Every finding on record at Schuyler Hospital Inc and Long Term Care Unit

Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse were reported to the New York State Department of Health within the required timeframe for two of five residents reviewed (Resident #15 and Resident #111). Specifically, on 06/07/2026, Resident #108 alleged Resident #15 placed both hands around Resident #111's neck. Facility staff became aware of the allegation on 06/07/2026 when Certified Nursing Assistant #2 and Certified Nursing Assistant #6 notified Licensed Practical Nurse #1 and Licensed Practical Nurse #2 and Resident #111 was assessed. The allegation was not reported to facility administration until 06/09/2026 and was not reported to the New York State Department of Health until 06/09/2026 at 4:25 PM.The findings include:The facility Abuse Policy, dated July 2025, included investigations of resident abuse must begin immediately upon receipt of a concern, regardless of the time of day or day of the week. The Administrator, Director of Nursing, Director of Social Work, or Clinical Nurse Manager would investigate all reports of resident abuse and report the allegation to the Department of Health within two hours of becoming aware of the incident.Resident #15 had diagnoses including dementia (a progressive disease affecting memory, thinking, and behavior), anxiety (a mental health condition causing excessive worry), and depression (a mood disorder causing persistent sadness). The Minimum Data Set (a resident assessment tool) dated 05/07/2026 revealed Resident #15 had severely impaired cognition and behavioral symptoms not directed toward others, such as pacing and screaming, during the assessment period. Review of the Comprehensive Care Plan last revised 06/15/2026 revealed Resident #15 had the potential for behaviors and a history of resident-to-resident altercations related to the dementia process. Symptoms included limited insight and judgement, physical aggression, and impulsive behaviors. Resident #111 had diagnoses including dementia, muscle weakness (reduced muscle strength), and depression. The Minimum Data Set, dated [DATE] revealed Resident #111 had severely impaired cognition and physical and verbal behavioral symptoms directed toward others, such as grabbing and screaming, during the assessment period. Review of the Comprehensive Care Plan last revised 06/06/2026 revealed Resident #111 had behaviors related to dementia, including physical aggression with others. The resident was at risk for becoming a victim related to resident-to-resident altercations.Review of a witness statement obtained from Resident #108 on 06/09/2026 revealed Resident #108 observed Resident #15 lunge toward Resident #111, appeared to place a hand around Resident #111's throat, and Resident #111 screamed for help. The statement further documented Resident #108 was cognitively intact and was generally considered an adequate historian, although staff noted the resident occasionally embellished details.Review of a statement completed by Registered Nurse #3 on 06/09/2026 at 4:00 PM revealed certified nursing assistants reported concerns on the evening of 06/08/2026 regarding an incident occurring on 06/07/2026 in which Resident #15 grabbed Resident #111 by the neck. Registered Nurse #3 documented staff reported Licensed Practical Nurse #1 was aware of the incident. Registered Nurse #3 reviewed the electronic health record and found no nursing note, behavior note, or incident documentation related to the event. Registered Nurse #3 documented informing Registered Nurse Manager #1 on 06/09/2026 because of concerns regarding the seriousness of the allegation.Review of a progress note dated 06/09/2026 at 4:33 PM, Registered Nurse Manager #1 documented they were informed at approximately 3:30 PM of an incident occurring on 06/07/2026 between 9:00 PM and 10:00 PM. Resident #108 reported Resident #15 placed hands around Resident #111's neck. The Administrator was notified immediately after becoming aware of the allegation, Resident #111 was assessed on 06/09/2026, and no redness, bruising, swelling, difficulty talking, swallowing, or breathing was observed.Review of a progress note dated 06/09/2026 at 4:44 PM, Registered Nurse Manager #1 documented they were informed at approximately 3:30 PM of the alleged incident involving Resident #15 on 06/07/2026. The Administrator and Resident #15's family were notified and Resident #15 was placed on behavior monitoring and 15-minute checks.Review of the facility Accident and Incident Report dated 06/09/2026 revealed the incident occurred on 06/07/2026. The report documented the supervisor, physician, and family were notified on 06/09/2026 after Registered Nurse Manager #1 became aware of the allegation.Review of the New York State Incident Reporting System documented the incident was reported to the New York State Department of Health on 06/09/2026 at 4:25 PM by the Administrator. The report documented the incident occurred on 06/07/2026 at 9:40 PM and facility staff first became aware of the incident on 06/07/2026 at 9:40 PM.Review of the facility investigation dated 06/09/2026 documented Certified Nursing Assistant #2 heard Resident #111 screaming and responded to the end of the hallway. Resident #108 reported Resident #15 had choked Resident #111. Certified Nursing Assistant #2 documented Licensed Practical Nurse #1 and Licensed Practical Nurse #2 were notified immediately following the incident. The investigation concluded a resident-to-resident altercation could not be ruled out and documented the allegation was reported to the New York State Department of Health on 06/09/2026.During an interview on 07/17/2026 at 12:09 PM, Registered Nurse Manager #1 stated they became aware of the allegation after the incident had already occurred. Registered Nurse Manager #1 stated staff did not believe the witness because the resident could fabricate stories; however, regardless of whether staff believed the allegation, administration should have been notified immediately.During an interview on 07/17/2026 at 3:40 PM, Licensed Practical Nurse #1 stated they were working on 06/07/2026, did not witness the incident, but were told about it shortly after it occurred. Licensed Practical Nurse #1 stated they should have notified the nursing supervisor immediately but did not because the witness resident was not always reliable.During an interview on 07/17/2026 at 2:56 PM, the Director of Nursing stated allegations of abuse with injury must be reported to the New York State Department of Health within two hours and allegations without injury within 24 hours. The Director of Nursing stated Resident #108 alleged Resident #15 choked Resident #111, staff did not report the allegation to administration for two days because they did not believe it occurred, and administration should have been notified immediately regardless of staff's opinion.Title 10 New York Codes, Rules and Regulations 415.4(f)(1-4)

Based on interviews and record review, the facility failed to ensure all alleged violations involving abuse were thoroughly investigated and residents were protected from further potential abuse while the investigation was in progress for two of five residents reviewed (Resident #15 and Resident #111). Specifically, on 06/07/2026, facility staff became aware of an allegation Resident #15 placed both hands around Resident #111's neck. Although Licensed Practical Nurse #1 and Licensed Practical Nurse #2 were notified immediately following the alleged incident on 06/07/2026, the facility did not begin a documented investigation until Registered Nurse Manager #1 became aware of the allegation on 06/09/2026 at approximately 3:30 PM. The facility failed to immediately initiate a thorough investigation, implement interim measures to protect the residents while the investigation was in progress, and complete a thorough and accurate investigation.The findings include:The facility Abuse Policy, dated July 2025, included investigations of resident abuse must begin immediately upon receipt of a concern, regardless of the time of day or day of the week. A thorough investigation may consist of an interview log identifying staff interviewed along with signed and dated statements and required the facility to protect residents while the investigation was in progress.Resident #15 had diagnoses including dementia (a progressive disease affecting memory, thinking, and behavior), anxiety (a mental health condition causing excessive worry), and depression (a mood disorder causing persistent sadness). The Minimum Data Set (a resident assessment tool) dated 05/07/2026 revealed Resident #15 had severely impaired cognition. Review of the Comprehensive Care Plan last revised 06/15/2026 revealed Resident #15 had the potential for behaviors and a history of resident-to-resident altercations related to the dementia process. Symptoms included limited insight and judgement, physical aggression, and impulsive behaviors. Resident #111 had diagnoses including dementia, muscle weakness (reduced muscle strength), and depression. The Minimum Data Set, dated [DATE] revealed Resident #111 had severely impaired cognition. Review of the Comprehensive Care Plan last revised 06/06/2026 revealed Resident #111 had behaviors related to dementia, including physical aggression with others. The resident was at risk for becoming a victim related to resident-to-resident altercations.Review of the electronic health records for Resident #15 and Resident #111 revealed no nursing assessment, behavior note, incident report, physician notification, family notification, or other investigative documentation completed on 06/07/2026 or 06/08/2026 related to the alleged incident.Review of a statement completed by Registered Nurse #3 on 06/09/2026 at 4:00 PM revealed certified nursing assistants reported concerns on the evening of 06/08/2026 regarding an incident occurring on 06/07/2026 involving Resident #15 and Resident #111. Registered Nurse #3 documented staff reported Licensed Practical Nurse #1 was aware of the incident. Registered Nurse #3 reviewed the electronic health record and found no nursing note, behavior note, or incident documentation related to the event before notifying Registered Nurse Manager #1 on 06/09/2026.Review of progress notes dated 06/09/2026 at 4:33 PM and 4:44 PM documented Registered Nurse Manager #1 first became aware of the allegation at approximately 3:30 PM on 06/09/2026. Resident #111 was assessed on 06/09/2026, and Resident #15 was placed on behavior monitoring and 15-minute checks on 06/09/2026. There was no documented evidence protective interventions were implemented between 06/07/2026 and 06/09/2026 after facility staff became aware of the allegation.Review of the facility investigation dated 06/09/2026 revealed Certified Nursing Assistant #2 immediately notified Licensed Practical Nurse #1 and Licensed Practical Nurse #2 following the alleged incident. The investigation did not include signed statements from Licensed Practical Nurse #1 or Licensed Practical Nurse #2.Review of the Nursing Home Investigative Report submitted to the New York State Department of Health on 06/16/2026 documented the incident date as 06/09/2026 rather than 06/07/2026. The report documented staff found Resident #15 with hands around Resident #111's throat; however, earlier facility documentation documented staff responded after hearing Resident #111 scream and learned of the allegation from Resident #108. The report verified the allegation despite conflicting investigative documentation regarding how the event was discovered and the incident date.During an interview on 07/17/2026 at 3:40 PM, Licensed Practical Nurse #1 stated they were informed of the allegation shortly after it occurred and could not remember completing a written statement regarding the incident.During an interview on 07/17/2026 at 3:45 PM, Licensed Practical Nurse #2 stated they remembered the incident but did not remember completing a written statement.During an interview on 07/17/2026 at 2:56 PM, the Director of Nursing stated the investigation was incomplete because statements were not obtained from all staff involved in the incident. The Director of Nursing stated the investigation should have included statements from Licensed Practical Nurse #1 and Licensed Practical Nurse #2.Title 10 New York Codes, Rules and Regulations 415.4(b)(1)(i), (2), (3)

Based on record review and interview conducted during the Recertification Survey, it was determined that for two of seven newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry abuse screening was not completed for newly hired employees prior to starting work. The findings are: A review of the [NAME] Hospital Policy & Procedure for Resident Abuse, effective date February 1992 and last revised August 2017, included screening procedures that all staff will have a verification completed prior to hire through the New York State Nurse Aide Registry Verification (Prometric Report). On 3/26/24 beginning at 1:05 PM, seven newly hired employee files were reviewed and included the following: A Resident Assistant was hired on 2/19/24 and a nurse aide registry screen for prior abuse findings was not submitted until 3/26/24. A Dietary Aide was hired on 3/23/24 and a nurse aide registry screen for prior abuse findings was not submitted until 3/26/24. During an interview at this time, the Human Resources Generalist was asked by the surveyor why there had been a delay in submitting the nurse aide registry check. The Human Resource Generalist stated that the Onboarding Department completes the whole new hire process, and that the Onboarding Specialist thought they only had to run the Certified Nursing Assistants through the nurse aide registry. 10NYCRR: 415.4(b)

Based on interviews and record reviews conducted during the Recertification Survey, for five (Resident #15, #23, #48, #59 & #64) of five residents reviewed the facility did not ensure that the influenza and/or pneumococcal immunizations were offered and provided if appropriate or that education was provided to the residents or the resident representative if appropriate. Specifically, there was no documented evidence that Resident #64 (who was eligible) or their representative had been offered, provided, declined, and/or educated on the pneumococcal immunization or had received it prior to admission. For Residents #15, #23, #48 and #59, there was no documented evidence that the residents had been offered, received, had declined and/or been educated on the influenza immunization for this year's flu season. The evidence includes but is not limited to the following: The facility policy Pneumococcal Vaccine - Resident, dated 1/14/22 documented: on admission, staff will attempt to verify if pneumococcal vaccine status is current. Residents will be offered any pneumococcal vaccine that they have consented to and is eligible to receive based on Center for Disease Control recommendations. The facility policy Influenza Vaccine - Resident, dated 1/14/22 documented: all residents will be offered the influenza vaccine annually during the flu season, October 1st through March 31st. 1.Resident #64 had diagnoses including chronic obstructive pulmonary disease, heart failure, and dementia. The Minimum Data Set Resident assessment dated [DATE], documented the resident was over [AGE] years of age, had severe cognitive impairment, that their pneumococcal vaccine was not up to date and that they had not been offered the pneumococcal vaccine at the facility. Review of Resident #64's electronic medical record revealed no documented evidence that the resident/resident representative had received, been offered, declined, or been educated regarding the pneumococcal vaccine. 2.Resident #15 had diagnosis including dementia, anxiety, and depression. The Minimum Data Set Resident assessment dated [DATE], documented the resident had severe cognitive impairment, and that they had not received the influenza vaccine in the facility for this year's influenza season and did not include the reason why not. Review of Resident #15's electronic health record revealed the influenza vaccine was last administered 10/11/22. There was no documented evidence that the resident/resident representative had been offered, administered, declined, or been educated regarding the vaccine for this year's flu season. 3.Resident #59 had diagnosis including chronic obstructive pulmonary disease, diabetes, and kidney disease. The Minimum Data Set Resident assessment dated [DATE], documented the resident had moderate cognitive impairment and did not receive the influenza vaccine in the facility for this year's flu season due to having received it previously. Review of Resident #59's electronic health record revealed that the New York State Immunization Information System form documented that the resident last received the influenza vaccine in 2022. There was no documented evidence in the record regarding if the resident had received, been offered, declined or educated regarding the vaccine for this year's influenza season. 4.Resident #23 had diagnoses including spinal stenosis (a condition where the spinal cord narrows and compresses the spinal column), atrial fibrillation (irregular heartbeat), and depression. The Minimum Data Set Resident Assessment, dated 2/16/24, documented the resident had moderate cognitive impairment, that the resident had not received the influenza vaccine in the facility for this year's influenza season due to it being offered and declined. Review of Resident #23's electronic health record revealed no documented evidence that the resident/resident representative was educated regarding the vaccine or evidence of a declination of when it was offered and declined. During an interview on 3/28/24 at 12:27 PM the Infection Control Nurse, after review of Resident #64's electronic health record, stated they could not find evidence the resident had received or had been offered the pneumococcal vaccine. After review of Resident's #15, #23, #48 and #59 documentation, the Infection Control Nurse stated they could not find verification the residents were offered or declined the influenza vaccine for this year's flu season. In an interview on 3/28/24 at 12:41 PM the Director of Nursing stated the resident's pneumococcal vaccine should be reviewed on admission and offered if they had not received it. The influenza vaccine should be offered during the influenza season and any vaccinations received or declined should be documented in the electronic health record. 10 NYCRR 415.19(a)(3)

Based on observations, interviews and record review conducted during the Recertification Survey for two (Residents #5 and #59) of four residents reviewed, the facility did not ensure the residents were treated with respect and dignity and care for the resident in a manner and environment that promotes enhancement of their quality of life. Specifically, staff did not provide the resident privacy during the medication administration of injections. This is evidenced by the following: 1. Resident #59 was admitted to the facility with diagnoses that included diabetes, obesity, and lymphedema (tissue swelling in the arms or legs). The Minimum Data Set Resident assessment dated [DATE] revealed Resident #59 was moderately impaired cognitively and received daily insulin injections. Review of the resident's Comprehensive Care Plan revealed that Resident #59 was dependent on staff for locomotion in their wheelchair while on the unit. During an observation on 3/26/24 at 12:15 PM, Resident #59 was sitting in their wheelchair in the dining room awaiting lunch with two other residents at their table. Registered Nurse #1 approached Resident #59 who proceeded to lift the bottom of their shirt, exposing their abdomen and Registered Nurse #1 administered an injection into the resident's bared abdomen. At the time, seven additional residents were in the dining room. 2. Resident #5 was admitted to the facility with diagnoses that included diabetes, dementia, and gastritis (inflammation of lining of the stomach). Review of the Minimum Data Set Resident assessment dated [DATE] revealed Resident #5 was cognitively impaired and received daily insulin injections. During an observation on 3/26/24 at 12:35 PM, Resident #5 was wheeled out of the dining room into the unit's hallway/common area by Licensed Practical Nurse #1. Licensed Practical Nurse #1 proceeded to administer an injection into what appeared to be Resident #5's abdomen while sitting in the hallway/common area where other residents were sitting. During an interview on 3/26/24 at 3:08 PM, Registered Nurse #1 said when administering medications, the general rule is to give them to residents in their rooms, including injections but that occasionally they are given to residents when they are in the dining room. Registered Nurse #1 said they had given Resident #59 the injection earlier and that Resident #59 lifts their shirt for the nurses to give the injection in their abdomen, which was common practice. Registered Nurse #1 said it was difficult to push Resident #5 back to their room due to their size. Registered Nurse #1 said there were other residents in the dining room at the time and some may not have been able to voice any concerns related to observing the resident's abdomen or an injection being administered. During an interview on 3/26/24 at 3:15 PM, Registered Nurse Manager #3 said injections should be administered to residents behind a door or curtain to provide dignity and privacy. Registered Nurse Manager #3 said the unit's hallway/common area, or the dining room were not appropriate places to give injections. Registered Nurse Manager #3 said there were residents on the unit that would not have been able to communicate if the observations bothered them. During an interview on 3/28/24 at 1:07 PM, the Director of Nursing said blood glucose checks and injections are not to be given in public areas but instead, residents should be taken to a secluded area where other residents could not see them. The Director of Nursing said the dining room or hallway/common area were not appropriate places to give injections. 415.3(d)(1)(i)

Based on interviews and record reviews conducted during the Recertification Survey for one (Resident #27) of two residents reviewed for positioning and mobility, the facility did not ensure that the resident's person-centered care plan was implemented to ensure the resident's goals and outcomes were met. Specifically, Resident #27 was not provided a hand roll to their left-hand contracture (permanent tightening of the muscles, tendons and skin causing a decrease in range of motion and often painful) on multiple observations per physician orders, therapy recommendations and the resident's care plan. This is evidenced by the following: Resident #27 had diagnoses including Alzheimer's disease, anxiety, and contractures. The Minimum Data Set Resident Assessment, dated 1/5/24, included that the resident had severely impaired cognition, was totally dependent on staff for care and had limitations in range of motion to both upper extremities (including both hands) that interfered with daily functions. Review of current Physician orders revealed an order initiated 10/17/22 for a hand roll (soft cloth rolled up and placed in palm of hand) to left hand at all times and to remove for meals and for care every shift. Review of Resident #27's Comprehensive Care Plan revealed that the resident had contractures of both hands as identified by a rehabilitation assessment but did not include the use of hand rolls. Review of Resident #27's Kardex (care plan used by the Certified Nursing Assistants for daily care) revealed under Dressing/Splint Care: hand rolls to the left hand at all times, remove for meals and care and to monitor for any signs or symptoms of contractures forming or worsening. During an observation on 3/24/23 at 11:20 AM Resident #27 was sitting in a recliner chair in the common area. There was no hand roll in the resident's left hand. During an observation on 3/26/24 at 1:25 PM Resident #27 was transferred back to bed after lunch with the assist of two staff. No hand roll was placed in the resident's left hand. During an observation on 3/27/24 at 3:43 PM Resident #27 was resting in bed. There was no hand roll in their left hand. In an interview on 3/28/24 at 9:48 AM the Occupational Therapist stated that Resident #27 had an assessment on 1/4/24 and recommendations at that time were to continue to apply the hand roll in the left hand at all times except for hygiene and eating. In an interview on 3/27/24 at 3:58 PM Certified Nursing Assistant #2 stated that Resident #27 has contractures to both hands and that the roll should be their hand all the time. In an interview on 3/28/24 at 12:13 PM Certified Nursing Assistant #3 stated that they had taken care of Resident #27 several days this week and that they were sorry they did not put the hand roll in the resident's left hand. In an interview on 3/28/24 at 11:43 AM Nurse Manager #2 stated that staff should follow the resident's care plan and did not know why the hand rolls were not being used. 10 NYCRR 415.11(c)(1)

Based on observations, interviews and record review conducted during the Recertification Survey, for one (Resident #5) of one resident reviewed for insulin administration, the facility did not ensure that the services and care provided met professional standards of quality. Specifically, several nurses did not clarify a contradictory physician order regarding insulin injections, when to give and when not to give as it relates to Resident #5's meal intakes. This is evidenced by the following: The facility policy, Medication Administration - General Guidelines, dated January 2018, included that medications were to be administered in accordance with the written orders of the attending physician. Additionally, if a medication order was not clear, or questionable in any way, the nurse should contact the provider for clarification. Resident #5 had diagnoses that included diabetes, dementia, and gastritis (inflammation of lining of the stomach). Review of the Minimum Data Set Resident assessment dated [DATE] revealed Resident #5 was cognitively impaired and received insulin injections. In a nursing progress note dated 3/13/24 Licensed Practical Nurse #3 documented that Resident #5 did not eat any supper except for Ensure (nutritional supplement drink) and orange juice and that their blood glucose (sugar) level prior to supper was 59 (normal values approximately 80-120). Licensed Practical Nurse #3 documented that no insulin sliding scale coverage was given per orders from the On-Call Medical Provider Review of a physician's (telephone) order dated 3/13/24 revealed Regular insulin sliding scale (insulin dose based on resident's blood glucose level) subcutaneously (injection of medication beneath the skin) before meals and at bedtime for diabetes. Additionally, the order included to not give insulin if Resident #5 did not eat their meal. Review of the March 2024 Medication Administration Record and the Nutrition-Amount Eaten Report revealed that 44 doses of insulin were administered to Resident #5 from 3/13/24 to 3/27/24 when the amount eaten at meals was documented as refused all meal (for all three meals a day with the exception of two meals in the 15 days reviewed). During an observation on 3/26/24 at 12:38 PM, Licensed Practical Nurse #1 administered Resident #5's insulin injection before lunch. Resident #5 was then brought into the dining room and their lunch tray set up by staff. At 1:15 PM Resident #5's lunch tray was removed from the table by facility staff. All solid foods remained on the tray (not consumed by the resident) and only the Ensure drink and cranberry juice had been consumed. During an observation on 3/26/24 at 5:59 PM, Resident #5 was in bed with their dinner tray in front of them. The Ensure drink and cranberry juice had been consumed but all solid food remained untouched. Review of the 3/26/24 Medication Administration Audit Report revealed Resident #5 had received an insulin injection prior to both lunch and dinner meals despite not eating any of their meals with the exception of Ensure and juice. During an interview on 3/27/24 at 11:00 AM, Licensed Practical Nurse #1 stated Resident #5 had blood glucose checks four times a day and should not receive insulin if their blood glucose was less than 100. Licensed Practical Nurse #1 said Resident #5's food intake was terrible, but that they would drink the Ensure. When the current physician order for insulin was reviewed at that time, Licensed Practical Nurse #1 said they were not aware the instructions to 'not give coverage if the resident did not eat' was there. Licensed Practical Nurse #1 said Resident #5 had not been eating food for a long time, but with that order, they should encourage the resident to eat. Licensed Practical Nurse #1 said the order was contradictory, (to give insulin before meals and do not give if resident did not eat). Additionally, Licensed Practical Nurse #1 said their view of the electronic Medication Administration Record did not include the additional instructions to not give the insulin if the resident did not eat. Review of the electronic medical record with the surveyor at this time, revealed that the nurses view of the medication administration record did not include to hold the insulin if the resident did not eat their meal. During an interview on 3/27/24 at 11:19 AM, Registered Nurse Manager #3 said Resident #5's orders changed when the resident had an episode of a low blood glucose level due to not eating. Registered Nurse Manager #3 said the nurses should read through the entire insulin orders to see if there were any additional instructions at the bottom. Registered Nurse Manager #3 said Resident #5 had been receiving insulin but had not been eating (solid foods) but felt that the Ensure would qualify as meal. Registered Nurse Manager #3 said they were unsure of medical provider's intent for the order (give insulin before meals and to not give insulin coverage if not eating) but would clarify it. During an interview on 3/27/24 at 11:42 AM, Nurse Practitioner #1 said insulin doses (via a sliding scale) should be given based on the blood glucose value and insulin coverage is typically given before meals. Nurse Practitioner #1 said the nurses should have clarified the insulin sliding scale order (give before meals and do not give if resident not eating) with the medical provider. During an interview on 3/28/24 at 12:07 PM, the Director of Nursing said the nurses should have clarified the insulin sliding scale order with a medical provider, since it said to give before meals and to not give if resident did not eat. The Director of Nursing said Resident #5 does not eat (solid foods) but that their weight has maintained with Ensure. 10 NYCRR 415.11(c)(3)(i)

Based on observations, interviews, and record reviews conducted during a Recertification Survey, for one (Resident #50) of five residents reviewed, the facility did not ensure that a resident who is unable to carry out Activities of Daily Living received the necessary services to maintain good oral hygiene. Specifically, Resident #50 who is dependent on staff for assistance with oral hygiene was observed on several occasions with poor oral hygiene. Additionally, interviews with staff revealed that oral hygiene had not been completed despite documentation that it had been. This is evidenced by the following: Resident #50 had diagnoses including traumatic brain injury (injury to the brain caused by an external force), left sided hemiparesis (weakness on one side of the body), and seizure disorder (temporary disruption of normal brain function caused by abnormal electrical discharges in the brain). The Minimum Data Set Resident Assessment, dated 12/15/23, revealed Resident #50 had severely impaired cognition, had no behavioral symptoms, including that rejections of care had not been exhibited, and that the resident was dependent (on staff) for oral hygiene. Review of Resident #50's Comprehensive Care Plan, dated revised 3/5/24, revealed the resident had the potential for oral problems related to poor oral hygiene. Interventions included oral care twice daily and as needed. Review of Resident #50's Kardex (care plan used by the Certified Nursing Assistants for daily care) located in the resident's room revealed the resident was dependent for oral care. The Kardex did not include instructions to staff on how often or when to provide the oral care. Review of Resident #50's current Physician's orders included oral care to be completed twice daily. Review of Resident #50's most current dental note dated 9/2/23, revealed Resident #50 had gingival inflammation and heavy generalized plaque. Review of a Physician's progress note dated 3/12/24, revealed that Resident #50 was able to answer questions using a thumbs up (for yes) or thumbs down (for no) with their right thumb. In an observation on 3/24/24 at approximately 10:47 AM, Resident #50 was sitting in the dining room. Their lower teeth had large amounts of thick yellow plaque over all visible teeth. In an observation and interview on 3/26/24 at approximately 11:51 AM, Resident #50 was awake and dressed. All lower teeth were visible with a large amount of thick yellow plaque buildup. When interviewed at the time, Resident #50 indicated by putting their thumb down that staff had not brushed their teeth that morning and when asked if they wanted their teeth brushed Resident #50 demonstrated a thumbs up. Review of Resident #50's Treatment Administration Record (documentation by licensed nurses) 3/1/24-3/27/24 revealed that Resident #50's oral care was scheduled twice daily with morning care and at hour of sleep. All (with the exception of one day) had been signed off (by the nurses) as completed. Review of Resident #50's Certified Nursing Assistants oral care documentation (in the electronic medical record) 3/1/24-3/27/24 revealed oral care was documented as completed twice daily. During an interview on 3/27/24 at 10:26 AM, Certified Nursing Assistant #2 stated that brushing teeth should be included with morning care and overnight staff were assigned to do it for Resident #50. Certified Nursing Assistant #2 stated the resident was totally dependent (on staff), and that the overnight staff do not always do what they are supposed to do. During an interview on 3/28/24 at 11:06 AM and again at 1:34 PM, Registered Nurse Manager #1 stated that brushing resident's teeth was part of morning and bedtime care. Nurse Manager #1 stated the night shift gets Resident #50 up and the evening shift puts the resident back to bed and that the Certified Nursing Assistants on these shifts knew it was their responsibility. Registered Nurse Manager #1 said that oral care was also documented on the Treatment Administration Record for the nurses (licensed) to sign off that it had been completed. Registered Nurse Manger #1 stated that the oral care should be on the resident's Kardex but when reviewed with the surveyor, Registered Nurse Manger #1 stated that when to do the oral care was not listed. Registered Nurse Manager #1 stated if staff are signing that the oral care had been completed without knowing if it was, it was falsifying records and thinks that the nursing staff were assuming the oral care had been completed for Resident #50 when it had not. During an interview on 3/28/24 at 12:05 PM, Resident #50's representative stated that they have noticed oral care not being completed when they visit twice weekly and they try and do it. During an interview on 3/28/24 at 12:07 PM, Director of Nursing stated oral care should be completed as ordered and at minimum daily if the resident allows. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record reviews conducted during a Recertification Survey, the facility did not ensure the nurse staffing information was posted daily and included the required information. Specifically, the nurse staffing information did not consistently include the total number and actual hours worked by licensed and unlicensed nursing staff who were directly responsible for resident care, the current resident census (the number of residents currently residing in the facility) and was not posted on a daily basis at the beginning of each shift to include any staffing changes as per the regulations. This is evidenced by the following: During an observation on 3/24/24 at 1:24 PM, the facility's nurse staffing information posted was dated 3/23/24 and did not include the current resident census. There was no information posted throughout the day for 3/24/24. During an observation on 3/25/24 at 10:56 AM, the current nurse staffing information posted did not include the resident census. Review of the nurse staffing information form titled Nursing Staffing Daily Reporting Tool from 2/26/24 to 3/26/24 revealed multiple days that did not include the total number of actual hours worked by each discipline or the resident census. During an interview on 3/28/24 at 9:58 AM, Administrative Assistant #1 said the night supervisor completed and then posted the nurse staffing information before leaving in the morning and the unit nurse managers kept track of the nursing staffing levels during the day. During an interview on 3/28/24 at 10:05 AM, Nursing Coordinator #1 said the night supervisor was responsible for posting the nurse staffing information. Nursing Coordinator #1 said when staff called off for their shift it would be updated in the scheduling book and that they did not know who would update the posting (if required). Nursing Coordinator #1 said they were not aware that the current resident census was required. During an interview on 3/28/24 at 12:07 PM, the Director of Nursing said the night shift supervisor was responsible for completing and posting the nurse staffing information and should include the date, the current resident census, the number of nurses per discipline, and the number of hours worked by each discipline. The Director of Nursing said no one was updating the postings during the day when there were staffing changes but that it should be. 10 NYCRR 415.13

Based on observations, interviews and record reviews conducted during the Recertification Survey, completed on 12/17/21, it was determined that for one (Resident #21) of two residents reviewed, the facility did not provide the necessary services to maintain personal hygiene. The issue involved lack of nail care. This is evidenced by the following: Resident #21 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 10/14/21, documented that the resident had moderately impaired cognition and required extensive assistance for personal hygiene. Review of the Comprehensive Care Plan dated 10/21/21, and the current Certified Nursing Assistant (CNA) Kardex (used by the CNA to drive daily care) revealed that Resident #21 required extensive assistance of staff for personal hygiene. During an observation on 12/13/21 at 10:46 a.m., Resident #21's fingernails had dark colored debris under all of the nail beds of both hands. During an observation on 12/14/21 at 12:54 p.m., Resident #21 was observed eating a sandwich with their hands, at times putting their fingers in their mouth. The resident's fingernails remained visibly dirty with brown debris under the nailbeds on both hands. In an interview on 12/15/21 at 11:56 a.m., the CNA stated that Resident #21 gets a shower on Tuesdays (previous day) day shift but could not remember if they or someone else did Resident #21's shower and nail care. The CNA stated that Resident #21 is not diabetic so the CNAs should clean and trim their nails and that Resident #21 is not resistive to their shower or nail care. During an observation on 12/15/21 at 11:57 p.m., Resident #21 was asleep in their wheelchair and several fingers that were observable remained with brown debris under the nailbeds and were approximately 1/8 to 1/4 inches long. During an observation and interview on 12/15/21 at 1:18 p.m., the Registered Nurse (RN) stated that the CNAs do fingernail care on shower day and if unable to for any reason there is a list to put the resident's name on in order to have nail care completed. The RN, with the surveyor, looked at Resident #21's nails and stated that the resident's nails had not been cut on their shower day and needed to especially as Resident #21 eats with their hands. Resident #21 stated at this time that they would like their nails cut. In an interview on 12/15/21 at 1:37 p.m., the Licensed Practical Nurse (LPN) stated they did not realize Resident #21's nails did not get cleaned and cut on their shower day. The LPN stated that if the CNAs were unable to complete nail care, they should come to them so they could have documented that and provided the care. In an interview on 12/16/21 the RN Manager (RNM) stated that per the documentation, Resident #21's nails were last done 11/30/21. The RNM stated that they would call the CNA who assisted with the resident's shower the previous day and find out what happened because the nurse should have been notified. [10 NYCRR 415.12(a)(3)]

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #111) of four residents reviewed for accidents, the facility did not thoroughly investigate an injury to rule out abuse, neglect, or mistreatment. Specifically, the facility did not thoroughly or timely investigate an incident involving injury following a transfer. This is evidenced by the following: Resident #111 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/1/19, revealed the resident was cognitively intact, required extensive assist of two staff members for transfers, and had no behaviors. The Comprehensive Care Plan, initiated 5/13/19, and Certified Nursing Assistant (CNA) Kardex revealed that the resident required the assistance of two staff members with a gait belt for toileting and transfers. On 12/17/19 it was added that the resident required a left ankle orthotic to be worn during transfers and ambulation. In an interview on 5/15/19 at 1:50 p.m., the resident stated that she broke her heel several months ago while transferring to the toilet. The resident stated that one of the CNAs was in a hurry and did not put her ankle brace and correct shoes on, and she hit her foot on the wheelchair and broke her heel. The resident said that she was non-weight bearing for weeks, could not go visit her family, and could not do her normal activities due to the injury. The resident said while she had no issues with male caregivers in general, she did not wish for that CNA to care for her any longer. Review of the Incident Report, dated 3/22/19 and signed by Registered Nurse (RN) #1, revealed that on the evening of 3/22/19 the resident stated that she hit her left heel on the wheelchair while attempting to get out of bed to go to the bathroom. The resident's left foot was not in the right position and it hit the metal on the wheel, sustaining a heel abrasion that was painful to touch. The report did not include any mention of any staff with the resident during the transfer, any staff statements, or any information about care plan compliance at the time of the incident. In a nursing progress note, dated 3/23/19, RN #2 documented that the resident complained of extreme pain in her left heel, that the medical team was notified, and an x-ray was ordered. In nursing progress notes, dated 3/29/19, the RN Manager (RNM) documented that the resident was still having heel pain (despite a negative x-ray) from the previous week's incident. The medical team was notified and orders were given to apply ice, wear a heel boot, and repeat the x-ray. The RNM later documented that the x-ray was positive for a heel fracture and orders included non-weight bearing status, use of a mechanical lift for transfers, and an orthopedic consult. Review of a posted no male caregiver list at the nurses' station revealed the resident's name was added on the side of the list. Interviews conducted on 5/15/19 included the following: a. At 3:42 p.m., CNA #1 stated that the resident is now a two person transfer since she hurt her ankle. She said the resident wears an ankle splint whenever she gets up and that she never attempts to get up on her own. CNA #1 said the resident always calls for help and uses the splint. CNA #1 said that the resident was added to the list for no male caregivers, but she did not know why. b. At 3:48 p.m., RN #2 stated that the resident refused to have the male caregiver over the weekend, but she did not know why, and she did not ask. She said that the resident has never attempted to self-transfer as far as she knew. c. At 4:02 p.m., the RNM stated that she obtained a statement from CNA #2 (which she pulled out of her desk drawer at surveyor request) who assisted with the transfer on 3/29/19. She said CNA #2 could not recall if the resident hit her foot but he did recall the resident did not have the splint on because she refused it. The RNM said that CNA #2 did not report the refusal and he should have. The statement also included that CNA #2 was aware of the resident's complaints of heel pain. The RNM said she was not aware that the resident was now refusing male caregivers. She said she did not get a statement from CNA #2 sooner as he was off. The RNM said she called him after the positive x-ray. When interviewed on 5/16/19 at 10:49 a.m., the Director of Nursing (DON) stated that she was notified of the injury a week after it occurred. She said it was reported that the resident bumped her heel on her wheelchair. The DON said she was concerned about the delay in treatment and spoke to the physician who told her it could have been pathological as opposed to traumatic. The DON said she was not aware of CNA #2's involvement. She said the CNA that assisted with the transfer should have been interviewed immediately. She said the RNM should have been notified regarding the resident's wishes for no male caregiver so she could determine why. The DON said that the RNM should have interviewed the resident the next day as opposed to a week later to get the full story. (10 NYCRR 415.4(b)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for activities of daily living, the facility did not provide the necessary care and services to maintain personal hygiene. Specifically, Resident #15 did not receive the necessary assistance or support to maintain good oral hygiene. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/20/19, revealed the resident had moderately impaired cognition, required extensive assistance of one staff member for personal hygiene, and rejected care on one to three days during the look back period. Review of a dental note, dated 7/26/18, revealed the resident had gingival inflammation (inflammation of the gums surrounding the teeth), [MEDICAL CONDITION] (gums enlarge or increase in size), and to treat with [MEDICATION NAME] (a disinfectant and antiseptic that is used to disinfect skin). The current Certified Nursing Assistant (CNA) Care Card included oral care twice a day and as needed with limited assist and set up. If the resident resists care, reassure, leave, and re-approach in five to ten minutes. The Comprehensive Care Plan (CCP) for oral/dental health revealed poor oral hygiene, with a goal to be free of infection, pain or bleeding in the oral cavity, to coordinate arrangements for dental care as needed, monitor and report any signs or symptoms of oral/dental problems needing attention, and provide oral care per the care card. In observations on 5/13/19 at 1:13 p.m. and on 5/14/19 at 8:49 a.m., a foul odor was noted in the resident's mouth. Observations and interviews conducted on 5/14/19 included the following: a. At 2:02 p.m., the CNA said the resident does not refuse cares with consistent CNAs. She said the resident is set up for oral care and if he cannot do it on his own, staff should brush his teeth. b. At 2:45 p.m., the CNA approached the resident and said she could smell mouth odor. She said the resident had a history of [REDACTED]. Observations and interviews conducted on 5/15/19 included the following: a. At 8:46 a.m., the CNA said she had reported the mouth odor the previous night to a nurse who said the resident has a long history of halitosis (bad breath). b. At 8:56 a.m. and again at 9:57 a.m., the Licensed Practical Nurse (LPN) said the resident was previously on [MEDICATION NAME] to treat bleeding gums and that staff had not told her about any current bleeding in his mouth. She said the resident cannot brush his teeth on his own, staff have to do that. The LPN said when she gave the resident a medication, she could smell his bad breath. c. At 10:47 a.m., the CNA wheeled the resident into his bathroom, set him up with a toothbrush and toothpaste, and asked him to brush his teeth. The resident looked at the toothbrush then backed himself out of the bathroom. When the CNA again offered the toothbrush, the resident said, I can't. When the CNA put the toothbrush in the resident's mouth and brushed along the gum line, the resident said it hurt. There was blood visible on the toothbrush and lower teeth. d. At 11:07 a.m., the Registered Nurse Manager said staff had not reported any bleeding when brushing. e. At 11:27 a.m., the dentist said she would come in and evaluate the resident. Review of a dentist note, dated 5/15/19 following the evaluation by the dentist, revealed marginal gingivitis secondary to heavy plaque and gingival [MEDICAL CONDITION] due to poor oral hygiene. The dentist ordered [MEDICATION NAME] twice a day. (10 NYCRR 415.12(a)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #6 and #89) of four residents reviewed for pressure ulcers, the facility did not identify and provide care and services to address residents' skin care/wound care needs in accordance with professional standards of practice based on the comprehensive assessment, person centered care plan, and resident's choice. Specifically, wound care was not thoroughly identified, assessed, and/or treated according to physician orders [REDACTED]. This is evidenced by the following: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 5/7/19, revealed that the resident had moderately impaired cognition, was understood and was able to understand others, and required extensive assistance of staff for all activities of daily living. Current physician orders [REDACTED]. There were no other orders for wound or skin care. The Comprehensive Care Plan (CCP), dated 12/2/18, included the resident has pressure injuries on both heels and coccyx. Interventions included, but were not limited to, inform the family and caregivers of any new area of skin breakdown and administer treatments as ordered. Orthopedic surgical follow-up notes included the following: a. On 4/24/19, the left knee wound care following surgical repair included removal of the surgical dressing after three days, maintain a dry sterile dressing over incisions for seven days, change with bathing, and may shower after three days. b. On 5/6/19, instructions included for staff to put a proper dressing on the left heel ulcer (arrived for visit with a Band-Aid), continue with a dry sterile dressing to the left knee, and to follow up in two weeks for removal of staples. A wound clinic visit note, dated 5/1/19, revealed that the resident had Stage III pressure ulcers to both heels and a surgical incision of the left knee. Instructions for care of both heel ulcers included to apply a thin layer of Santyl, cover with a small piece of Vaseline gauze over the Santyl, then cover with an ABD pad and gauze wrap. The left knee surgical incision care is as ordered by the surgeon. In a nursing progress note, dated 5/12/19, Registered Nurse (RN) #1 documented that the resident has green purulent drainage from the penis, and the meatus is red and painful when cleaned. Observations conducted on 5/13/19 at 11:03 a.m., on 5/14/19 at 1:38 p.m. and again at 2:27 p.m., the resident was in bed and both of his heels were lying on the mattress. The heel booties were on the window sill. Observations of care on 5/14/19 included the following: a. At 1:38 p.m., the Certified Nursing Assistant (CNA) cleansed the resident of stool. The penis was red and excoriated, and the resident cried out when it was cleansed saying that it hurt. The CNA did not apply anything to the excoriated area on the penis or put the heel booties on. When interviewed at that time, the resident stated that he would wear the heel booties. He said sometimes staff put them on and sometimes they do not, but no one asked him that day. b. At 2:27 p.m., RN #2 cleansed both heels, applied a very thick layer of Santyl over both heel wound beds, and covered the wounds (including both skin edges) with a Vaseline gauze that she folded over into three layers. The left knee was covered with an undated gauze wrap, which was left unattended, and nothing was applied to the penile excoriation. Review of the (MONTH) 2019 Treatment Administration Record revealed daily treatments for the heels, but nothing documented for the left knee surgical wound or the excoriation to the penis. When interviewed on 5/15/19 at 2:30 p.m., the wound clinic RN stated that Santyl should always be applied in a thin layer, the Vaseline gauze in a single layer in the wound bed only so that the intact, surrounding skin does not macerate. The RN said that the wound clinic did not look at the resident's left knee since it was surgically re-opened but it should be assessed daily for signs and symptoms of infection and redressed with a dry gauze. When interviewed on 5/16/19 at 9:05 p.m. and again on 5/17/19 at 12:51 p.m., the RN Manager (RNM) stated that she thought the Santyl order was for a thick layer. She said the Vaseline gauze should only go in the wound bed and not on intact skin. The RNM said she saw that the resident's knee wound dressing was not dated and there were no orders. The RNM said she called the medical team to get an order to maintain the dry dressing until the resident's orthopedic appointment. The RNM said she would expect staff to assess daily for signs of infection. The RNM said the resident should wear the heel booties at all times although she knows the resident does not like them. When asked about the excoriation of the resident's penis, the RNM said she was not aware of it until 5/16/19. In an interview on 5/17/19 at 12:51 p.m., RN #2 stated that she was not aware that Santyl should only be applied in a thin layer or that Vaseline gauze should be applied in a single layer in the wound bed only. She said she has never seen the left knee as there are no treatments ordered. 2. Resident #89 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident also has pyoderma (an [MEDICAL CONDITION] condition of the skin that causes ulcers). The MDS Assessment, dated 3/22/19, revealed that the resident was cognitively intact, had multiple pressure ulcers, multiple venous and arterial ulcers, and an open lesion on the foot. The CCP, dated as initiated on 11/6/16, revealed that the resident had potential or actual impairment to skin integrity related to fragile skin, immobility, diabetes, [MEDICAL CONDITION] and catheter use. Interventions included weekly treatment documentation to include the measurement of each area of skin breakdown width, length, depth, type of tissue and exudate and any other notable changes. The CCP included a Stage IV ulcer on the left heel with interventions but did not include the [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The orders did not include cleansing the wounds prior to applying any dressings or the use of Vaseline gauze. The Nursing Admission Assessment, dated 4/15/19, revealed that the resident had multiple chronic wounds on both legs, but location, type, size and description of all wounds were not included in the assessment. Review of the wound clinic recommendations for wound care, dated 4/22/19, included to cleanse with Saline, pat dry, apply [MEDICATION NAME] Blue, cover with ABD (thick absorbing dressing) pads, and wrap with flexicon (self-adhering durable stretch gauze wrap to help keep dressings in place). The notes included to also use Vaseline gauze to the anterior (front) leg wounds prior to the ABD pads. The Weekly Wound Assessments, including 5/10/19, did not include location, type, or depth of wounds and did not describe the wounds. The assessments directed to see documents for wound measurements and pictures. When reviewed, the pictures did not include depth or provide a description of the wounds and did not include all the resident's wounds. In an observation of the resident on 5/15/19 at 12:40 p.m., both elbows had dark brown scabbed areas surrounded by dry skin in addition to heel and leg dressings. When interviewed at that time, the resident and a family member stated that the scabs happen when they get him out of bed with the lift. Both stated that it has happened several times before and that the open areas heal when the resident has to stay in bed for a while. The resident and family member said that sometimes staff spray something on his elbows when open, but once they scab over, they leave them open to air to heal. They both said they have asked if there was something they could get to protect the resident's elbows, and staff have told them they would get something. In an observation of wound care on 5/16/19 at 11:14 a.m., the Licensed Practical Nurse (LPN) cleansed all areas of the legs and heels with normal Saline, and without patting the areas dry (prevents maceration of surrounding skin), the LPN covered them with the [MEDICATION NAME] Blue and gauze wrap (as opposed to flexicon). The LPN covered the knee wounds with Vaseline gauze (as opposed to the leg wounds). The elbows were not addressed. When interviewed on 5/15/19 at 1:12 p.m. regarding skin breakdown on both elbows, RNM #2 stated that any documentation about new issues should be in the progress notes but that their focus has been primarily on the resident's legs. She said that with the pyoderma the resident gets blisters that pop, and she takes pictures and measurements. She said the problem with the Weekly Wound Assessments is that the areas change and are difficult to describe where they are located, and she was not sure how to label each wound. After reviewing the physician orders, the RNM said that the treatment orders do not designate specific wounds. She said a nurse coming on to the unit would not know where the wounds were located or the treatment. Interviews conducted on 5/16/19 included the following: a. At 11:26 a.m., the LPN stated that the elbow wounds started as blisters and are re-occurring. b. At 1:24 p.m., the Director of Nursing stated that there was nothing documented regarding the resident's skin breakdown of both elbows. She said there was nothing in the CCP related to the pyoderma skin condition. She said all wounds should be documented, monitored, and treated per physician orders. (10 NYCRR 415.12)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #95) of two residents reviewed for nutrition, the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrated that it was not possible. The issue involved lack of timely interventions following a significant weight loss. This is evidenced by the following: Resident #95 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/22/19, revealed that the resident was cognitively intact, required extensive assist of staff for eating, and had no swallowing issues. The Comprehensive Care Plan (CCP), dated 1/7/19, and current Certified Nursing Assistant (CNA) Kardex revealed that the resident was on a regular diet, independent with eating, and received Ensure [MEDICATION NAME] at lunch and for a bedtime snack. On 4/23/19, it was added to the CCP that the resident occasionally refused meals. Interventions included to review preferences, encourage family to bring in food items, review circumstances regarding refusals, and report results to the medical team. During observations on 5/13/19 during the lunch meal, on 5/15/19 for breakfast and lunch, and on 5/16/19 during the lunch meal, the resident remained in bed sleeping. Review of the resident's weights for the past six months revealed that the resident weighed 128 pounds (lbs.) in (MONTH) (YEAR) and 122 lbs. in (MONTH) 2019. The 4/9/19 weight was recorded as 127 lbs. (5 lb. gain). A reweigh was done later on 4/9/19 that revealed 119 lbs. which presented as a loss instead of a gain. On 5/10/19, the resident's weight was 111 lbs. for an additional 8 lb. loss. Review of the meal intake recorded for the past 30 days revealed the resident refused 57 of 90 meals offered, 14 of 19 Ensure supplements offered at lunch, and 20/30 bedtime snacks were either refused or not given due to the resident sleeping or not available. In a dietary progress note, dated 4/26/19, the Dietary Technician (DT) documented that the resident had an 11 percent loss in the past three months but a 5 percent weight gain in the past 30 days. Intake was poor, with frequent refusals of meals, and per nursing, the resident will drink but not eat. The plan was to continue to monitor acceptance of supplements. There was no mention of the reweigh which identified a loss as opposed to a gain. Review of the most recent medical note, dated 4/17/19, revealed that the resident had a urinary tract infection and was on an antibiotic. The resident was not eating or drinking adequately and to encourage oral intake and fluids. There was no documented evidence that dietary, medical, or family were notified of the extent of the resident's refusals and/or significant weight loss, and there were no revisions to the nutritional plan of care. When interviewed on 5/13/19 at 1:33 p.m. and again on 5/15/19 at 12:05 p.m., the CNA stated that the resident needs to be fed. She said the resident refused her lunch which she usually does. Interviews conducted on 5/16/19 included the following: a. At 1:27 p.m., the covering Registered Dietician (RD) stated that she was unaware of the resident's weight loss as the usual DT was out for medical purposes. The RD said that if there was a discrepancy of a 5 lb. weigh loss or a gain of 3 lbs., a re-weigh should be done. She said medical and family should be notified of the weight loss, preferences should be reviewed, different supplements tried, and weekly weights initiated. b. At 4:03 p.m. and again on 5/17/19 at 11:22 a.m., the Registered Nurse Manager (RNM) stated that she knew the resident was not eating well but was unaware of the extent of the refusals. The RNM said that the resident has been unstable for a while but usually rallies. She said the resident was now refusing to be weighed. She said they really need to meet with the family and Social Work and decide what to do next. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #48) of eight residents reviewed for unnecessary medications, the facility did not ensure that all identified irregularities noted by the pharmacist had been reviewed by the physician and/or a response was documented in the medical record. In addition, the facility did not have a policy for the Medication Regimen Review that included the necessary minimum information regarding timeframes for the different steps in the process and medical responsibilities. This was evidenced by the following: Review of the policies, [MEDICAL CONDITION] Medication, dated (MONTH) 2019, and Management of Residents on [MEDICAL CONDITION] Medications, dated (MONTH) 2014, revealed that documentation regarding pharmacy recommendations is placed in the resident's medical record. Neither policy addressed the timeframes for the different steps in the process, steps the pharmacist must take when an irregularity is identified that required urgent action, and/or that the physician must document in the medical record that the recommendation was reviewed and/or acted upon in a timely manner. Resident #48 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/19/19, revealed the resident had severely impaired cognition and physical behaviors occurred one to three days during the seven day look back period. The admission orders [REDACTED]. The Medication Regimen Review, dated 5/19/18, revealed that [MEDICAL CONDITION] was an off-label indication for [MEDICATION NAME] and that the resident remained on Quetiapine for that diagnosis. The pharmacist requested clarification, support orders, and to consider 14 days of behavior documentation for the interdisciplinary team to review. The physician/provider response section of the form was blank. A review of the behavior notes, from 3/26/18 through 6/3/18, revealed there were no documented behaviors. Physician notes, dated 5/7/18 and 5/31/18, revealed that the resident was confused as usual and did not have any episodes of increased anxiety or [MEDICAL CONDITION]. The note included a history of [MEDICAL CONDITION] that was stable and to continue the present medications. In a medical progress note, dated 8/31/18, the physician documented that the resident had been receiving [MEDICATION NAME] and Quetiapine, does not have any behavioral issues, was stable, and to continue the same doses of [MEDICATION NAME] and Quetiapine. There was no medical documentation that the pharmacy recommendation was reviewed and/or addressed. Review of the medical record revealed that a gradual dose reduction was eventually completed 3/15/19 for the Quetiapine, and the resident remains on the [MEDICATION NAME]. Interviews conducted on 5/16/19 included the following: a. At 10:57 a.m., the Registered Nurse Manager stated the pharmacist had a form for recommendations but she never saw them. b. At 12:05 p.m. and again at 2:05 p.m., the consulting pharmacist stated he reviewed every resident's drug regime monthly and that recommendations were e-mailed to the Director of Nursing (DON) and Nurse Practitioner (NP). He said hard copies of the recommendations were printed out and the provider documents their response on the form. He said the form is placed in the medical record. The pharmacist said that if the recommendation was not urgent, he would follow up on the next visit to ensure it was addressed. c. At 1:58 p.m. and again at 4:07 p.m., the DON stated that the NP received the hard copy of the pharmacy recommendations but was unsure as to where they went after the NP addressed them. The DON stated the pharmacist should follow up to ensure the recommendations are addressed timely. The DON later said that she thought the NP was following up on the recommendations; however, she was not. The DON said she was not aware there was a lack of follow up. d. At 2:49 p.m., the Administrator stated the pharmacy recommendations are going to the different units, and the process is different on each unit. He stated they were trying to change the process to be consistent. The NP was unavailable for interview. (10 NYCRR 415.18(c)(2))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of eight residents reviewed for unnecessary medications, the facility did not ensure orders for as needed [MEDICAL CONDITION] medications were limited to 14 days. Specifically, Resident #91's as needed order for an anti-anxiety medication was not limited to 14 days. This is evidenced by the following: Resident #91 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 4/18/19, revealed the resident was cognitively intact and had received an antidepressant medication. The MDS Assessment, dated 4/25/19, revealed an anti-anxiety ([MEDICAL CONDITION]) medication had been administered one time. A medical provider's note, dated 4/5/19, documented that the resident verbalized that [MEDICAL TREATMENT] caused a great deal of anxiety and requested an anti-anxiety medication prior to [MEDICAL TREATMENT]. When interviewed on 5/16/19 at 2:05 p.m., the consulting pharmacist stated an as needed [MEDICAL CONDITION] medication order should be renewed every 14 days. When interviewed on 5/17/19 at 9:51 a.m., the Director of Nursing stated an as needed [MEDICAL CONDITION] order should only be ordered for 14 days. She said the nurses know when they transcribe an as needed [MEDICAL CONDITION] medication order it can only be written for 14 days. She said the physicians and pharmacist also know that as needed [MEDICAL CONDITION] medications can only be ordered for 14 days. (10 NYCRR 415.12)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not provide food and drink that is palatable, attractive, or at a safe and appetizing temperature. Specifically, the issues involved food that was unpalatable and at suboptimal temperatures. This is evidenced by the following: Observations of the lunch meal on Unit 1 conducted on 5/13/19 included the following: a. At 12:23 p.m., staff applied margarine to peas and pearl onions (main vegetable) and rice, and the margarine did not melt. b. At 12:28 p.m., Licensed Practical Nurse (LPN) #1 said the margarine was not melting but she thought it was the product. c. At 12:31 p.m., Resident #33 said she has not been eating because of the meals served. She said the food was bland and had no flavor. d. At 1:00 p.m., Resident #71 said she was not going to eat her meal because it was cold and tasted awful. e. At 1:50 p.m., Resident #26 said she did not like the food because it did not taste like home cooked food. When interviewed on 5/13/19 at 12:30 p.m. on Unit 2, Resident #89 said the food was not hot and the soup was cold. He said he did not think the food trucks were heated. Interviews conducted on 5/14/19 included the following: a. At 8:57 a.m., Resident #86 said the food was not overly warm. He said the trays sit in the food trucks for 15 to 20 minutes before staff start to pass them. b. At 9:11 a.m., Resident #81 said the food was often not warm enough. She said she had been served mashed potatoes the other day. She said the margarine did not melt and the mashed potatoes did not taste good. During a Resident Council Meeting on 5/15/19 at 10:45 a.m., eight of eight residents (Residents #14, #72, #75, #79, #81, #83, #107 and #111) said the food was cold, including the soup, and the margarine does not melt on the food. They said the food carts are not heated. On 5/16/19 at 11:55 a.m., a test tray of regular diet whole food consistency was requested by the surveyor to be sent to Unit 3. The meal consisted of beef tips and gravy, mashed potatoes, green beans, lemon pudding, milk and coffee. The tray line temperatures were recorded as 180 degrees Fahrenheit (*F) for the beef tips, 178*F for the gravy, 185*F for the mashed potatoes, 160*F for the green beans, and 44*F for the lemon pudding. At 12:08 p.m., the test tray was placed on the tray line, and at 12:12 p.m., the tray had been loaded into a food truck and started to the unit. At 12:15 p.m., the truck arrived and staff immediately started to serve trays. At 12:30 p.m., all residents had been served and assisted with set up. At 12:35 p.m., the Director of Food Service (DFS) and the surveyor took food and beverage temperatures using recently calibrated thermometers (Nursing Home (NH)(NAME)digital model #DPP800W and Surveyor Thermo couple AquaTuff 351). The DFS said the goal was for hot foods to be served at a minimum 130*F. Food temperatures were as follows: a. Green beans: NH 114.4*F, Surveyor 112.0*F When interviewed at that time, the DFS said the beans were not hot enough and needed to be warmed. She said the taste was watery. b. Mashed potatoes: NH 128.3*F, Surveyor 129.4*F When interviewed at that time, the DFS said the potatoes needed to be warmer because the margarine had not melted. c. Beef tips: NH 106.8*F, Surveyor 106.5*F When interviewed at that time, the DFS said the beef tips had good flavor but were not warm enough. d. Lemon pudding: NH 58.4*F, Surveyor 58.8*F When interviewed at that time, the DFS said the pudding needed to be colder, it tasted warm. e. Milk: NH 58.6*F, Surveyor 58.3*F The Surveyor tasted the milk because the DFS does not drink milk. The milk needed to be colder. When interviewed at that time, the DFS said that the milk was set in ice on the tray line, so she does not understand the rise in temperature. f. Hot water (for tea): NH 123.2*F, Surveyor 122*F When interviewed at that time, the DFS said it was not hot enough to make good tea. (10 NYCRR 415.4(d)(1)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one walk-in freezer in the main kitchen, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. The issues included a visible build-up of ice on and around the evaporator fan unit and the insulated pipe servicing it, pieces of ice were in direct contact with food inside of open boxes, and ice was observed frozen on the top and sides of food packaging (boxes) and the wire shelving unit directly below the evaporator. This is evidenced by the following: On 5/13/19 at 9:33 a.m. during the initial walk through of the main kitchen with the Director of Food Service (DFS), the evaporator fan unit in the walk-in freezer was observed to have a build-up of white ice on the unit, on the insulated pipe servicing the unit (frosty thick white ice), and on the wire shelving unit directly below it (four to five shelves). Additionally, there were chunks of ice inside two of the open boxes of fish fillets, in direct contact with the fillets. Ice chunks were inside an open box of pierogis in direct contact with plastic packaging, and there were patches of ice frozen solidly on the tops and sides of eight to ten boxes of food stored on shelves below the evaporator. The DFS said she had submitted many requests for repair, an adjustment had been made here or there, but the primary issue of ice build-up remained and has been on-going. The DFS said she would instruct her staff to discard the fish fillets and sanitize all plastic packaging and boxes as the ice was contaminated. A review of five maintenance requests, dated 10/15/18 to 5/13/19, included four requests to remove ice and two related to temperatures running greater than 20 degrees Fahrenheit. In an interview on 5/17/19 at 10:43 a.m., a Maintenance Supervisor said he started at the facility the end of (MONTH) (YEAR) and has a specialty in refrigeration units. He said the last action taken for freezer repair was the purchase of a digital thermometer, delivered 5/9/19, which still needed to be installed. He said the water coming from the evaporator during the defrost cycle is considered contaminated. (10 NYCRR 415.29(b))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #66) of one resident reviewed for hospitalization , the facility did not ensure that the resident's representative and the Office of the State Long Term Care Ombudsman were notified in writing of the resident's transfer/discharge to the hospital. This is evidenced by the following: Resident #66 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/29/19, revealed the resident was unable to complete the Brief Interview for Cognitive Status, and that the resident was independent in making decisions regarding tasks of daily life. Review of the nursing progress note, dated 4/5/19, revealed the resident was seen by the physician, admitted to the hospital, and the family agreed with the transfer. The resident was readmitted to the facility on [DATE]. Further review of the medical record revealed there was no documented evidence that the resident's representative or the Office of the State Long Term Care Ombudsman had been notified in writing of the resident's transfer or discharge to the hospital. Interviews conducted on 5/17/19 included the following: a. At 9:38 a.m., the Social Worker (SW) stated the facility does not have a formal discharge or transfer form to use when residents are sent to the hospital. The SW said she has never notified the Office of the State Long Term Care Ombudsman of a resident's transfer or discharge to the hospital. b. At 9:51 a.m., the Director of Nursing (DON) stated she did not know who notified the Office of the State Long Term Care Ombudsman of the resident's transfers and/or discharges. (10 NYCRR 415.3(h)(1)(iii)(a))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #66) of one resident reviewed for hospitalization , the facility did not ensure a written notification, which specifies the duration of the bedhold policy, was provided to the resident and/or the resident's representative at the time of transfer to the hospital. This is evidenced by the following: Resident #66 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Review of the nursing progress notes revealed the resident was admitted to the hospital on [DATE] and returned to the facility on [DATE]. Further review of the medical record revealed there was no documented evidence that the resident and/or resident's representative had been notified in writing of the facility's bedhold policy. Interviews conducted on 5/17/19 included the following: a. At 9:38 a.m., the Social Worker stated the Admission's Coordinator was responsible for the bedholds. b. At 9:48 a.m., the Admission's Coordinator stated the Finance Department would call the resident's representative following a discharge to the hospital regarding the bedhold policy. c. At 9:51 a.m., the Director of Nursing stated the Admission's Coordinator reviewed the facility's bedhold policy on admission; however, finance would address the bedhold policy with the resident's representative at the time of discharge. d. At 10:12 a.m., the Director of Revenue Cycles stated when the resident is discharged to the hospital, their representative is usually notified by phone regarding the bedhold policy. She stated an e-mail is sent internally to Administration and documented in the billing system. She stated the phone call reviewing the bedhold policy was not documented in the medical record. (10 NYCRR 415.3(h)(4)(i)(a))

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 276), it was determined that for one (Resident #109) of seven residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen was monitored. Specifically, a resident receiving [MEDICATION NAME] (blood thinner) did not have blood levels PT/INR ([MEDICATION NAME] Time/International Normalized Ratio, a blood test that measures how long it takes blood to clot) obtained as ordered. The resident developed bleeding and required a hospital stay including blood [MEDICAL CONDITION] and Vitamin K therapy to reverse excessive anticoagulation (blood thinning). This is evidenced by the following: Resident #109 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital discharge paperwork included laboratory values, dated 8/5/15, with an INR 2.38. Review of the facility's physician history and physical, dated 8/5/15, revealed that the plan for the new onset [MEDICAL CONDITION] was to continue [MEDICATION NAME] and to maintain the PT/INR between 2 and 3. The 8/5/15, Physician admission orders [REDACTED]. The orders were signed as noted in the bottom right hand corner by a Registered Nurse (RN) on 8/5/15 at 4:35 p.m. Review of the August 2015 Medication Administration Record [REDACTED]. A nursing progress note, dated 8/11/15, documented that frank blood (visible presence of blood) was found in the resident's ostomy bag. A physician's orders [REDACTED]. A review of the hospital Critical (Laboratory) Value Notifications form, dated 8/11/15, revealed that the resident's PT was 208.6 and INR was 20.47. Review of the 8/11/15 facility incident report revealed that no PT/INR was completed as ordered on admission. Review of the Hospital Discharge Summary, dated 8/19/15, revealed that the resident was treated for [REDACTED]. The resident was then transferred to a swing bed service. Review of the Swing Bed Discharge Summary, dated 8/26/15, revealed that the resident was originally admitted to the hospital on [DATE], known to be coagulopathic with a gastro intestinal bleed through his stoma. The resident's coagulopathy was reversed, but he appeared to be very weak. It was decided to observe the resident on the swing bed service for Physical Therapy and Occupational Therapy. Interviews conducted on 8/27/15 included the following: a. At 11:13 a.m., the Registered Nurse Manager (RNM) stated that the resident returned to the facility on [DATE] and was a late admission (3:00 p.m. to 3:30 p.m.). The RNM said she placed a call to the physician regarding the medication orders and was told to transcribe the orders based on the discharge summary. The RNM stated she was in a rush because the pharmacy closed at 4:00 p.m., and her primary focus was getting the medication orders to the pharmacy as soon as possible. She said that she did not transcribe the ancillary orders including the labs. The RNM stated that the Unit Clerk normally transcribes the ancillary orders. She said there was a substitute Unit Clerk that day, and she did not transcribe the ancillary orders. The RNM said that the nurse on the next shift and the night nurse should have checked all new orders including ancillary orders. She said that both the evening and night nurses missed the lab orders. The RNM added that during the facility investigation, interviews with the off-shift nurses revealed that they both checked the medication orders but not the ancillary orders. She said the evening nurse reported that her focus was on medications because it was a crazy night. She said the night nurse reported that she focused on medications and did not check everything. The RNM added that all of the nurses who administered [MEDICATION NAME] doses should have noticed that there was no PT/INR level documented. b. At 12:50 p.m., the Director of Nursing (DON) stated that the facility completed an investigation and met with the pharmacy director, pharmacy consultant, physician, and RNM to identify the root cause of this incident. She said it was human error, there was a physician order [REDACTED]. The DON said that the regular Unit Clerk was on vacation, it was the change of shift, the RNM had the chart trying to write orders and order medications before the pharmacy closed at 4:00 p.m. The DON explained that the facility uses a two-nurse check system, the orders were not double checked by the evening nurse, and the night nurse only checked the medication orders. c. At 2:20 p.m., the physician stated that the resident was started on [MEDICATION NAME] for [MEDICAL CONDITION] while in the hospital. He said the resident was readmitted to the facility on [MEDICATION NAME], as it helps to thin blood. The resident had a clot in his left lower extremity, and there was a concern for a [MEDICAL CONDITION] emboli. The physician said due to thinning blood, the INR needs to be followed. He said the resident's INR went so high on [MEDICATION NAME] that the resident was bleeding from the [MEDICAL CONDITION]. The physician said the resident was admitted to the hospital and the coagulopathy was reversed using fresh frozen plasma and Vitamin K. He said this could have been avoided by checking the PT/INR sooner. The facility completed an investigation and root cause analysis and submitted an incident report to the Department of Health on 8/12/15. As a result of the investigation, the facility identified that the ancillary orders (labs) were not transcribed. Contributing factors included the following: a. The Unit Clerk transcribes the ancillary orders and writes the blood work on the calendar. The Unit Clerk was on vacation, an alternate Unit Clerk left at the end of her shift, and the orders had not been written. b. The resident was admitted at the change of shifts. c. The RNM's focus was to finish the medication orders as quickly as possible in order to give the pharmacy the information before they closed. d. The RNM never takes off the ancillary orders, so she did not think to transcribe them. Steps taken by the facility, prior to survey, to prevent a reoccurrence of this problem included the following: a. The facility reviewed all residents receiving [MEDICATION NAME] and their PT/INRs, and no additional concerns were identified. b. A meeting was held including nursing, medical, and pharmacy to discuss the incident and measures to prevent reoccurrence. It was determined that the pharmacy will track measures including residents on [MEDICATION NAME] and will have a monthly PT/INR per policy, and new admissions will have PT/INR on admission and again in seven days. If a resident on [MEDICATION NAME] receives a new medication order, pharmacy will review and notify nursing that a PT/INR needs to be done in three days and every three days thereafter if receiving an antibiotic. New medications ordered for residents will have a green sticker attached to the medication card to check PT/INR, and the pharmacy will notify nursing of any potential drug interactions. c. The transcription policy was revised to include that all orders will be checked, not just medications. The ancillary orders including labs must be verified on Meditech (electronic software program). d. The Therapeutic Drug Monitoring policy was revised to include PT/INR on admission for residents on [MEDICATION NAME]. e. The [MEDICATION NAME] policy was revised to include all new admissions on [MEDICATION NAME] will have a PT/INR done on admission. [MEDICATION NAME] drug interactions and risk factors will be monitored by the pharmacy, and the physician will be notified if significant drug interactions or risks are identified, monitoring of INR, and [MEDICATION NAME] will not be dispensed by nursing or the pharmacy without a recent INR being available. f. A checklist was developed to ascertain that orders were checked, and ancillary orders were entered. Included on the checklist is a reminder to add all labs to Meditech and the calendar. g. When a resident is on [MEDICATION NAME], the next blood draw PT/INR is scheduled on the electronic Medication Administration Record [REDACTED]. h. The licensed nursing staff were provided education on the policy and procedure changes. The education outline was obtained and reviewed by the surveyors. Interviews were conducted with licensed staff, and it was determined that the staff were aware of the change in policies and procedures. i. The facility will be completing audits of the entire process weekly for three months, then monthly. All of these steps were verified by the surveyors on or before 8/27/15. (10 NYCRR 415.12(l)(1))