04/15/25 at 1:48 PM, they stated the Assistant Director of Nursing Infection Control Preventionist was responsible for surveillance of infections. They stated a surveillance report should include date of onset of symptoms, signs and symptoms, laboratory tests and results, isolation and outbreak potential. They stated the Infection Control Preventionist would revise the line list. 10 NYCRR 415.19 (b) (4)

Based on observation, interview, and record review, conducted during the recertification survey from 4/10/2025 to 4/16/2025, the facility did not ensure proper storage, preparation, distribution, and service of food in accordance with professional standards for food safety. Specifically, 1) the kitchen had damaged tile and linoleum flooring and 2) staff did not wear a hairnet in order to prevent hair from contacting food. The findings include: A facility policy dated 3/1/2022 and titled Preventive Maintenance and Inspections documented Preventive Maintenance is the care and servicing by personnel for the purpose of maintaining fixtures, equipment and facilities in a satisfactory operating condition by providing for systematic inspection, detection and correction of incipient failures either before they occur or before they develop into major defects. A schedule is developed to delineate all inspections that are to be completed on a regular basis. Inspections verify that all equipment and furnishing are in working order, esthetically pleasant, clean and free from safety hazards. Kitchen will be inspected and documented weekly. A facility policy dated 11/14/2024 and titled Foodborne Handling and Preparation to Reduce Foodborne Illnesses documented it is the policy of this facility to ensure that all foods are handled and prepared in a manner that is sanitary and reduces the risk of foodborne illnesses. Food service staff will present themselves in a manner appropriate for the kitchen, with clean clothing, hair covered, facial hair covered and fingernails trimmed. Food Service Director/Designee will monitor sanitation procedures regularly and adjust tasks as needed. During the initial tour of the kitchen on 04/10/2025 at 9:20 AM, with the Food Service Director, observation of the area around the dishwashing machine and pot washing sink revealed damaged tile flooring which formed an uneven and wobbly surface. Observation of the paper products storage room revealed damaged linoleum flooring which formed an uneven surface. The Food Service Director was interviewed during the observation and stated they were aware of the broken tiles and cracked linoleum but had not reported it to the Maintenance Department. During a follow up visit to the kitchen and observation of tray line on 04/10/2025 at 11:33 AM, dietary service aide # 10 entered the kitchen without a hairnet and passed the tray line towards the beverage area. When interviewed during the observation, dietary service aide #10 stated they knew they were supposed to wear a hairnet but did not wear one. During an interview on 4/10/2025 at 11:42 AM the Director of Food Service stated they were responsible for making sure staff wore hair covering when entering the kitchen area. They further stated that they had instructed all the dietary service staff to wear a hairnet when entering the kitchen. During an interview with Director of Maintenance/Housekeeping on 04/16/25 at 12:26 PM, they stated they inspected the kitchen equipment but had not checked the kitchen floor in the last 6 months. They stated that they were not aware of broken tiles or cracked linoleum in the kitchen. 10NYCRR 415.14(h)

Based on record review and interviews conducted during the recertification survey from ,d+[DATE]-[DATE], the facility did not ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after a change in condition and conversion to comfort care for 1 of 1 residents investigated for death . Specifically, Resident #113 was admitted to the facility for short term rehabilitation, had a decline in condition during their stay, elected comfort care, and expired at the facility, and the Comprehensive Care Plan did not reflect these changes. Findings include: Resident #113 was admitted to the facility for short term rehabilitation with diagnoses that included fracture of pubis, bacteremia, and pain. The Admission Minimum Data Set, dated dated dated [DATE] documented the resident had intact cognition; was dependent on staff for all activities of daily living except eating; and received physical and occupational therapy. The Facility Policy titled Comfort Care/Palliative Care, last reviewed [DATE], documented that Nursing will initiate and maintain a comprehensive care plan to ensure accurate and current information of resident wishes are being reflected. The Facility Policy titled Comprehensive Care Planning, last reviewed [DATE], documented the facility will develop and implement a comprehensive person-centered care plan for each resident and updates to the care plan will be completed as needed, with changes in treatment, needs, and condition. Social Services note dated [DATE] documented Resident #113 was admitted to the facility for short term rehabilitation with the intention of returning home where he lived with his wife after completing rehabilitation. The Medical Orders for Life-Sustaining Treatment form dated [DATE] documented Resident #113's advance directives were Do Not Resuscitate, Do Not Intubate, Do Not Hospitalize unless pain or severe symptoms are not controlled, no feeding tube, and to determine use of antibiotics when infection occurs. Nursing progress notes dated [DATE]-[DATE] documented changes in Resident #113's condition including jumbled words, changes in urinary pattern, hematuria, and oxygen use. Resident #113's Respiratory Care Plan, last updated on [DATE], did not reflect the use of oxygen as an intervention. Nursing progress notes dated [DATE] documented a change in Resident #113's condition including not eating, temperature increase, and a change in their breathing pattern. Nursing progress note dated [DATE] documented a further decline in Resident #113's condition. The Registered Nurse notified the family and physician of the resident's condition, orders were received to hold all medications and provide comfort measures. The family visited and requested last rites for resident. Physician Order dated [DATE] documented Comfort Care. There was no documented evidence of a care plan for Comfort Care for Resident #113. Resident #113's Psychosocial Care Plan and Discharge Care Plan, both last updated on [DATE], did not reflect any changes to goals for discharge or new interventions for psychosocial support despite resident change in status. Physician Orders dated [DATE] and [DATE] documented Morphine Sulfate Concentrate 20 MG/ML 0.25 ml By Mouth Every 4 hours as needed. Resident #113's Pain Care Plan, last updated on [DATE], and Respiratory Care Plan last updated [DATE], did not reflect the addition of morphine for pain management or shortness of breath. Nursing progress note dated [DATE] documented Resident #113 with agonal breathing, Physician and family notified resident actively dying. Nursing progress Note dated [DATE] documented Resident #113 pronounced dead at 12:15 AM, Physician and family notified. During an interview on [DATE] at 2:04 PM, Licensed Practical Nurse Unit Manager #2 stated Resident #113 was admitted for short term rehabilitation, had a change in condition during their stay, and then passed away at the facility. Resident #113 did not want to be hospitalized . Stated they can update care plans but cannot initiate them. New orders or a change in condition would warrant an update to the care plan and new orders did transfer over to Resident #113's care plan, but they did not revise the care plan any further when Resident #113 was declining and converted to Comfort Care. During an interview on [DATE] at 03:06 PM the Director of Social Work and Social Worker #1, stated they would typically have a meeting to discuss a change in resident's condition and update the care plan as applicable. They only had an interdisciplinary care plan meeting for Resident #113 prior to their decline. They did not make any changes or updates to the care plan when Resident #113 was declining or when they elected comfort care. During an interview on [DATE] at 10:01 AM and follow up interview on [DATE] at 2:55 PM, the Director of Nursing stated that care plans were initiated shortly after admission. Care plans would be updated when new orders came in or if there was a change in a resident's status. They stated the new orders came over to a general care plan for Resident #113, and some areas on the Care Plan were updated, but the care plan was not updated to reflect Resident #113's overall decline or comfort care. 10 NYCRR 415.11(c)(2)(i-iii)

Based on record review and interviews during an abbreviated survey (NY00362632) the facility did not ensure the physician reviewed the resident's total program of care, including treatments at each visit and a decision about the continued appropriateness of the resident's current medical regimen for 1 out of 3 residents (Resident #1, #2) reviewed for Foley catheter use. Specifically, (1) Resident #1 was admitted to the facility with a Foley catheter on 10/18/2024. Attending Physician #1 did not address Resident #1's Foley catheter when they completed their history and physical. The history and physical documented Resident #1 had stress incontinence and the catheter section documented not applicable. Resident #1 was discharged back to the hospital on 11/14/2024 with the foley catheter still in place. (2) Resident #2 was admitted to the facility with a Foley catheter on 11/16/2024. Attending Physician #1 did not address Resident #2's Foley catheter when they completed their history and physical. The history and physical documented Resident #2 had stress incontinence and the catheter section documented not applicable. Resident #2 still had a foley catheter in place during the onsite visit. The findings are: The facility Physician's Visit policy dated 2/1/2016 and last revised 1/2020 documented the attending physician must make visits in accordance with applicable state and federal regulations. The attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. 1)Resident #1 was admitted with diagnoses including but not limited to Sepsis, Malignant Neoplasm of the Prostate and Bacteremia. A Comprehensive Minimum Data Set (a tool that measures health assessment) dated 10/24/2024 documented the resident had moderate cognitive impairment. The resident had impairment to the upper extremities on both sides and required a walker or a wheelchair for locomotion. The resident required moderate assistance with eating, maximal assistance with bed mobility and was dependent for toileting and transfers. The resident had an indwelling catheter and was always incontinent of bowel. Review of Attending Physician #1's history and physical documentation dated 10/18/2024 revealed Resident #1's Foley catheter use was not documented or addressed for appropriateness of continued use. Resident #1 was documented to have stress incontinence and the catheter status stated not applicable. 2) Resident #2 admitted to the facility admitted to the facility 11/15/2024 with diagnoses including but not limited to Malignant Neoplasm of Bladder, Hyperkalemia and Hypotension. A Comprehensive Minimum Data Set (an assessment tool that measures health status) dated 11/20/2024 documented the resident had moderate cognitive impairment. The resident was dependent for all cares. The resident had a indwelling catheter and was always incontinent of bowel. Review of Attending Physician #1's history and physical documentation dated 11/16/2024 revealed Resident #2's Foley catheter use was not documented or addressed for appropriateness of continued use. Resident #2 was documented to have stress incontinence and the catheter status stated not applicable. During an interview on 12/5/2024 at 1:48 PM the Director of Nursing stated foley catheters orders for discontinuation are determined by the physician. When the physician comes they review the resident's chart, they complete the history and physical and they also complete monthly assessments including addressing the Foley catheter and document. During an interview on 12/6/2024 at 2:14 PM Attending Physician #1 stated they have been servicing the facility for about a year now. Attending Physician #1 stated the history and physical documentation dated 10/18/2024, regarding Resident #1 having stress incontinence and the catheter being not applicable was a documentation error reflected from the hospital documentation. The provider could not provide a reason why the residents were not offered a void and trial or a discontinuation of foley catheters. 10NYCRR 415.15(b)(2)(iii)

Based on record review and interviews during an abbreviated survey (NY00362632) the facility did not ensure that a resident who entered the facility with an indwelling catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that catheterization was necessary for 2(Resident #1,#2) out of 3 residents reviewed for indwelling catheters. Specifically, (1) Resident #1 was admitted to the facility on [DATE] with a Foley catheter in place, and they were never assessed or trialed for the Foley catheter removal, as per the facility policy. (2) Resident #2 was admitted to the facility on [DATE] with a Foley catheter in place, and they were never assessed or trialed for the Foley catheter removal, as per the facility policy. The findings are: The facility Catheter Care, Urinary policy dated 2/1/2017 and last revised 11/1/2019 documented the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Catheter Evaluation included review and document the clinical indications for catheter use, nursing and the interdisciplinary team should assess and document the ongoing need for a catheter that is in place, use a standardized tool for documenting clinical indications for catheter use and remove the catheter as soon as it is no longer needed. 1)Resident #1 was admitted with diagnoses including but not limited to Sepsis, Malignant Neoplasm of the Prostate and Bacteremia. A Comprehensive Minimum Data Set (a tool that measures health assessment) dated 10/24/2024 documented the resident had moderate cognitive impairment. The resident had impairment to the upper extremities on both sides and required a walker or a wheelchair for locomotion. The resident required moderate assistance with eating, maxima assistance with bed mobility and was dependent for toileting and transfers. The resident had an indwelling catheter and was always incontinent of bowel. Review of a urinary incontinence care plan dated 10/23/2024 documented Resident #1 had a potential for urinary incontinence secondary to their foley catheter. Interventions listed included encourage oral fluids, encourage/support resident to use call bell to notify staff of need to void, monitor for signs and symptoms of urinary tract infection and monitor output as needed. Review of a Foley catheter care plan dated 10/23/2024 documented Resident #1 had altered elimination pattern related to the Foley catheter. The goal was the catheter would be patent and draining every shift. Interventions listed included attempt to remove catheter when appropriate, catheter care every shift, change Foley every 30 days and as needed, ensure urinary drainage bag is covered and monitor for and document signs and symptoms of urinary tract infection. There was no documented evidence of Resident #1's clinical indication for continued catheter use or any assessments by the interdisciplinary team documenting the ongoing need for the Foley catheter in place. There was no evidence of Resident #1 having a voiding trial to evaluate if their Foley catheter could be removed. 2) Resident #2 was admitted with diagnoses including but not limited to Malignant Neoplasm of Bladder, Hyperkalemia and Hypotension. A Comprehensive Minimum Data Set (an assessment tool that measures health status) dated 11/20/2024 documented the resident had moderate cognitive impairment. The resident was dependent for all cares. The resident had an indwelling catheter and was always incontinent of bowel. Review of a urinary incontinence care plan dated 11/14/2024 documented on 11/21/2024 Resident #2 had a Foley. Interventions listed included monitor output as indicated. There was no documented evidence of Resident #2's clinical indication for continued catheter use or any documentation or assessments by the interdisciplinary team regarding the ongoing need for the Foley catheter in place. There was no evidence of Resident #2 having a voiding trial to evaluate if their Foley catheter could be removed. During an interview on 12/5/2024 at 1:48 PM the Director of Nursing stated if a resident comes to the facility with a Foley catheter, and they do not have a Urology consult in place, the physician will review the chart and decide on whether to remove the foley catheter or not. During an interview on 12/6/2024 at 2:14 PM, the Attending Physician #1 stated Resident #1 presented with a history of prostate cancer, sepsis and urinary tract infection and they were on intravenous antibiotics. Attending Physician #1 stated if a resident is admitted to the facility with a catheter, then it is protocol to wait 2 or 3 days to determine if it can be removed. During an interview on 12/6/2024 at 5:00 PM Licensed Practical Nurse #2-unit 2 manager stated generally if a Foley catheter is not for long-term use, then the residents are usually started on Flomax and a voiding trial to try and remove the foley catheter. Licensed Practical Nurse #2-unit 2 manager stated depending on what is happening with the resident, the physician decides when the foley catheter is removed. During the void trials if the resident has not voided in 8 hours or has pain, or distention then the physician is informed, and the Foley catheter may be re-inserted. There was no documented evidence that a voiding trial was initiated for Resident #1. Resident #1 was discharged to the hospital on 11/14/2024 with foley catheter in place. 10NYCRR 415.12(d)(2)

Based on interview, and review of facility records during the Recertification Survey beginning on 1/31/2023 and ending on 2/7/2023, the facility did not ensure sufficient nursing staff to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the resident population in accordance with resident needs. Specifically, three of three resident care units reviewed for sufficient staff did not consistently meet the facility staffing minimum. In addition, during a Resident Council meeting, residents verbalized staffing was inadequate. Findings include: The facility Staffing Policy and Procedure, revised 3/5/2020, documented for the facility to provide adequate staffing on each shift to ensure that our resident's needs and services are met. During a Resident Council meeting on 2/3/23 at 10:03 AM members expressed concerns about the lack of staff available to provide care to the residents. Resident Council members stated they felt that things had changed drastically since the onset of Covid-19. Staff were constantly being removed to help on other units. Members stated the more regular nurses were being sent to other units and agency nurses were floated to the unit and often did not know the residents' plan of care. In addition, the Resident Council stated they did not have enough CNAs and the recreation aides were pulled to be CNAs on the units. During an interview on 2/7/23 at 4:00 PM, the staffing coordinator (SC) stated she started working as the SC in May 2021 and was directed to staff the units according to the PAR levels unless the unit census dropped below 30 residents. The minimum staffing requirements were confirmed as: - Day shift -Unit P1 - 3 CNAs and 1 nurse; Unit P2 - 3 CNAs and 2 nurses; and Unit P3 - 3 CNAs and 1 nurse. - Evening shift - Unit P1 - 3 CNAs and 1 nurse; Unit P2 - 3 CNAs and 2 nurses; Unit P3 - 3 CNAs and 1 nurse. - Night shift - Unit P1 - 2 CNAs and 1 nurse; Unit P2 - 2 CNAs and 1 nurse; Unit P3 - 2 CNAs and 1 nurse. Review of the census and daily nursing staffing sheets for October, November and December 2022 confirmed staffing was below the PAR levels on the following days: - On 10/2/22, Unit P1 had 40 residents and 1 CNA and 1 Temporary Nursing Assistant (TNA) on day shift. - On 10/23/22, Unit P3 had 40 residents and 2 CNAs on day shift. - On 10/30/22, Unit P3 had 40 residents and 2 CNAs on day shift. - On 11/12/22, Unit P2 had 40 residents, 2 CNAs on the evening shift. - On 12/3/22, Unit P1 had 40 residents and 1 CNA on night shift; Unit P3 had 39 residents and 2 CNAs and 1 LPN on the day shift. - On 12/4/22 , Unit P1 had 40 residents, 2 CNAs, 1 LPN on the day shift, and 1 CNA on the night shift; Unit P3 had 39 residents and 2 CNAs and 1 LPN on the day shift. - On 12/10/22, Unit P3 had 39 residents, 1.5 CNAs, and 1 LPN on the evening shift. - On 12/11/22, Unit P1 had 39 residents, 2 CNAs and 1 LPN on day shift; Unit P2 had 36 residents and 1 CNA on day shift and 1 LPN on evenings, - On 12/17/22, Unit P1 had 38 residents with 2 CNAs and 1 LPN on evening shift, and Unit P3 had 39 residents and 1 CNA on night shift. - On 12/18/22, Unit P1 had 38 residents with 2 CNAs and 1 LPN on day shift, 2 CNAs and 1 LPN on evenings, and 1 CNA on nights; Unit P2 had 32 residents with 2 CNAs on evening shift; and Unit P3 had 2 CNAs and 1 LPN on day shift, and 2 CNAs and 1 LPN on evening shift. - On 12/24/22, Unit P1 had 38 residents with 2 CNAs and 1 LPN on day shift, and 2 CNAs on evening shift; Unit P2 had 31 residents with 2 CNAs on day shift, and 2 CNAs on evening shift. Unit P3 had 40 residents with 2 CNAs and 1 LPN on day shift. - On 12/25/22, Unit P1 had 38 residents with 2 CNAs and 1 LPN on day shift, 2 CNAs and 1 LPN on evening shift, and 1 CNA on night shift. Unit P3 had 31 residents with 2 CNAs and 1 LPN on evening shift and 1 CNA on night shift. - On 12/31/22, Unit P1 had 40 residents with 1 LPN on evening shift and 1 CNA on night shift; Unit P3 had 1 CNA on night shift. During an interview on 02/07/23 at 4:15 PM, Registered Nurse (RN #2) stated when they had 1 nurse and 2 CNAs per unit it was not sufficient staffing. RN #2 stated they had about 18 residents who needed Hoyer lift transfers and when short staffed, had to start putting people to bed around 4 PM. During an interview on 02/07/23 at 4:18 PM, LPN #2 stated they were responsible for 40 residents and usually had 2 CNAs on the unit. When there was not sufficient staffing it caused increased wait times. LPN #2 stated there was not much difference between weekdays and weekends. LPN #2 stated they were often asked to stay for the night shift. During an interview on 02/07/23 at 4:32 PM, LPN #3 stated they had 38 residents, with 2 CNAs and 1 LPN at times. LPN #3 stated it became more stressful when CNAs were dealing with residents with behaviors. LPN #3 stated the impact of having less staff made it difficult to do their job. LPN #3 stated they did the best they could with residents' preferences for going to sleep but at times would have to put the residents to bed early. During an interview on 2/07/23 at 4:41 PM, CNA #5 stated there was not enough staff to manage resident care. CNA #5 stated when a resident needed assistance of 2 staff it could be difficult to complete assignments. CNA #5 stated sometimes they had to put residents to bed early as a result. Residents at times could be waiting 20 minutes after ringing the call bell when the 2 CNAs were busy helping one resident that needed a 2 person assist. CNA #5 stated that they often had to stay an extra shift and management was aware that there was a need for more staffing. During an interview on 02/07/23 at 4:47 PM, the Assistant Director of Nursing (ADON)stated they felt there was not enough staff in the building to manage resident care, as staff often reported that they needed help and had difficulty completing their assignments. The ADON stated they usually had a difficult time staffing facility. The ADON stated that due to staff feeling overworked there was burnout which resulted in call outs. The ADON stated they felt resident needs were not completely being met. During an interview on 02/07/23 at 4:49 PM, the Administrator stated they were aware of staffing concerns and the staff call outs can at times affect resident care. The Administrator stated the Resident Council President had brought staffing concerns to his attention. During an interview on 02/07/23 at 4:54 PM, the Director of Nursing (DON) stated some days were better than others with staffing and they could be short staffed at times. The DON stated they were aware they had not been meeting their staffing minimums. 415.13(a)(1)(i-iii)

Based on observation, record review, and interview during the recertification survey from 1/31/23 through 02/7/23, the facility failed to ensure residents remained free of accident hazards, for 1 of 3 resident reviewed for accidents. Specifically, Resident #60 was not provided liquids in the prescribed consistency, and was not provided supervision during meals as planned. Findings include: Resident # 60 had diagnoses including Cerebral Vascular Event with a Hemiplegia (one side of body paralyzed), Dysphagia (difficulty swallowing) and history of pneumonia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview Mental Status (BIMS) Score of 15 indicating his/her cognition was intact. The resident required supervision for eating; complained of difficulty or pain with swallowing; and required a mechanically modified diet. Review of the physician orders dated January 2023 documented nectar thickened liquids. Review of the Activities of Daily Living (ADL) Care Plan, revised 1/10/23, documented to escort the resident in and out of the Dining Room for meals, position appropriately at the table, provide items within reach, and provide continued help. Review of the Nutrition Care Plan, revised 1/25/23, documented aspiration and choking precautions were in place. Review of the Speech Therapy Evaluation dated 1/11/23 documented resident (#60) was referred to Speech Therapy for Dysphagia and swallowing treatment 2-5 times per week. Review of Discharge Summary for Speech Therapy dated 2/1/2023 documented recommendations for ground solids and nectar thick liquid per hospital swallow evaluation. During an observation on 01/31/23 at 12:26 PM in the main dining room, Resident #60's meal ticket documented a modified diet, built up utensils, nectar thickened tea, 2 packets of thickener and to provide 2 mugs. The tea was thickened at the table by the recreation aide (RA) using 1 teaspoon of thickener per cup, from the Active Food Thickener container. During an interview on 01/31/23 at 12:57 PM, with the Recreation Aide (RA) regarding thickened liquids, the RA stated I put the thickener in and keep checking it until it is the correct consistency. During an Observation on 02/02/23 at 12:18 PM, the Resident's meal tray had two 8 ounce (oz.) cups for tea and an additional 4 oz. bottle of thickened water. CNA #4 took 1 scoop of thickener into each of the residents' 2 cups for tea from the Active Food Thickener container. The meal tray ticket documented to use 2 packets of thickener. No packets were used. The packets where unavailable in the main dining room. During an interview on 2/2/2023 at 1:00 PM, Certified Nurse Assistant #4 (CNA #4) stated he/she knew how to measure the thickener. CNA #4 stated it says on the container 1 scoop is for nectar thick. CNA #4 stated they had education regarding thickening liquids from nursing. Review of the instructions on the Active Food Thickener container documented to use 1 tablespoon plus 1/2 teaspoon or use 1 large scoop and a 1/2 a small scoop of thickener to make nectar thick liquids. During an interview on 02/02/23 at 4:00 PM, the Registered Dietician (RD) stated the big scoop was 1 tablespoon, and the small scoop was 1 teaspoon. The RD stated at lunch she/he noted the tea was not the correct consistency and could have been a little thicker. The RD stated she/he thought the proper amount of thickener was added. During a telephone interview on 02/03/23 at 03:40 PM, the Speech Therapist (ST) stated Resident #60 was at risk for aspiration pneumonia. When he/she evaluated the resident it was determined the resident would aspirate thin liquids and he/she recommended the continuation of nectar thick liquids. During a meal observation on 2/4/2023 at 5:15PM, Resident #60 was eating alone in his room with no staff present. During an interview on 2/6/2023 at 3:15 PM with LPN #3 stated she was aware Resident #60 required supervision at meals and assumed staff was present since the roommate required assistance. 415.12

Based on observation, record review and interview conducted during 1/31/23-2/7/23 Recertification Survey the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and/or the comprehensive person centered care plan for 1 of 5 residents (#24) reviewed for pressure ulcers and 1 of 1 resident (Resident #65) reviewed for skin conditions. Specifically, 1) bilateral heel protectors were not applied for Resident #24 who was assessed as high risk for pressure ulcers and had bilateral heel pressure ulcers and 2) the facility did not provide routine wound assessments and or skin checks for Resident #65 assessed with right heel bogginess upon admission. The findings are: 1. Resident #24 was admitted with diagnoses including Peripheral Vascular Disease, Renal Insufficiency and Stage 3 Left Heel pressure ulcer (PU). The 8/15/22 Admission Minimum Data Set (MDS, a resident assessment and screening tool) documented the resident had a Brief Interview Mental Status (BIMS) score of 14 which indicated cognition was intact. The resident required extensive assistance of 1 person for bed mobility and toileting; extensive assistance of 2 persons for transfer; and had (1) stage 3 PU that was present upon admission. The 8/30/22 Left Heel DTI (Deep Tissue Injury) Care Plan documented a pressure ulcer of the left heel, unstageable with an onset date of 8/8/22. Left heel stage 3 with an onset date of 12/20/22. The interventions indicated heel protectors for pressure relief, left heel protector/boot to be worn at all times for pressure relief, remove for care and skin check. The 12/23/22 Quarterly MDS documented the resident had a Brief Interview Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. The resident was totally dependent x 2 staff assistance for for bed mobility, transfer and toileting; and had (2) stage 3 PU's. The 1/9/23 Right Heel Pressure Ulcer Care Plan documented a pressure ulcer of the right heel, stage 3 with an onset date of 11/2/22. The interventions indicated right heel protect/boot to be worn at all times for pressure relief, remove during care and skin check. The 1/9/23-2/7/3 Certified Nurse Assistant Accountability sheets documented bilateral heel boots to be worn at all times. There was no documented evidence that bilateral heel boots were applied on 1/11-1/13/23, 1/16/23, 1/18/23, 1/20-1/22/23, 1/24/23-1/30/23, 2/1/23, 2/3/23 and 2/7/23. During an observation on 1/31/23 at 12:38 PM Resident #24 was in their geri chair with bandages to both feet. There were no heel protectors/ offloading devices observed. During an observation on 2/2/23 at 10:28 AM Resident #24 was in bed with both legs bent up toward the chest. Both feet were wrapped with a dressing. There were no heel protectors/ offloading devices observed. During an observation on 2/3/23 at 2:38 PM Resident #24 was in their geri chair and both feet were resting on the geri chair footrest. There were no heel protectors/off loading devices observed. During an interview on 2/07/23 at 1:30 PM with the Registered Nurse Unit Manager (RNUM #1), RNUM #1 stated they had not seen the bilateral heel booties on the resident until yesterday when the resident was being seen by rehab. RNUM #1 stated rehab usually notified nursing if a resident needed heel booties. RNUM #1 stated if the heel booties were scheduled to be put on in the morning the CNA would put them on. RNUM #1 stated if the resident was supposed to be wear heel booties for 24 hours, then the CNA would take the booties off for care or hygiene and then put them back on. During an interview on 2/07/23 at 2:38 PM with Certified Nurse Assistant (CNA #2), CNA #2 stated they had never seen heel booties on the resident or been informed to use them. CNA #2 stated they were unaware that they were supposed to document in the CNA accountability for the bilateral heel booties. During an interview on 2/07/23 at 3:21 PM with the Wound Nurse Practitioner (WNP), The WNP stated the positioning device or heel booties were to be used to relieve pressure and help with the wound healing process. 2. The facility Policy and Procedure titled Pressure Injury Assessment and Protocol dated 10/2018 documented resident's skin is viewed and evaluated/inspected regularly by the direct care giver/certified nurse's aide and any changes in condition or unusual findings will be reported to the nurse immediately. Resident #65 was admitted to the facility on [DATE] and with diagnoses which included Diabetes Mellitus Type 2, Peripheral Vascular Disease, Dementia, and diabetic ulcers on the left heel and left malleolus (ankle). The 12/16/2022 Nurse's Admission note documented right heel boggy. The 12/16/2022 Braden Assessment documented 14 (moderate risk) for breakdown. Th 12/19/2022 Risk for Impaired Skin Integrity Care Plan documented interventions included cleanse skin with AM and PM care, report changes to the nurse, heel boots right and left worn in and out of bed, offload heels, pressure relief mattress, skin checks weekly and sign TAR by nurse. The 12/23/2022 Admission Minimum Data Set documented the resident had a BIMS score of 3 which indicated severe cognitive impairment and required extensive assistance with bed mobility. Resident is at risk for developing pressure ulcers., Infection of the foot, Surgical Wound. No Pressure Ulcer or Vascular Ulcers. Interventions Pressure reducing device in chair, pressure reducing device in bed, nutrition or hydration intervention, surgical wound care, application of non surgical dressing, application of ointments/medications other than to feet. The 1/25/2023 Physician's order documented skin prep to bilateral heels. The 1/25/2023 through 2/5/2023 Treatment Administration Records (TAR) documented skin prep to the resident's bilateral heels as ordered. There was no documented evidence in the TAR that weekly skin checks were conducted from 12/2022-2/2023. There was no documented evidence in the wound care nurse consult notes that a right heel assessment was conducted 12/27/2022, 1/3/2023, 1/10/2023, and 1/24/2023. On 2/6/23 at 3:20 PM, a wound care observation was conducted. When the resident's right sock was removed by the Licensed Practical Nurse (LPN #2), brown drainage was noted covering the heel area of the sock. The heel of the right foot was discolored, dark and had drainage. During interview on 2/6/2023 at 3:20 PM with LPN #2 they stated this was the first time they saw any issues with the resident's right foot. LPN # 2 stated they had been providing treatments to the resident's left foot and never noted any issues with the resident's right foot. During an interview on 02/07/23 at 11:20 AM with the Wound Nurse Practitioner (WNP), they stated they had been following the resident's left foot wounds and did not recall ever seeing the resident's right foot. The WNP stated they would have checked the right foot when they first started seeing the resident, but were not aware of the resident's boggy right heel. During an interview on 02/07/23 at 12:14 PM, CNA #2 stated when the resident was transferred to the unit approximately 2 weeks ago, the resident had treatments on both feet. CNA #2 stated they were the regular aide responsible for the resident's care on the day shift, but had not removed the resident's socks on that day. CNA #2 stated they had not noted anything on the right foot prior. 483.25 (b)(1) 47626

Based on observation, interview, and record review conducted during Recertification Survey between 1/31/2023 -2/7/2023, the facility did not ensure they provided a safe, clean, comfortable, and homelike environment. Specifically, on 3 of 3 units there were window curtains hanging off the tracks, peeling chipped wall paint, damaged sheet rock, and dirty/stained bed mattress were observed. The findings are: The facility Policy and Procedure titled Preventive Maintenance and Inspections documented routine inspections to promote safety throughout the facility and aid in keeping fixtures and equipment in good working order and operating in accordance with manufacturer's guidelines. The policy further documented Interior inspection of windows, screens, walls, doors and door frames, paint/wall coverings, and flooring would be conducted and documented monthly. During observation tours of units 1, 2, and 3 on 1/31/23, 2/1/23, 2/2/23, and 2/6/23 the following were observed: - window curtains hanging off the tracks in rooms 115, 118 and 137. - peeling chipped wall paint in rooms [ROOM NUMBER] and in the unit 3 dining room. - damaged sheet rock in room [ROOM NUMBER]. - a dirty bed mattress with dark brown stains in room [ROOM NUMBER]. During an interview on 2/6/23 at 3:30 PM, Resident #88 stated the damaged sheet rock in their room had been in this condition for some time and nothing had been done to repair it. During an interview on 2/7/23 at 1:17 PM, the Director of Maintenance (DOM) stated a sample of the rooms were toured by maintenance staff daily. The maintenance department was made aware of issues when input in the facility work order system (Tels). The DOM stated they were aware of the curtains hanging off the track and damaged walls in multiple resident rooms and were in the process of addressing the issue. The DOM stated they were not aware of the damaged wall in the unit 3 dining room. During an interview on 2/7/23 at 1:46 PM, the Registered Nurse Unit Manager (RNUM#1) stated nursing staff would report maintenance issues using Tels. Sometimes nursing would inform the unit supervisor of the concern, and the supervisor would put the work order in Tels. The RNUM #1 stated chipped wall paint and hanging curtains were issues that should have been reported by staff to the maintenance department. RNUM #1 was unaware of the condition of Resident #75 mattress. During an interview on 2/07/23 at 1:56 PM, Certified Nursing Assistant (CNA #3) stated they were told to go to the front desk and ask to speak with maintenance to report a concern. CNA #3 stated they were not aware of Tels system process. During an interview on 2/07/23 at 2:29 PM, CNA #2 stated they were not certain if the stains on the mattress of Resident #75 were urine stains, as the resident is always incontinent. CNA #2 stated they did not report the condition of the mattress to anyone because the mattress did not have any rips or a bad deep dip. CNA #2 stated Resident #75 needed a new mattress. CNA #2 stated concerns were reported to the nurse and the nurse was responsible for putting in a work order to maintenance. 415.5(h)(2)

Based on observation, interview and record review the facility did not ensure that proper cooling procedures were implemented for food that was cooked and cooled to be used at a later date. Specifically, temperature logs used to document cooling temperatures to ensure that food is cooled according to acceptable timeframes were not being completed. The findings are: Initial tour of the kitchen was conducted on 12/03/19 at 10:38 AM. A cooked whole roast beef was observed in the walk-in refrigerator. It had not been cut into smaller pieces for proper cooling. Ground and pureed turkey were also observed in the walk-in refrigerator. The Food Service Director (FSD) stated the turkey had been cooked ahead of time, taken off the bone and used for the ground and puree diets. When asked about proper cooling procedures he verbalized the cooling procedure with the required timeframes and looked for cooling logs but could not find any. The FSD stated there were no cooling logs to make sure food was cooled according to acceptable procedures. He stated there was no way of knowing if the roast beef was cooled properly so he would throw it out. The turkey would be reheated to 165 degrees (a temperature that is high enough to destroy any potential bacterial contamination). Potentially hazardous foods requiring refrigeration must be cooled by an adequate method so that every part of the product is reduced from 120 degrees Fahrenheit to 70 degrees Fahrenheit within two hours, and from 70 degrees Fahrenheit to 45 degrees Fahrenheit or below within four additional hours. Bacteria that cause food poisoning grow at temperatures between 45 degrees Fahrenheit and 120 degrees Fahrenheit. The cooling requirement limits the length of time that potentially hazardous food is in the temperature range at which harmful bacteria can grow. Foods particularly important to meet the cooling requirement include soups, sauces, gravies, stews, rice, chili, whole turkeys, turkey breasts and whole roast beef. Food temperatures should be measured with a stem thermometer. https://www.health.ny.gov/environmental/indoors/food_safety/coolheat.htm 415.14(h)

Based on observation, interview and record review during the recent recertification survey, it could not be ensured that the facility implemented care plan intervention for positioning devices. Specifically, Resident #[AGE] required wheelchair positioning devices in order to sit upright in the chair. This was evident for one resident reviewed for positioning. The findings are: Resident #[AGE] was admitted to the facility with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS; a tool to assess a resident's care needs) dated 3/5/19 indicated the resident was severely impaired for cognition. The assessment indicated that the resident required extensive assistance of one person for all Activities of Daily Living (ADLs) including bed mobility, transfers, locomotion, toilet use and personal hygiene. Review of the ADL care plan initiated on 6/26/19 included an intervention to provide assistive devices for independence in mobility and for positioning and support. The intervention was dated 8/7/19. The 10/29/19 significant change assessment indicated that the resident required extensive assistance of two people for most ADLs and required total assistance of one person for eating. The assessment indicated that the resident was receiving Occupational Therapy 155 minutes over 6 days. No end date was identified. Review of the Rehabilitation Communication Form dated 9/25/19 showed an order to discontinue Resident #[AGE]'s high back wheelchair, water gel cushion and overlay. The Resident is to utilize a standard hemi height wheelchair with a wedge seat cushion, lateral support with a head rest and an elevated calf/foot board. The form also recommended that the round blue foam headrest can be removed if Resident #[AGE] is actively holding her head in a neutral position. A travel pillow is given as well to help keep her head/neck in a neutral position while sleeping in the wheelchair. The following observations were made of the resident: 1. On 12/3/19 at 10:30AM, Resident #[AGE] was observed to be leaning to the right and sleeping in the wheelchair with the leg rests down during an activity. A rectangular board covered in black vinyl was in place on the right side of the wheel chair. Resident #[AGE]'s head was resting on the board. 2. On 12/3/19 at 12:30PM, Resident #[AGE] was observed to be positioned in the same manner as she was at 10:30AM. A family member placed a pillow in the chair, on the right side for positioning prior to assisting with lunch. 3. On 12/04/19 at 12:38 PM, Resident #[AGE] was observed to be leaning to the right with her head resting on the board without a pillow in place while in the dining room waiting for lunch. The leg rests were also down. 4. On 12/9/19 at 11:15AM, Resident #[AGE] was observed to be in the common area with a U shaped neck pillow around her neck as well as blue bolsters on either side for head and neck support. The foot rests were observed to be up. Review of the December 2019 Certified Nurse Aide (CNA) Accountability Record for Resident #[AGE] was reviewed and did not include instructions to apply positioning devices for Resident #[AGE]. In an interview with the RN unit manager on [DATE] 9:40AM she explained that the CNAs are responsible for applying the positioning devices. When asked how the Occupational Therapy (OT) recommendations are communicated to the CNA, she stated that the information is added to the CNA Accountability Record. She was unaware that the instructions were not transcribed onto the CNA Accountability Record. The CNA who was caring for the resident was interviewed on [DATE] at 10:35AM regarding the positioning devices, she stated that she knows the bolsters are supposed to be applied along with the gel cushion. She stated there is another positioning device that seems to be missing (the resident was still in bed). She stated she knows to apply the positioning devices. She could not say why the devices had not been in place during the initial observations. 415.11(c)(1)

Based on record review and interview during the recent recertification survey, it could not be ensured that the facility reviewed, revised and updated a nutrition care plan to address the declining nutritional status for Resident #82. This was evident for 1 of 4 residents reviewed for nutrition. The findings are: Resident #82 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS; a tool to assess care needs of a resident) dated [DATE] included the following [DIAGNOSES REDACTED]. Review of the resident's weights showed that in [DATE], Resident #82 weighed 1[AGE].8lbs and no significant weight loss or gain was identified in the previous ,[DATE] months. The [DATE] quarterly assessment was reviewed and indicated the resident's weight was 166 lbs at the time of the assessment. A significant weight loss was identified; however the resident was not on a physician prescribed weight loss program. The following was the resident's weight history from [DATE] through [DATE] showing a 56.8 lbs weight loss: January - 1[AGE].8 lbs February - 1[AGE].5 lbs March - 1[AGE].0 lbs [MEDICAL CONDITION] lbs May - no weight June - 158.0 lbs July - 1[AGE] lbs Sept - 150 lbs Oct - 142.2 lbs Nov. - 141.8 lbs Dec - 130 lbs Review of the Nutrition care plan initiated on [DATE] indicated that Resident #82 has selective erratic eating patterns, leaving 25% or more at most meals. A [DATE] care plan update included a Liquid Protein Supplement. The last update to the care plan was dated [DATE] and indicated the resident's diet was downgraded to puree consistency. It further noted that Resident #82 should alternate solids and liquids while being provided close supervision for meals. There were no interventions in the care plan that addressed the resident's 56.8lbs weight loss since [DATE]. In an interview with the consulting Registered Dietitian on [DATE] at 1:35PM she stated she had only been at the facility for 3 days and was focusing on the new admissions. She reviewed the medical record and could not find any notes from the previous dietitian regarding the resident's declining nutritional status. In an interview with the Director of Nursing (DON) regarding nutrition documentation she was unable to find any documentation in the EMR (electronic medical record). She stated it should be in the chart. She checked the chart and found the last documentation in the chart was dated [DATE]. In an interview with the RN unit manager on [DATE] at 2:20PM she stated that the resident recently lost 11 lbs between November and December. She stated that the Nurse Practitioner ordered a 3-day calorie count at that time (after the December weight had been taken). When asked about a dietitian addressing the weight loss, she stated there was no dietitian. She stated there was someone floating but not here all the time. The Nutrition care plan had not been reviewed, revised and updated with new interventions to address the resident's 56.8 lb weight loss since January and abnormal lab values since July. The resident expired on [DATE]. 415.11(c)(2)(i-iii)

Based on record review, observation and interview during the recent recertification survey, the facility did not ensure that acceptable parameters of nutritional status were maintained for Resident #82. This was evident for 1 of 4 residents reviewed for nutrition. The findings are: Resident #82 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS; a tool to assess care needs of a resident) dated [DATE] included the following [DIAGNOSES REDACTED]. Review of the resident's weights showed that in [DATE], Resident #82 weighed 1[AGE].8lbs and no significant weight loss or gain was identified in the previous ,[DATE] months. The [DATE] quarterly assessment was reviewed and indicated the resident's weight was 166 lbs at the time of the assessment. A significant weight loss was identified; however, the resident was not on a physician prescribed weight loss program. The following was the resident's weight history from [DATE] through [DATE] showing a 56.8 lbs weight loss: January - 1[AGE].8 lbs February - 1[AGE].5 lbs March - 1[AGE].0 lbs [MEDICAL CONDITION] lbs May - no weight June - 158.0 lbs July - 1[AGE] lbs Sept - 150 lbs Oct - 142.2 lbs Nov. - 141.8 lbs Dec - 130 lbs Review of the Nutrition care plan initiated on [DATE] indicated that Resident #82 has selective erratic eating patterns, leaving 25% or more at most meals. A [DATE] care plan update included a Liquid Protein Supplement. The last update to the care plan was dated [DATE] and indicated the resident's diet was downgraded to puree consistency. It further noted that Resident #82 should alternate solids and liquids while being provided close supervision for meals. There were no interventions in the care plan that addressed the resident's 56.8lbs weight loss since [DATE]. A Progress Note dated [DATE] indicated Appetite poor @ breakfast, good @ lunch. Must remind resident to swallow and not hold food in her mouth. At 10:30AM on [DATE] the resident was observed in an activity asleep in her wheelchair with food debris on her face. Prior to lunch the food had been cleaned off. During the lunch observation, before the resident had eaten, she was observed tilted over in her chair with what looked like pureed food coming out of her mouth. A [DATE] note indicated - Asked to see patient who was not eating much today. Confused and anxious. The current MD orders were reviewed which showed an order for [REDACTED]. Supplements identified were Liquid Protein Supplement 30ml daily initiated on [DATE] (documented on the care plan). Review of Progress Notes in the Electronic Medical Record (EMR) since [DATE] (when the EMR was instituted) revealed no evidence of any dietary progress notes written on this resident to address her weight loss and the low [MEDICATION NAME] and total protein levels. There was no evidence of a Nutrition Assessment done for this resident since [DATE]. In an interview with the consulting Registered Dietitian on [DATE] at 1:35PM she stated that she reviewed Resident #9's medical record and could not find any notes from the previous dietitian regarding the resident's weight loss. In an interview with the Director of Nursing (DON) on [DATE] regarding nutrition documentation she shared that she was unable to find any documentation in the EMR. She stated it should be in the chart. She checked the chart and confirmed that the last documentation in the chart was dated [DATE]. In an interview with the RN unit manager on [DATE] at 2:20PM she stated that the resident recently lost 11 lbs between November and December. She stated that the Nurse Practitioner ordered a 3-day calorie count at that time. When asked about a dietitian addressing the weight loss, she stated there was no dietitian. She stated there was someone floating but not here all the time. Review of the resident's food intake since [DATE] indicated that the resident ate mostly 25% at meals. Her fluid intake at meals ranged between 120ml and 350ml at meals. There was no evidence that there was any dietary intervention to address the resident's 56.8 lb weight loss since January. The resident expired on [DATE]. 415.12(i)(1)

Based on observation and interview conducted during a recertification survey, the facility did not ensure that staff followed proper hand hygiene during wound care treatment for 1 of 5 residents (#55) reviewed for pressure ulcers. The findings are: Resident #55 was admitted with [DIAGNOSES REDACTED]. The [DATE] physician's orders [REDACTED]. gauze moistened with ns, cover with carboflex, then reinforce with [MED] daily. A dressing observation was conducted on [DATE] at 9:05 AM and the following was observed: The Director of Nursing (DON) washed her hands, donned a pair of gloves and measured the sacral wound, removed the dirty gloves, without washing or sanitizing her hands donned another pair of gloves, cleansed the wound, removed the dirty gloves, proceeded to go through the residents drawer to obtain wound care supplies, without washing or sanitizing her hands donned another pair of gloves, packed the wound, removed the dirty gloves, donned clean gloves and applied the dressing. The Director of Nursing (DON) was interviewed on [DATE] at 12:10 PM, and stated by the time she realized she had not washed/sanitized her hands, it was too late. She further stated she was very nervous. 415.19(b)(4)

Based on observations, interviews, and record review conducted during the Recertification Survey, it could not be ensured that the facility reviewed each resident's drug regime to certify that they are free of unnecessary medications for 1 of 5 residents (Resident #9) reviewed for unnecessary medications. Specifically, a lack of documentation to indicate the continued use of an antipsychotic medication. The findings are: Resident #9 was admitted to the facility with [DIAGNOSES REDACTED]. The 3/2/19 Admission Minimum Data Set (MDS; an assessment tool) revealed that Resident #9 had severe cognitive impairment and displayed no maladaptive behaviors. The 9/2/19 Quarterly MDS revealed that Resident #9 had a Brief Interview of Mental Status (BI[CONDITION]) score of 9 indicating moderate cognitive impairment and displayed no maladaptive behaviors. Further review of the 9/2/19 MDS showed that Resident #9 had [DIAGNOSES REDACTED]. At the time of the facility survey care plans were not provided despite several surveyor requests. Review of Resident #9's Electronic Medical Record (EMR) showed physician's orders [REDACTED]. Review of Resident #9's EMR showed physician's orders [REDACTED]. The 4/9/19 Psychiatry Consult revealed the resident had a [DIAGNOSES REDACTED]. The resident eloped the prior day (4/8/19) and this (4/9/19) evening she became combative, scratching at the nurse. The 5/13/19 Psychiatry Consult noted that Resident #9 still has incidences when she attempts to elope. The 7/1/19 Psychiatry Consult states that she is doing well behaviorally, with a history of delusional and disorganized thinking with attempts to leave the facility stating that she heard children, meds helpful continue [MEDICATION NAME]. On the 8/5/19 Psychiatry Consult, it was noted that Resident #9 was alert to person and immediate location but is disorganized, continues to talk about having to to go home to children and raise them or hearing children nearby, meds helpful continue [MEDICATION NAME], Psych history unspecified [MEDICAL CONDITION] since admission to facility earlier this year. The 9/9/2019 Psychiatry Consult states that she is still delusional , meds helpful, continue [MEDICATION NAME]. On 10/7/19 the Psychiatry Consult showed that Resident #9 was wheeling self around and appears more confused than last visit, meds helpful, may benefit from medication to address dementia, start [MEDICATION NAME] 1.5mg daily, then in 1 week increase to 1.5mg twice daily and continue [MEDICATION NAME]. On 11/4/19 The Psychiatry Note read that her thoughts are delusional at times, alert, oriented to person, place and time, meds helpful, symptoms managed with current regime continue medications. An interview was conducted on 12/6/19 at 2:57PM with the Registered Nurse Manager (RN). She stated that the resident did not have behavior issues. She went on to explain that the [MEDICATION NAME] had been started after the resident had eloped from the facility. She further stated that non-pharmacalogical interventions had not been implemented prior to the start of the [MEDICATION NAME]. An interview was conducted on 12/9/19 at 11:10AM with the Director of Nursing (DON) who stated that the resident did not have a psych history and only exhibited behaviors towards her daughter after having been admitted to the facility. She further stated that due to her wish to go home, the resident had become agitated in the past. There was no documented evidence that the facility had attempted non-pharmacological interventions to treat the resident's maladaptive behaviors prior to the initiation of the antipsychotic medication. The resident was treated with an antipsychotic medication, [MEDICATION NAME], without clear clinical justification for its initial and ongoing use. 415.12(l)(2)(ii)

Based on observations, interviews and record review conducted during the Recertification Survey it cannot be ensured that the facility provided care and services to address the resident's skin and wound care needs in accordance with professional standards of practice 1 of 5 residents (Resident #55) reviewed for pressure ulcers. Specifically, physician's orders [REDACTED]. The findings are: Resident #55 was readmitted to the facility with [DIAGNOSES REDACTED]. The 10/29/19 Significant Change Minimum Data Set (MDS; an assessment tool) revealed the resident had severe cognitive impairment, a stage 2 pressure ulcer and 2 unstageable pressure ulcers which were present on admission. The 12/2/19 nursing progress note revealed that Resident #55 had a left lower extremity Deep Tissue Injury (DTI) of the medial aspect measuring 4.5cm x1.5cm with intact skin and a left lower extremity (LLE) DTI of the distal aspect measuring 0.5cmx2.7cm with intact skin. The note went on to document that the Nurse Practitioner on the unit was aware and had assessed the resident. The 12/5/19 Pressure Ulcer Care Plan was updated to include the LLE proximal aspect brown eschar, LLE DTI medial aspect intact skin, and LLE DTI distal aspect intact skin. Interventions included treatment per physician/nurse practitioner order. A wound observation was conducted on [DATE] at 9:05AM confirming that Resident #55 had wounds to the left lower leg. [MED] was applied to the wounds at the time of the observation. The [DATE] physician's orders [REDACTED]. An interview was conducted on [DATE] at 10:25AM with the Nurse Manager. She stated the Assistant Director of Nursing (ADON) had reported to her on the previous day (12/9/19) that Resident #55 had new wounds of the lower leg. She further stated that she was not aware that the physician's orders [REDACTED]. An interview was conducted on [DATE] at 10:40AM with the ADON. She stated that on 12/2/19 she had noted that Resident #55 had new LLE wounds and had brought the Nurse Practitioner (NP) to the resident's room on 12/2/19 to observe the wounds. She further stated that the NP was supposed to put treatment orders in place and that she was not aware that the orders were not put in place. An interview was conducted on [DATE] at 11:11AM with the Director of Nursing (DON). She stated that last week she was informed that the resident had new wounds of the lower leg. She stated she did not know until [DATE] that the treatment orders had not been put in place. 415.12

Based on record review and interview during the most recent recertification survey, the facility did not ensure that written notification was sent to the families (or resident representative) and the ombudsman with information regarding transfers from the facility to the hospital. This was evident for 2 of 2 residents reviewed for hospitalization (Residents # [AGE], #9). The findings are: 1) Resident #[AGE] was transferred to the hospital on [DATE]. The 12/3/19 Nurse Practitioner progress note indicated the following: Severe [DIAGNOSES REDACTED] despite multiple [MEDICATION NAME] injections. Unable to insert Intravenous access. Will send to emergency room for further management of [DIAGNOSES REDACTED]. Discussed resident's condition with family. Resident #[AGE] did not return to the facility. 2) Resident #9 was transferred to the hospital on [DATE]. The 8/21/19 nursing progress note indicated the following: transferred to the hospital due to increased confusion, moist cough and a chest x ray which indicated infiltrates of the right lung. Family aware. Resident #9 returned to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documented evidence in the resident's medical record that the family and/or the state ombudsman's office were notified of either of the hospitalization s in writing. An interview was conducted on 12/6/19 at 4:38 PM with the Registered Nurse (RN #1). She stated when a resident was transferred to the hospital the nursing staff call the resident's family to make them aware. She stated she did not notify the Ombudsman when a resident was transferred to the hospital. She further stated she did not send written notification to the family. An interview was conducted on 12/6/19 at 4:42 PM with the Social Worker (SW). She stated that when a resident was discharged to the hospital, the nursing supervisor notified the family and the Ombudsman. An interview was conducted on 12/9/19 at 11:49 AM with the Director of Nursing (DON). She stated nursing notified the family via telephone when a resident was transferred to the hospital. She further stated the nursing staff did not notify the ombudsman when a resident was transferred to the hospital. 415.3(h)(1)(iii)(a-e)

Based on observation, interviews and record review during an abbreviated survey (NY 903), the facility did not ensure that adequate supervision was provided to prevent unsafe wandering and elopement for one of five residents reviewed for accidents (Resident #1). Specifically, a cognitively impaired resident was previously assessed to have low risk for elopement. Risk for elopement was not reassessed to address needs for supervision when the resident demonstrated behavior changes potentially related to increased risk for elopement. The resident exited the building undetected, passing thorough a supervised common room and a supervised lobby, when the assigned staff were distracted by residents that required immediate attention in each of those areas. Staff discovered and reached the resident approximately 20 minutes later and escorted the resident back to the building. The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the comprehensive MDS (Minimum Data Set) assessment dated [DATE], the resident had a BIMS (Brief Interview for Mental Status) score of 3 out of 15 indicating the resident had severe cognitive impairment. The MDS further documented that the resident used a wheel chair for mobility, required the extensive assistance of one person for locomotion on and off the unit, had no behaviors that would impact herself or others and demonstrated no wandering behavior. A Wandering Risk Assessment/Scoring Tool dated 2/27/19 identified that the resident had a low risk based on a score of 7 (0 - 8 = low risk). The tool documented that the resident had no history of wandering or elopement, no verbalizations of wanting to go home and noted that, if the resident was identified as low risk to wander, no nursing action to prevent wandering was needed. There was no care plan developed to address unsafe wandering or elopement. Nurse Practitioner (NP) Progress Notes of 4/4/19 documented escalation in behaviors, agitation, difficult to redirect at times, delusional in thinking that the facility was a house and the NP was the owner. The NP documented on 4/6/19 that the resident had a change in personality, searches for children and mother, believes the facility is the NP's house and she (the resident) is visiting, becomes agitated during family visit which escalates when they leave. There was no evidence of unsafe wandering, exit seeking behavior or elopement attempts in Nursing Progress Notes or Incident/Accident Reports reviewed from 2/22/19 - 4/7/19. The resident was not reassessed for risk of unsafe wandering or elopement and the care plan was not revised to address the behaviors identified by the NP or potential for unsafe wandering and elopement. Facility surveillance camera recordings for 4/8/19 and the Summary of Investigation Report revealed the following: 6:12 PM (18:12:55) The CNA (Certified Nurse Aide) assigned to monitor the common area between the resident rooms and the lobby (CNA #3), the NP and the supervising nurse were present in the common area attending to an agitated resident. Resident #1 wheeled independently through the common area headed down the hall leading to the lobby. 6:14 PM (18:14:43) The resident wheeled herself into the main lobby towards the front door. Two EMTs, a resident on a gurney and the administrator were in the lobby positioned in front of the receptionist blocking the receptionist's view. 6:17 PM (18:17:28) The resident was on the walkway in front of the building watching a visitor leave. 6:19 PM (18:19:49) The resident wheeled herself off the walkway into the driveway moving away from the facility. 6:25 PM A CNA driving to the facility found the resident at the end of the driveway approaching the road. Two EMTs leaving the facility stopped to assist the resident. The CNA returned to the building and notified staff of the resident's location. 6:37 PM The Director of Nursing (DON) arrived at the resident's location. 6:46 PM (18:46:14) The resident was returned to the facility and was assessed with [REDACTED]. The Incident Accident Report and Investigative Summary dated 4/8/19 was signed by the RN supervisor (RN #1) and noted that the resident had a visit from a family member prior to the incident. The family member was notified of the incident and reported that the resident had stated she missed her dog and wanted to go home. The family member had not previously shared that exchange with the facility. The DON was interviewed on 5/31/19 at 11:00 AM and stated that the resident was confused and asked for her mother but had no exit seeking behavior and never attempted to exit the facility. The DON stated that the resident was not identified previously with an elopement risk. CNA#1 was interviewed on 5/31/19 at 1:19 PM and stated that the resident started saying she had to go see her mother and she had to feed the dog or go home or to the store about a month ago. When her family came, after they left, the resident had an increase in behaviors and would express wanting to leave. The RN supervisor (RN #1) was interviewed on 5/31/2019 at 1:30 PM and stated that, when she arrived at the resident's location at the time of the incident, the resident said she was going home because she had to feed her dogs. The NP was interviewed on 5/31/19 at 4:00 PM and stated that the resident first started to have increased behaviors after family left in February 2019. She had short periods of looking for her family, wandering, in March 2019 with personality changes, refusing treatment, aggression. She was easily redirected. The NP discussed the changes with psych and sent her for a CAT scan on 3/1/2019 due to the changes in personality and the test was negative. The behaviors de-escalated for a while but increased again lately. She was wheeling around looking for her mother on 3/29/19. The NP stated the behaviors increased with exposure to family, that staff were aware, and that they did not think the behavior changes were related to exit seeking behavior. CNA #3 who was assigned to monitor the common area at the time of the incident was interviewed on 6/12/19 at 1:38 PM. She stated that another resident was extremely agitated and trying to get up. She was afraid he was going to fall. She was focused on attending to that resident and she stated she never saw the resident wheel through the room. If she saw her she would have stopped her and never let her go out into the lobby alone because the resident is confused. 415.12(h)

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 949), the facility did not ensure that one (Resident #1) of three residents reviewed for medications was free from significant medication error. Specifically, Resident #1 had a physician's orders [REDACTED]. The order was not transcribed accurately to the Medication Administration Record [REDACTED]. Findings include: The facility's policy for Anticoagulant Therapy, issued 12/1/2017 and updated 9/1/2018 documented the purpose of the policy was to provide oversight/monitoring of anticoagulant therapy for side effects and serious risk associated with its use. The implementation for anticoagulant therapy documented that Licensed Practical Nurse (LPN) will notify Registered Nurse (RN) when there is a change in existing order. The RN will provide oversight of transcription and discontinuance of [MEDICATION NAME] orders to ensure orders have been transcribed accurately. Each time a new [MEDICATION NAME] order is written (started or discontinued) it will be noted in the [MEDICATION NAME] Medication Administration Record [REDACTED]. All discontinued orders will be highlighted in yellow or blue marker. If using electronic Medication Administration Record [REDACTED]. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 11/1/2018 Minimum Data Set (MDS), (a resident assessment tool) indicated the resident scored 15 out of 15 on the Brief Interview for Mental Status (BIMS, used to measure memory recall and orientation) which suggested she had no cognitive impairment. The MDS further documented the resident received an anticoagulant ([MEDICATION NAME]) on 2 days during the past 7 days. The resident was discharged to home on 11/1/2018. The resident had physician's orders [REDACTED].) tablet plus one [MEDICATION NAME] 2.5mg. tablet by oral route every evening at 9PM, for a Total Dose (TD) of 4.5 mg. daily. physician's orders [REDACTED]. According to the Electronic Medical Record (EMR), the orders were transcribed by LPN #1 on 10/8/2018. LPN #1 documented in the Nursing Progress Note of 10/8/2018 at 10:30 PM to hold [MEDICATION NAME] for 2 days, PT/INR draw on 10/11/2018. The shift to shift 24-hour report (documentation of MD notifications, new orders, and changes in resident status) for 10/8/2018 documented resident stable, hold [MEDICATION NAME] X2. The Paff 2 report sheets documented: 10/10/2018 hold [MEDICATION NAME] ([MEDICATION NAME]). 10/11/2018 resident refused PT/INR. 10/12/2018 report PT/INR done, new order for PT/INR 10/18/2018. Laboratory reports documented: 10/8/2018, PT/INR, 4.73 (normal range 2.00-3.00). A written entry by the NP on the report noted to hold [MEDICATION NAME] for 2 days, recheck PT/INR 10/10/2018. 10/10/2018 No evidence that blood was drawn/tested . 10/11/2018, resident refused blood draw. 10/12/2018, INR 1.48 10/18/2018, INR 1.07 The Anticoagulant Flowsheet (a facility tracking system for anticoagulant laboratory results, and new orders) documented: 10/08/2018 INR elevated, 4.73, [MEDICATION NAME] on hold for 2 days, Next INR to be drawn 10/10/2018. 10/12/2018 INR low at 1.48, current dose 4.5mg, new dose 4.5mg., Next INR to be drawn 10/18/2018. 10/30 INR low 1.1, current dose 4.5mg, new dose 5mg., repeat INR 10/31/2018. The MAR for (MONTH) (YEAR) documented to give [MEDICATION NAME] 2.0mg tablet 1 tablet in evening, and [MEDICATION NAME] 2.5mg.1 tablet in evening, TD 4.5mg., every day. Nursing staff initials were entered signifying Resident #1 was given [MEDICATION NAME] until 10/7/2018. The signature boxes on the MAR for 10/8 and 10/9 had an X entered in them. After the X on 10/9, a small line/squiggle was drawn through 10/10-10/14/2017 and no initials were entered. Boxes for 10/14/2017 through 10/29/2017 had no initials, indicating [MEDICATION NAME] was not administered to resident from 10/10/2019 through 10/29/2019 (20 days). A Facility Investigation documented that on 10/30/2018 the MDS Coordinator discovered Resident #1 had not received [MEDICATION NAME] from 10/10/2018. There was an order to hold the resident's [MEDICATION NAME] for two days on 10/8 and 10/9, then draw INR on 10/10 due to her 10/8 elevated INR of 4.75 (normal 2.50-3.50). The medication was signed for until (MONTH) 7th. The MAR for (MONTH) was noted to have X in the 10/8 and 10/9 boxes for nurse initials and then a line was drawn after the 2 X's. No other signature followed. The MDS Coordinator could not find proof that [MEDICATION NAME] was discontinued and asked the NP who said the resident was still on [MEDICATION NAME]. The anticoagulant flowsheet documented: 10/31/2018 INR low 1.4, current dose 5mg., new dose 8mg. Next INR to be drawn 11/1/2018. 11/1/2018 INR low 1.8, current dose 8mg., new dose 8mg. LPN #1was interviewed on 2/25/2018 at 11:00AM via phone and stated that she picked up the orders to hold [MEDICATION NAME] and for a PT/INR to be checked on 10/11. She stated she was done early that night, so she tried to help by picking up RN#1's orders. LPN #1 stated she wrote a Nursing Note for the new order to hold [MEDICATION NAME] for 2 days and noted it on the 24-hour report. She could not be sure if she made out a lab request for resident. She remembered telling RN #1 the medication was to be held for two days. She did not transcribe the order to the MAR. RN #1 was interviewed on 2/21/2018 at 11:05 AM via phone and stated that LPN #1 informed her she received the order to hold [MEDICATION NAME] for 2 days because of a high INR and RN #1 marked the MAR indicated [REDACTED]. RN #1 denied putting a line through the next few days in the MAR. She stated she did not check the order and did not write a lab slip or document because LPN #1 took the order from the doctor. RN #2 was interviewed on 2/21/2018 at 11:40AM via phone and confirmed she was assigned to the resident for the evening shift on (MONTH) 15th - 18th, 20th - 22nd, 24th - 26th and 29th - 30th. She stated that when the facility showed her the MAR indicated [REDACTED]. She stated she did not check the physician's orders [REDACTED]. RN #3 was interviewed on 2/21/2018 at 1:35 PM via phone and confirmed that she took care of the resident on the evening shift on (MONTH) 13th, 14th, 19th, 23rd, 27th, and 28th and did not give [MEDICATION NAME] as ordered. She stated she remembered after the incident that there was a line through a few days after the X's and that must have made her think the medication was discontinued. She never heard anything about the resident's [MEDICATION NAME] in reports she received. If [MEDICATION NAME] was discontinued, then D/C should have been written across the page and yellowed out at least. There were no red flags and she never checked the physician's orders [REDACTED]. The Director of Nursing (DON) was interviewed on 2/07/2019 at 1:30 PM and stated the facility retrained staff due to this mistake. She stated the facility acted to remedy the issue and to prevent the incident from reoccurring by conducting quality assurance [MEDICATION NAME] audits completed on 10/30, 11/1, 11/2, 11/9, 11/20, an 11/25/2018. They conducted in-service trainings to staff that included two on 10/31, 11/1, two on 11/2, 11/5 and 11/20. The inservice included information of transcribing a H for hold on the MAR indicated [REDACTED]. She stated she reviewed with nursing and staff the facility policy that, for any changes in existing orders, the RN will provide oversight of transcription and discontinuance to ensure orders have been transcribed accurately. Each time a new anticoagulant order is written, started, or discontinued it will be noted in the MAR indicated [REDACTED]. Audits are ongoing. The facility was found to have identified and corrected its self-reported noncompliance for anticoagulant/[MEDICATION NAME] administration prior to survey. The facility provided documented evidence of [MEDICATION NAME] audits, that will be ongoing, and of in-service training for all nursing staff for anticoagulant therapy completed by 11/20/2018 and policy and procedure for medication administration that was completed 11/20/2018. Based on interviews with 8 nurses between 2/7/2019 and 2/25/2019, the staff were found to be knowledgeable about the facility policy and procedures for anticoagulant/[MEDICATION NAME] therapy. No concerns were identified with other sampled residents. 10 NYCRR 415.11 (C)(3)(i))

Based on staff interviews and record review conducted during an abbreviated survey (Complaint #NY 007), the facility failed to ensure that adequate supervision and effective use of the facility's monitoring program to prevent falls and injuries were provided for 1 of 3 residents reviewed for accidents (Resident #1). Specifically, monitoring checks and toileting assistance were not provided as care planned and as recommended by facility investigations to prevent further falls. Resident #1 had 8 falls between 8/9/17 to 2/18/18 and the facility did not implement recommended care plan changes for supervision of the resident. Subsequently, on 2/18/18 Resident #1 fell and sustained a subdural hematoma (or SDH; refers to a collection of blood between the skull and the outermost covering of the brain and usually associated with head trauma) following a fall. This resulted in actual harm that is not immediate jeopardy. The findings are: The Facility Falls and Fall Risk Managing policy dated 9/1/17 documented that if falls recur despite initial interventions, the staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, the staff will try various interventions, based on assessment of the nature or category of falling, until falls are reduced or stopped, or until the reason for the continuation of the falls is identified as unavoidable. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Annual Minimum Data Set (MDS; a comprehensive resident assessment tool) dated 4/03/17, the resident scored 10 out of 15 on the BIMS test (Brief Interview for Mental Status; a test used to measure memory recall and orientation), indicating that the resident's cognition was moderately impaired. This MDS identified the resident as always continent of bowel and bladder, required extensive assistance of one person for bed mobility, transferring, dressing, toilet use and personal hygiene, and total assistance of one person for locomotion on and off the unit. The resident used a wheel chair and did not walk in his room or the corridor during this assessment period. This MDS further indicated that the resident did not have any falls during this assessment period. A standardized care plan for Falls was initiated on 4/27/17. Selected interventions included, but were not limited to, ensure call bell was within reach at all times and is answered in a timely manner, encourage resident to call for assistance, provide family/resident education on falls prevention, low bed position, proper non-skid footwear, clutter-free environment with adequate lighting and monitor medications and mental status. The Fall Risk assessment dated [DATE] scored the resident for criteria including Mental Status, History of Falls, Elimination Status, Vision Status, Gait/ Balance/ Ambulation, Systolic Blood Pressure, Medications and Pre-Disposing Diseases. The assessment documented a total score of 9 and identified that a total score above 10 represented high risk. According to the Occurrence Reports, Fall Interview forms (a section of the occurrence report is used as part of the facility investigations of incidents), and the Nurse's Notes, the resident experienced eight falls between 8/9/17 to 2/18/18 and four of these falls resulted in injuries. - First Fall - 8/9/17 at 11:10 AM - Occurrence Report - The resident was found lying on the floor on the right side of his bed. Sustained skin tear to left forearm, scratch to left lower inner shin and was complaining of right side mid-back pain. The resident was changed or toileted at 10:00 AM and the last time the resident was seen prior to the incident was at 11:05 AM. The Conclusion of Report Commentary section documented that the resident was self-directed with no safety awareness. The Fall Risk assessment dated [DATE] documented a change in status from regularly continent to requiring regular assistance with elimination and noted a total score of 13, indicating high risk. - Second Fall - 9/18/17 at 12:15 PM - occurrence Report - Observed sitting on his buttocks on floor next to his bed in front of his wheel chair; no injury. Last seen at 11:30 AM. The Fall Risk assessment dated [DATE] documented increased total score of 17 with points added for an additional fall and change in mental status from disoriented to place and time, to disoriented to person, place and time. - Third Fall - 9/23/17 at 10:30 AM - Occurrence Report - observed sitting on floor in his room next to his bathroom; stated he was going to the bathroom; no injury. Last seen 30 minutes prior to finding the resident on the floor. The Conclusion of Report Commentary in the facility investigation documented the resident was self-directed, demonstrated short term memory impairment, poor safety awareness and was impulsive. The Fall Risk assessment dated [DATE] documented increased a score of 20 with additional points for another fall, change in vision status from adequate to poor, with or without glasses, and decline in Gait/Balance/Ambulation. The Falls care plan was revised on 9/23/17 with Quick Check Program (QCP) added as an intervention. According to the facility QCP guideline initiated on 9/26/17, the purpose of this program is to initiate interventions for safety and to lower incidents of falls with residents that are high risk for falls. All staff can be more aware of what the resident is doing, where the resident is currently located. For example if the resident is in the bathroom alone, attempting to get out of bed, unclipping alarms, getting up without assistance. The resident can be checked more frequently on walking rounds, when walking in the hallway past the resident's room. This intervention program will alert the staff by a square orange icon placed on the doorway. There was no documented evidence that the responsible staff and the frequency to conduct the quick checks were identified. - Fourth Fall - 11/29/17 at 7:45 AM - Occurrence Report - observed lying on the floor in his room on his left side, head next to the wall in between dresser and end of the bed; contusion measuring 3 x 2 cm on the left temple and complained of pain on the left shoulder. Last seen at 7:05 AM. The Falls Care Plan was revised on 11/29/17 to note a frequency of 15 minutes for the Quick Check Program. There was no documented evidence that quick check was implemented including no evidence that the resident was checked every 15 minutes. The care plan for ADL (Activities of Daily Living) - ROM (Range of Motion) initiated on 4/27/18 was updated on 12/14/17 to include toileting schedule for the resident every 2-4 hours as needed. - Fifth Fall - 1/23/18 at 6:50 AM - Occurrence Report - observed lying on floor in his room on his left side next to his bed. Last seen at 6:30 AM. The 1/23/18 Occurrence Report Immediate Corrective Actions/Interventions section documented by a Registered Nurse (RN #2) noted to educate the resident to call for assistance, continue Quick Check Program every 15 minutes and to evaluate for toileting schedule. -Sixth Fall - 1/24/18 at 3:45 AM - Occurrence Report - observed sitting on his bathroom floor between the toilet and his wheelchair when staff responded to resident's call for help; complaining of back pain per nurse's notes of 1/24/18. Last seen at 3:30 AM. Immediate Corrective Actions/Interventions documented that staff was educated to toilet the resident while awake (time of this event was 3:35 AM) and will recommend assessment for frequency and timing of micturition (discharge of urine from the bladder) and formulating a toileting schedule. Falls care plan interventions added on 1/24/18 included to toilet the resident while awake. There was no documented evidence in the medical record to reflect when the resident was toileted while awake. A Radiology report dated 1/24/18 indicated compression fractures of the vertebral bodies of lumbar spines 1 and 2. The Physician's Progress Notes entered on 1/25/18 documented that, when weight bearing, the resident still reported mild low back pain. -Seventh Fall - 1/26/18 at 11:15 AM - Occurrence Report - observed sitting on the bathroom floor; the floor was wet; complaining of back pain; [MEDICATION NAME] (a narcotic [MEDICATION NAME]) as needed was started. Last seen 30 minutes prior to finding resident. Immediate Corrective Actions/Interventions documented toileting schedule before and after meals, referral to therapy due to back pain, labs in the morning. The Falls care plan was revised on 1/26/18 with interventions for shoes when getting out of bed and toileting before and after meals. The resident's Care Card had instructions on 1/26/18 for the Certified Nurse Aides (CNA) to toilet the resident before, after, in between meals and as necessary. The CNA documentation indicated that the resident was toileted or had incontinence briefs changed daily on each shift. There was no documented evidence that toileting as per the specified schedule was done and no evidence of an evaluation of the effectiveness of this intervention was conducted. The Physician's Progress notes dated 1/29/18 indicated to continue Tylenol as needed with [MEDICATION NAME] for breakthrough pain or severe pain. The resident must always be toileted with assistance and should be offered toileting every 4 hours. The Physician's Progress Notes dated 1/30/18 documented status [REDACTED]. No parameters for close monitoring were identified. There was no documented evidence that assistance for toileting, toileting every 4 hours or monitoring the resident closely were assessed to ensure implementation or to evaluate their effectiveness. An addendum to the 1/26/18 Occurrence Report Interventions on 2/2/18 noted an ad hoc (committee established for a specific propose) care plan team meeting was convened with discussion on the multiple falls, the resident with confusion, does not ask for help, self-directs by getting up himself without assistance, resident being impulsive and at any time will get out of bed by himself. Urinalysis was negative, tap bell will be placed along with a sign to use tap bell and Stop sign on bathroom door, and [MEDICATION NAME] for back pain. The Falls care plan revealed no documented evidence that the interventions discussed in the ad hoc care plan team meeting were addressed or that quick checks or toileting were evaluated to verify implementation and determine their effectiveness. A Physical and Occupational Therapy screening tool dated 2/5/18 documented the resident was noted to have decreased right upper extremity AROM (active range of motion), noted to require maximum assist for completion of grooming, dressing and toileting, required mechanical lift for transfers and was unable to ambulate. The resident was found with right sided weakness, had garbled speech and inability to stand, needed maximum assist of 2, and unable to use right upper extremity. The Physician's Progress Notes dated 2/5/18 indicated that the resident seemed weak during rehab. No further treatment or recommendations were written by the physician as the resident did not show any signs of facial or neurological deficits. -Eighth Fall - 2/18/18 at 4:30 PM - Occurrence Report - Observed lying on floor beside his low bed; abrasion to right temple and bilateral shins, vomited moderate amount of undigested food and complained of headache. Last seen at 4:00 PM. The resident was transferred to a hospital emergency room for evaluation on 2/18/18 at 6:00 PM. The hospital records of 2/18/18 at 9:17 PM indicated that CAT scans (Computerized Tomography: An X- ray procedure that views multiple images) revealed bilateral SDH. The neurosurgeon recommended bilateral craniotomies (temporary removal of bone flaps on the skull to reach the brain in order to remove blood clots or hematomas resulting from injuries including SDH). The procedure was declined by the resident's representative and agreed to conservative approach with pain control and neurological monitoring. Interviews were conducted of 10 Certified Nurse Aides (CNA) and a Registered Nurse (RN #2) between 2/15/18 and 2/23/18 regarding the resident's toileting and the facility's QCP for fall prevention. - 2/15/18 at 2:15 PM - CNA #1 (7-3 shift) stated that the resident fell a few times in January. CNA #1 stated that those falls changed everything and the staff used to toilet him before but not anymore. CNA #1 verbalized awareness of QCP. She stated that staff were supposed to check the resident whenever they pass by the room. She stated that the staff did not document anywhere that they checked the resident and sometimes hours could pass by without checking the resident. - 2/15/18 at 6:10 PM - CNA #2 (3-11 shift) stated that the resident was occasionally incontinent of bowel and bladder and she didn't take him to the bathroom. She stated that the staff used to take him to the bathroom a few months ago and that she had no idea what is the meaning of QCP. CNA #2 stated she guessed that the staff were supposed to check the resident but wasn't sure. - 2/15/18 at 6:20 PM - CNA #3 (3-11 shift) stated that she did not know much about the QCP and thought it meant frequent check. CNA #3 stated she checks the resident when she could because they were always busy taking care of other residents. CNA #3 stated the resident used to be continent few months ago and at that time the staff used to take him to the bathroom but not anymore. - 2/15/18 at 6:30 PM - CNA #4 (3-11 shift) stated that she put the resident back to bed after dinner and don't take him out of bed after that to toilet him. CNA #4 stated she changed his incontinence brief. She stated that the QCP meant to check the resident every 15 minutes, but she don't have time to do that. - 2/20/18 at 1:30 PM - CNA #5 (7-3 shift) stated that she knows the resident very well. He needed one-person assistance for care with activities of daily living. Now, the resident is transferred by Hoyer lift (a type of mechanical lift) and he can still participate with care. CNA #5 stated she does not know about the QCP. She stated she sees a sticker on the doors, but has no idea about what it meant and that the facility doesn't use alarms anymore. - 2/20/18 at 1:45 PM - CNA #6 (7-3 shift) stated that the staff change the resident in bed and that they used to take him to the toilet a few months ago. Now, they just check and change. She stated that she does not know about QCP. She stated that the staff conducts 15-minute checks and don't document this action anywhere. - 2/20/18 at 2:15 PM - RN #2 (7-3 unit nurse) stated that she spoke to his family on multiple occasions. She stated that the resident was toileted until his (MONTH) (YEAR) falls. RN #2 stated that the resident always tried to toilet himself and was able to wheel himself around, but never walked. RN #2 stated she thought the falls made him go downhill. She stated that the facility didn't use bed or chair alarms. She stated she knew about the QCP which meant that when the staff walk by the resident's room they should check the resident. - 2/20/18 at 2: 30 PM - CNA #7 (7-3 shift) stated that the resident used to propel himself in wheelchair before until the (MONTH) falls. CNA #7 stated that now he is using the Hoyer lift transfer. CNA #7 stated the staff used to toilet him but not anymore. This CNA stated she doesn't know anything about QCP. - 2/21/18 at 12:15 PM - CNA #8 (11-7 shift) stated that nobody inserviced her about the QCP and that they were supposed to check the resident every 15 minutes but wasn't sure. She further stated that the staff never took the resident to the bathroom and always changed the incontinence brief while in bed. - 2/21/17 at 1:20 PM - CNA #9 (3-11 shift) was interviewed and stated that she used to toilet him months ago but not anymore. She stated she doesn't remember if she was inserviced about the QCP. CNA #9 stated she thinks that the CNA who was assigned to the resident is supposed to check the resident every 15 minutes. - 2/23/18 at 10:58 AM - CNA #10 (3-11 shift) was interviewed and stated that she had the resident on her assignment on the evening of 2/18/18 when the resident fell . She stated that when the staff comes in the evening, the resident was always in bed because the day staff put him to bed after lunch. CNA #10 stated that she takes the resident out of bed around 5:00 PM for supper every evening. She stated that when she walked to the resident's room on the evening of 2/18/18, she found the resident on the floor and immediately called the nurse. She stated that she was aware of the QCP and that she checks the residents every 15 minutes. The Director of Nursing (DON) was interviewed on 2/15/18 at 11:00AM and on 2/20/18 at 2:00PM. The DON stated that the QCP was initiated before she started working at the facility and she did not get a chance to review the program. She stated that 15-minute checks were not a facility practice and the staff should visually check the residents as they pass by their rooms. She further stated that there was no proof to clarify that the resident was checked for safety and there was no specific staff assigned to the resident for safety monitoring. The DON further stated that the resident was never placed on a toileting schedule. The Administrator was interviewed on 2/15/18 at 3:00PM and stated that she is aware that the resident had multiple falls and CNAs should know about the QCP program. RN #1 was interviewed on 2/15/18 at 2:00 PM and on 2/20/18 at 3:00 PM. RN #1 stated she initiated the Quick Check Program in (MONTH) (YEAR) with the Administrator's approval and stopped using bed and chair alarms facility wide at that time. RN #1 stated that all facility staff who pass by the resident's room should check the resident for safety. RN #1 stated that she realized that no staff member was accountable for the resident's safety checks and there was no documentation involved with the Quick Check Program. RN #1 stated she attends the daily morning meeting with all the interdisciplinary staff to discuss each resident's condition including falls. She stated she never started the resident on a toileting schedule. The Medical Director was interviewed on 2/21/18 at 2:00 PM and on 2/22/18 at 10:40 AM and stated he consulted the hospital physician and the hospital radiologist who interpreted the resident's head and pelvis CAT scan reports. The Medical Director stated the resident previously had a head CAT scan on 5/10/16 without any negative findings for hematoma. The Medical Director stated that the 2/19/18 CAT scan reports indicated chronic and two acute hematomas. 415.12(h)(2)