Every finding on record at Sky View Rehabilitation & Health Care Center L L C

Based on record review and interviews during the recertification survey 02/24/2026 to 03/03/2026, the facility did not ensure Certified Nurse Aide performance reviews were completed at least once every 12 months. Specifically, four (4) of five (5) Certified Nurse Aides (#1, #2, #3, #4) did not have a performance review documented at least once every 12 months. The findings include:The facility policy and procedure titled Performance Reviews and 12-hour Education for Certified Nurse Aides dated 8/1/2023 documented a performance review for Certified Nurse Aide is completed once every 12 months. The facility was asked to provide Performance Reviews for five (5) Certified Nurse Aides. There was no record of an annual Performance Review for Certified Nurse Aide #1 who was hired on 1/30/2025, Certified Nurse Aide #2 who was hired 2/10/2022, Certified Nurse Aide #3 who was hired 2/13/2019, and Certified Nurse Aide #4 who was hired 12/12/2012. During an interview on 02/25/2026 at 12:13 PM the Human Resources Director stated each department head was responsible for ensuring the Annual Performance Reviews were completed. For the Nursing Department the Unit Manager was responsible for completing the performance review timely. The performance reviews were filed in the employee file and they were unaware the reviews were not up to date. They stated an email was sent to the department heads last January reminding them to complete performance reviews at least every 12 months. During an interview on 02/25/2026 at 12:20 PM, the Director of Nursing stated Human Resources was responsible for tracking that performance reviews were completed and filed. They had been completing reviews and had not been able to catch up and ensure they were all completed. During an interview on 02/25/2026 at 12:38 PM, the Administrator stated they were aware performance reviews should have been completed every 12 months. The facility was completing them annually based on the hire date and was behind. The Director of Nursing was responsible for ensuring the performance reviews were completed and Human Resources was responsible for the reviews to be filed in the employee files. 10NYCRR 415.26 (c) (2) (iii)

Based on observations, interviews, and record review conducted during the recertification survey from 02/24/2026 to 03/03/2026, the facility did not ensure a safe, sanitary, homelike environment for residents. This was evident for two (2nd and 3rd Floor) of four resident units during observations of the environment. Specifically, 1) wheelchairs on the 2nd and 3rd Floors were observed soiled with an accumulation of dried and crusted food particles; 2) the 2nd floor had dusty fans, a stained feeding tube pump, and a dining room with stained window shades, sagging wallpaper, and damaged windowsills; and 3) the 3rd floor resident rooms and bathroom doors/walls were observed with dried rust-colored stains/scratches, peeled wall paper, chipped sheetrock, stained ceiling and a broken drawer handle. Findings include: Facility policy titled Wheelchair Cleaning Housekeeping Department revised 1/1/2019 documented the facility will ensure each resident's wheelchair is washed on a regular quarterly basis, or more often as clinically appropriate and/or determined by members of the interdisciplinary team. Facility policy titled Preventative Maintenance Maintenance/Environmental Services Department, revised 2/9/2023, documented personnel are required to describe faults, report malfunctions and make recommendations for improved maintenance equipment inspection. A log will be available 24/7 on each nursing unit and other areas as needed. 1)Wheelchair observations: During an observation on 2/25/2026 at 3:13PM, Resident #13 was in the 2nd floor day room in their wheelchair. The wheelchair was observed to be caked with old food on the large wheels. During observations on 02/25/2026 at 11:10 AM and 3:51PM; 02/26/2026 at 12:50PM; and 3/1/2026 at 11:45AM, Resident # 3 was in the 3rd floor day room sitting in a wheelchair. The wheelchair had stains on the metal bars and leg rest covers; and the left brake handle cover was torn. When interviewed on 03/02/2026 at 1:04 PM, the Director of Housekeeping stated housekeeping staff was responsible for wheelchair cleaning. Wheelchair cleaning was scheduled once a month. The wheelchairs were cleaned in the shower rooms on the unit during evening shift, and during wheelchair cleaning, housekeeping staff checked for rips and tears. 2) Second floor observations: During observations on 02/27/2026 at 11:26 AM and 12:53 PM, the 2nd Floor dining room had one of three windows with dried brown food particles and stains. The windowsill to the left of the entrance was cracked with a large six-foot section separating from the wall. The wallpaper throughout the room sagged and was separated from the wall at multiple different areas. room [ROOM NUMBER] had a tube feeding pump stained with dried formula. Dusty fans were observed at the nursing station and in room [ROOM NUMBER]. When interviewed on 03/02/2026 at 1:34 PM, the Director of Housekeeping stated they were unaware of the stained window shade in the dining room. The housekeeping department had a schedule for cleaning the general environment in the floor dining room but did not include window dressings in routine general cleaning of the area. When interviewed on 03/02/2026 at 1:40 PM, the Assistant Director of Maintenance stated the 2nd Floor dining room was part of a focused repair project in 11/2025. Maintenance worked on target areas throughout the facility every quarter to ensure concerns with the wallpaper and other environmental conditions were addressed. The Assistant Director of Maintenance stated they were unaware the wallpaper was sagging off the wall or that the wooden windowsill was damaged and loose. Unit staff did not report any repair concerns related to these areas in the logbook located on each unit. 3) Third floor observations: During observations on 02/24/2026 at10:03 AM and 03/02/2026 at 12:00 PM, in room [ROOM NUMBER] the bottom of the bathroom door was warped, and wallpaper was peeled off. The dry wall had deep gouges and plaster was showing. There were brown stains on the ceiling and walls. During observations on 02/25/2026 at 2:36 PM and 03/02/2026 at 11:57 AM, room [ROOM NUMBER], the bathroom wall/door had chipped/peeled plaster; the baseboard was peeled/chipped with brown and black discoloration, the drawer handle of the bottom drawer was broken, and the closet wall was warped with scattered chipped areas. When interviewed on 03/02/2026 at 11:40 AM, Certified Nurse Aide #5 stated there was a maintenance log book at the nurses station where staff wrote environmental concerns such as a bed or television remote not working, issues with light/water, and stripped floors. They also informed maintenance staff when they were on the unit. Maintenance staff usually came to the unit daily and checked the maintenance book. When interviewed on 03/02/2026 at 12:39 PM Licensed Practical Nurse Unit Manager#6 stated housekeeping cleaned the wheelchairs and maintenance did the repairs of broken items and wall repairs. There was a maintenance book in the unit that documented areas for repairs. Maintenance staff checked the book regularly. When interviewed on 03/02/2026 at 12:49 PM, the Director of Maintenance stated they did room checks quarterly on each floor, unit maintenance books were checked three times a day at 8:00 AM, 12:00 PM and 3:00 PM. The Director of Maintenance stated they were aware of the peeled wallpaper, stained ceiling and rust - colored discoloration of bathroom doors/walls. The Maintenance Director checked the 3rd floor maintenance book and confirmed that the last entry was on 02/24/2025 regarding no water in room [ROOM NUMBER]. There were no entries of repairs needed for bathroom doors/walls or broken drawer handle covers. The Director of Maintenance stated they were not aware of a broken drawer handle in room [ROOM NUMBER]. When interviewed on 03/03/2026 at 8:13 AM, the Administrator stated that facility was aware of room repairs needed. Maintenance staff was responsible for repairs of broken items. Maintenance should be checking the unit binder regularly for maintenance repairs. 10 NYCRR 415.5(h)(2)

Based on observations interviews and record conducted during the recertification survey from 02/24/2026 to 03/03/2026, the facility did not ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for storage. Specifically, Resident #128 had bottles of Aspirin, Tums, Tylenol and Vitamin B3 that were stored at their bedside.Findings Include:The Medication Storage policy dated 04/15/2018, documents the medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Medications are stored at proper temperatures and locked at all times except when under the direct supervision of staff.Resident # 128 had diagnoses including hypertension, major depressive disorder and vitamin D deficiency. The quarterly Minimum Data Set (an assessment tool) dated 1/13/2026 documented the resident's cognition was intact. The physician's order dated 01/20/2026 documented that the resident/representative deferred self-administration of medication to nursing staff.The physician's order dated 1/20/2026 documented enteric coated aspirin 81 milligram tablet, delayed release, give one tablet (81 milligrams) by oral route once daily.The physician's order dated 1/20/2026 documented vitamin D3 (1000 units) tablet, give one tablet by oral route once daily.The physician's order dated 02/13/2026 documented acetaminophen 325 milligram tablet, give two tablets by oral route every 6 hours as needed.During observations on 02/24/2026 at 11:00 AM and on 02/27/2026 at 9:41 AM, containers of Aspirin, Tums, Tylenol and Vitamin D3 were stored on a shelf in Resident #128's room, next to their bedside.During an interview on 02/27/2026 at 3:43 PM, Registered Nurse Unit Manager #8 stated that the medications stored at the bedside must have been brought in by the resident's family member. They stated that the medications were supposed to be stored in the medication room. Additionally, they stated that they did not know why the nursing staff did not see the medications being stored at the bedside.During an interview on 3/2/2026 at 2:35 PM, Registered Nurse #9 stated that medications should be stored in the locked medication cart and/or the medication room. They stated medications should not be stored at the residence bedside, not even over the counter medications. They stated that they did not notice the medications at the bedside. Additionally, they stated it was important to monitor what residents were taking, as some medications could interfere with other medications and cause an adverse effect. 415.18(e)(1-4)

Based on observation, interview, and record review during the recertification survey from 02/24/2026 to 03/03/2026, the facility did not ensure residents who required dialysis (a process that filters the blood for people in kidney failure) received such services consistent with professional standards of practice for one (1) of two (2) residents (Resident # 4), reviewed for dialysis. Specifically, Resident # 4 received hemodialysis treatments at a community- based dialysis center and the facility did not have on-going communication with the dialysis center including assessments and oversight before and after dialysis treatments. Additionally, the facility was unaware the dialysis center documented the resident was on a fluid restriction.The findings include: The Hemodialysis policy and procedure, revised 01/09/2018, ensures essential resident care information is shared using the communication book at the nurses' station, labeled with the resident's name. The book accompanies the residents to each dialysis treatment. Information may include changes in vital signs, appetite, labs, wounds, consultations, medications, tests, and behaviors. The interdisciplinary team may write in the communication book. After each dialysis treatment, the licensed nurse reviews the book and communicates pertinent information in the 24-hour report and to the nursing supervisor, nurse manager, and physician.Resident # 4 had diagnoses including end stage renal disease, hypertension, and diabetes mellitus. The 02/14/2026 Minimum Data Set (an assessment tool) documented the resident was cognitively intact and required hemodialysis treatments.The Comprehensive Care Plan dated 11/04/2025 documented the resident had renal failure and required hemodialysis on Monday, Wednesday, and Friday, with pick-up time at 1:15 PM.The physician's orders, renewed on 02/06/2026, documented hemodialysis on Monday, Wednesday, and Friday, with chair time at 2:15 PM and ambulette pick-up at 1:15 PM.Resident #4's dialysis communication book was a binder that contained facility generated forms with the facility logo on top. There were three sections to the form. The first section was for facility staff and included date/time, sign and symptoms check boxes, vital signs and a line for signature by the registered nurse or licensed practical nurse. The second section was the dialysis center nurse to complete and included places to record weight and vital signs before and after treatment, catheter site and condition, a line for comments, followed by a line to be signed and dated by the dialysis nurse. The third section was for the facility nurse to sign that the form was reviewed upon return from dialysis. Review of the dialysis communication forms revealed: on 01/21/2026, the facility nurse documented vital signs and signed off, the dialysis center completed their section and signed off; the facility nurse did not sign off for reviewing upon return. On 01/24/2026, the facility documented Resident #4's vital signs, but the facility nurse did not sign; the dialysis center completed their section and signed off; the facility nurse did not sign off for reviewing upon return. On 01/30/2026 the facility and dialysis center completed and signed their sections; the facility nurse did not sign off for reviewing upon return. There were no dialysis forms found in the binder after 01/30/2026. The dialysis center documented their findings on blank sheets of paper on 02/02/2026, 02/04/2026, 02/06/2026, 02/09/2026, 02/11/2026, 02/13/2026, 02/16/2026, 02/19/2026, and 02/25/2026. There was no documented communication on part of the facility or evidence the dialysis center notes were reviewed. The dialysis center notes on 02/11/2026 and 02/19/2026 included documentation that the resident was to remain on a renal diet and fluid restriction, fluid intake should be 1000 milliliters total per day.During an interview on 02/27/2026 at 4:18 PM, Resident #4 stated that the dialysis communication book was taken to each dialysis session and remained with them after each dialysis session. Resident #4 stated the staff were expected to collect the communication book upon their return from dialysis, however, the book was not collected or reviewed by staff when they returned. Resident #4 stated staff did not consistently take their vital signs prior to going to dialysis. During a telephone interview on 03/02/2026 at 11:40 AM, the dialysis center registered nurse stated the facility did not consistently complete the dialysis communicate forms including the resident's vital signs. They stated the last documented vital signs from the facility for Resident #4 were on 01/30/2026 and after that, they did not provide the communication form, so the dialysis center wrote the information on a blank piece of paper and sent it back to the facility in the resident's binder. They stated the facility had not called to give additional information that was not documented in the communication book.During an interview on 03/03/2026 at 08:13 AM, Licensed Practical Nurse Unit Manager #6 stated that a communication book was available for the facility nurse to record the resident's vital signs before sending the resident to the dialysis center. The communication book was kept in the resident's bag and went to dialysis with the resident. During the interview, Licensed Practical Nurse Unit Manager #6 asked the resident for the communication book; the resident identified the blue binder as the one taken to the dialysis center. Licensed Practical Nurse Unit Manager # 6 reviewed Resident # 4's binder and stated it was disorganized. They stated the facility had contact with the dialysis center and no issues had been reported. During an interview on 3/3/2026 at 10:15 AM, the Registered Dietitian, stated they occasionally communicated with the dialysis center staff, and that any recommendations from the dialysis center would be relayed to the resident's physician. They stated they were unaware of any fluid restriction in place for the resident. They stated the resident remained stable related to their diet.During an interview on 03/03/2026 at 10:23 AM, the Assistant Director of Nursing stated facility nurses were required to check the resident's dialysis site daily for any redness or changes and to report any changes to the resident's physician. Nurses were also required to document the resident's vital signs and any changes in the communication book. The communication book was kept in the facility and accompanied the resident to dialysis. Upon the resident's return to the facility, the nurses should have reviewed the communication book, took vital signs, checked the catheter site for bleeding, and documented the vital signs on the resident's medication administration records.10 NYCRR 415.12 (k)

Based on observations, interviews and record reviews conducted during the recertification survey from 02/24/2026 to 03/03/2026, the facility did not ensure residents had a right to a dignified dining experience for five (5) of eight (8) residents (Residents #33, #54, #57, #85 and #118) observed during dining. Specifically, Residents #57 and #85 were served lunch 20 minutes after tablemate, Resident #118; and Resident #33 was served lunch 17 minutes after tablemate, Resident #54. Findings include:The Resident's Rights policy dated 02/18/2018 documents that all residents have a right to a dignified existence. The facility will promote the exercise of rights for each resident, including any that face barriers such as communication problems, hearing problems and cognition limits.Resident # 85 had diagnoses including dementia, major depressive disorder and hypertension. The annual Minimum Data Set (an assessment tool) dated 1/13/2006 documented the resident's cognition was severely impaired and the resident required supervision or touch assistance with eating.Resident # 118 had diagnoses including diabetes, major depressive disorder and chronic obstructive pulmonary disease. The annual Minimum Data Set, dated [DATE] documented the resident's cognition was severely impaired and the resident required supervision or touch assistance for eating.Resident # 57 had diagnoses including dementia, chronic kidney disease and hypothyroidism. The annual Minimum Data Set, dated [DATE] documented the resident's cognition was severely impaired and the resident required supervision or touch assistance for eating.Resident # 33 had diagnoses including hypertension, hyperlipidemia and anxiety disorder. The quarterly Minimum Data Set, dated [DATE] documented the resident's cognition was severely impaired and the resident required supervision or touch assistance for eating.Resident # 54 had diagnoses including dementia, hyperlipidemia, and hypertension. The admission Minimum Data Set, dated [DATE] documented the resident's cognition was moderately impaired and the resident required set up or clean up assistance with eating.During a dining observation on 02/27/2026 from 11:53 AM to 12:40 PM, Residents #85, #118 and #57 were seated at the same table for lunch. Resident #118 received their lunch tray at 12:14 PM and started eating while Residents #57 and #85 waited. Resident #57 received their lunch tray at 12:34 PM and Resident #85 received their tray at 12:36 PM. At another table, Residents #33 and #54 were seated together. Resident #54 received their lunch tray at 12:16 PM and Resident #33 received their lunch tray at 12:36 PM.During an interview on 02/27/2026 at 11:57 AM Registered Nurse # 9 stated the residents ate at different times as the kitchen first sent the trays for the residents that live on the east side of the floor, and trays for the residents who lived on the west side of the floor were sent later. They also stated there was an earlier food truck that arrived at 11:30 AM for residents who needed assistance with eating.During an interview on 03/03/2026 at 12:35 PM, Licensed Practical Nurse/Unit Manager # 8 stated that they sat the residents according to who they got along with, rather than the time their trays arrived. They stated they had noticed that residents at the same table were being served at different times, and they intended to speak to the kitchen staff.10 NYCRR 415.3(d)(1)(i)

Based on record reviews and interviews conducted during an abbreviated survey (NY00382163/ 656232), the facility failed to ensure that each resident received adequate supervision/assistance to prevent accidents for one (1) of three (3) residents reviewed for accidents. Specifically, Resident #1 who required two (2) person assistance for bed mobility was provided one (1) staff assist by Certified Nurse Aide #10 which resulted in a fall from bed. Resident #1 sustained a fractured vertebra and head laceration. This resulted in actual harm for Resident #1 that was not Immediate Jeopardy.The Findings Include:The 07/2017 policy titled 'Activities of Daily Living Care Plan' documented appropriate care and services will be provided for residents who are unable to carry out Activities of Daily Living independently, in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting).Resident #1 was admitted with diagnoses including but not limited to dementia with cerebral infarction (stroke), Alzheimer's Disease, and had a history of ventriculoperitoneal shunt (a device to drain excess fluid from the brain to the abdomen).The quarterly Minimum Data Set (a resident assessment tool) dated 05/17/2025 documented the resident had moderate cognitive impairment and was dependent on staff for assistance with rolling from back to left and right. The resident was always incontinent of bowel and bladder.A Care Plan for Activities of Daily Living dated 02/13/2025 documented the resident required two (2) person assistance with bed mobility and transfer. The Certified Nurse Aide Care Guide (care instructions) dated 10/05/2023, documented the resident was totally dependent with a two (2) person physical assist. The facility Investigation Summary documented, on 05/30/2025, Resident #1 sustained a fall from bed witnessed by Certified Nurse Aide #10, who had performed care on them minutes earlier. The fall resulted in L1 and L2 lumbar (top two (2) vertebrae in the lower back) process fractures (break) and laceration (open wound) to the posterior (back of) scalp. The investigative findings documented that during an interview with Certified Nurse Aide #10, they stated they were preparing the draw sheet to change it, but was not yet in the process of turning and positioning the resident when the resident rolled off the bed and they were unable to stop the resident from falling. The nurse and nurse supervisor were notified, the physician and family were notified. The resident was sent to the hospital and was admitted due to an L1 and L2 lumbar transverse process fracture and received sutures to the posterior scalp. The report documented it was determined Certified Nurse Aide #10 was preparing to turn and position the resident on their own, despite the resident requiring a two (2) person assist. Certified Nurse Aide #10 was terminated upon the conclusion of the investigation.Certified Nurse Aide #10's written statement, dated 05/30/2025, documented Certified Nurse Aide #10 was aware that the resident required a two (2) person assist, however they did not see or ask if the other aide was available to help them. The resident was on their left side after they finished care, and they saw the draw sheet was soiled underneath the resident. As they went to grab a draw sheet at the end of the bed, the resident rolled off the bed.The hospital physician admission assessment, dated 05/30/2025, documented the resident had a scalp laceration near the shunt with bleeding and reported back pain. The X-rays showed acute fractures in the L1 and L2 transverse process. The review of systems was limited due to resident wincing if moved from side to side.During an interview on 10/09/2025 at 12:38 PM, Certified Nurse Aide #10 stated they were aware the resident required two (2) person assistance but had rolled them in bed by themselves in the past. On 05/30/2025, they were with Resident #1 and changed their brief. When Resident #1 was positioned on their left side, they noticed the draw sheet had a stain on it. When they saw the stain, they did not roll the resident to their back but left them on their left side and went to the bottom of the bed where the clean draw sheet was. At that time, they saw the resident roll off the bed and to the floor. The resident had blood on their head, and they called Licensed Practical Nurse #12.During an interview on 10/09/2025 at 2:48 PM, Registered Nurse Supervisor #9 stated they were called by Licensed Practical Nurse #12 regarding the fall. They were told Certified Nurse Aide #10 was about to change the draw sheet when the resident fell/rolled out of the bed. They did an assessment, suspected there were injuries, and the resident was sent out to the hospital. They stated Certified Nurse Aide #10 should have looked at the record to see if the resident required staff assistance of one (1) or two (2) staff prior to starting cares.During an interview on 10/10/2025 at 9:45 AM, Licensed Practical Nurse #12 stated they were not asked to help Certified Nurse Aide #10 with changing residents that night. It was expected the certified nurse aides would help each other and would organize themselves to be available. Certified Nurse Aide #10 came to them and stated the resident was on the floor. They went to the room and the resident was lying on their back and bleeding from their head. They called the supervisor, then called 911. They stated Certified Nurse Aide #10 told them they turned the resident, and the resident rolled out of bed. They stated they asked Certified Nurse Aide #10 if the resident required a two (2) person assist, and they said they thought so. They further asked Certified Nurse Aide #10 why they were turning the resident on their own and did not receive an answer.During an interview on 10/10/2025 at 10:06 AM, Physician #2 stated they were aware that Resident #1 fell out of bed, and it could have been avoided if there was assistance of two (2) certified nurse aides.During an interview on 10/10/2025 at 10:13 AM, Licensed Practical Nurse Unit Manager #3 stated this incident could have been prevented and Certified Nurse Aide #10 was not thinking. Resident #1 was very stiff and needed two (2) people to turn them. It would be very hard to do with one (1) person. They stated they could not understand why or how it happened. During an interview on 10/09/2025 at 2:43 PM, the Administrator stated Certified Nurse Aide #10 was at the facility for a short time and had just finished all the training. The resident rolled off the bed, received immediate help and was transferred to the hospital. Certified Nurse Aide #10 was terminated, and new interventions were put in place. Certified Nurse Aide #10 did not follow the care plan and get help for the two (2)person assist. 10NYCRR 415.12(h)(2)

Based on observation, interview, and record review conducted during the recertification survey [DATE] - [DATE], the facility did not ensure that foods were stored, prepared, distributed, and served in accordance with professional standards for food service safety. Specifically, 1) Equipment used for food service preparation, storage, and service was not maintained in a sanitary condition, 2) 1 of 4 nourishment refrigerators contained expired and undated food, and 3) Food was contaminated by server/cook's ID tag during prep and this server did not perform hand hygiene between glove changes. The findings are: 1) The initial tour of the kitchen was conducted on [DATE] at 11:13 AM with the Food Service Director (FSD) in attendance. The following were observed: A large, standing flour bin was observed in the dry storage room. The external surfaces of the flour bin, including the sliding lid used to access the flour, were heavily soiled with dirt and yellow-ish colored and brown-ish colored accumulations of grime. In an interview at that time, the FSD stated there was no cleaning schedule for the flour bin. The FSD stated the bin could use a cleaning. The FSD stated that the risk to the residents was contamination of the flour. An opened, 5-pound container of peanut butter was stored on dry storage room shelf. The lid of the peanut butter was soiled with peanut butter, jelly, and black-ish colored areas of unknown origin. In an interview at that time, the FSD stated that the lid on the peanut butter should have been wiped down and clean. The FSD stated that the risks to the resident were contamination of the peanut butter and illness, and they discarded the peanut butter. A 3-shelf rack in the pot washing area was in use for storage of cleaned and sanitized pots, pans, cutting boards, an immersion blender, a beater for a mixer, a meat-tenderizer tool, and 2 large strainers. All shelves of the rack were heavily soiled with an accumulation of grime, dried debris of unknown origin, dried, sticky-to-the-touch spills, and dust. In an interview at that time, the FSD stated the rack definitely needed to be cleaned. The FSD stated there is a scheduled monthly deep clean for the racks. The FSD was asked the risk to residents when clean, sanitized food equipment is stored on a soiled rack, and stated there was a risk is for contamination of the equipment and illness to the residents. In a follow up interview on [DATE] at 12:03 PM, the FSD was asked for documentation of scheduled cleaning, and was unable to produce documentation that cleaning tasks were being completed. 2) On [DATE] at 11:15 AM an inspection of the four nourishment refrigerators was conducted with the FSD in attendance. The following were noted: The fourth-floor nourishment refrigerator contained two food items with a resident's name. The items were an undated bowl of hot turkey, mashed potatoes, cranberry, and stuffing, and an expired container of fresh fruit dated [DATE]. During an interview at that time the FSD stated that foods brought in must be labeled, dated, and discarded within 3 days. The FSD stated that that all staff were responsible for checking dates and discarding outdated items. The FSD discarded the two food items. 3) On [DATE] at 12:30 PM, food server/cook #1 was observed prepping a lunch plate for a resident when the identification tag, hanging from server/cook #1's neck, touched the resident's food. During this lunch observation, server/cook #1 removed their gloves, left the area, return to continue serving food without performing hand hygiene and then put on another pair of gloves and then began to serve and prepare resident food plates. When interviewed on [DATE] at 12:40 PM, food server/cook #1 stated he was not aware his ID touched food that they was preparing and was unable to say why they did not perform hand hygiene. 10NYCRR 415.14(h) 48848

Based on observations, record review, and staff interviews during the recertification survey on 10/26/2023-11/2/2023, the facility did not ensure that needed services, care and equipment were provided to assure that a resident with limited range of motion and mobility maintained or improved function based on the resident's clinical condition for one of four residents (Resident #158) reviewed for range of motion. Specifically, Resident #158 was not provided with bilateral hand splint device as ordered by the physician to improve the resident's contractures. The findings are: A review of the Policy & Procedure titled Contracture Prevention and Management last revised on 5/26/2022, documented all departments would work in conjunction to apply preventative measures such as range of motion, positioning and splinting to prevent and manage contractures in the resident population. Resident #158 had diagnoses including pulmonary embolus, functional quadriplegia, and diabetes. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 10/6/2023 documented the resident had severely impaired cognition and was dependent on staff for all activities of daily living. The resident's functional limitation for range of motion was documented as impairment on both sides. A review of the current physician orders dated 10/18/2023, documented bilateral hand rolls to be worn at all times. A review of the Certified Nurse Aide (CNA) Kardex (care instructions) dated October 2023, documented bilateral hand rolls to be worn at all times. A review of the Activities of Daily Living care plan dated 6/9/2023, documented bilateral hand rolls to be worn at all times. During observations on 10/26/2023 at 10:12 AM, 10/27/2023 at 11:06 AM, and 10/30/2023 at 1:13 PM, the resident had bilateral hand contractures and had a hand roll in left hand and nothing in the right hand. During an interview on 10/31/23 at 10:12 AM, CNA #1 stated they looked at the Kardex for care instructions and the Kardex documented the resident had bilateral hand rolls. CNA #1 stated that meant the resident should have the roll in their hand but was not sure which hand. During an interview on 10/31/2023 at 11:00 AM, the Director of Rehabilitation stated they were informed the resident did not have the hand rolls in both hands and corrected the situation. The Director of Rehab stated if the resident did not receive the hand rolls as ordered, the resident could suffer further contracture, poor hygiene and possibly pain. During an interview on 10/31/23 at 01:21 PM, the Director of Nursing (DON) stated directions for hand rolls was written on the care plan and on the resident's Kardex, and Resident #158 should have the hand rolls in both hands. 415.12 (e)(2)

Based on interviews and record reviews during an abbreviated survey on 1/25/2021 (NY 803), the facility failed to ensure the resident's right to be free from neglect. Specifically, the Certified Nursing Assistant (CNA #1) failed to report that Resident #1 fell , resulting in a skin tear requiring stitches on his/her chin. The findings are: The Facility Policy on Abuse and Neglect - Prohibition, Prevention and Reporting dated 12/2019 documented that all staff are required to report all occurrences that may indicate potential abuse such us injuries of unknown cause immediately. Any individual who witnesses, hears about, or suspects resident abuse, mistreatment, neglect, exploitation or misappropriation of property must report it immediately to his/her supervisor. Employees who fail to report any known or suspected abuse or an incident/accident will be subject to disciplinary action up to and including termination. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS, an assessment tool) dated 12/30/2019 documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 12/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The resident required extensive 2-person assistance for bed mobility and transfers as well as extensive 1-person assistance for locomotion on the unit. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Fall Care Plan related to deconditioning due to recent hospitalization , falls at home and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident Nursing Instructions (CNA Plan of Care) initiated on 12/26/2019 documented that the resident was on safety monitoring every shift. The [NAME] Fall Risk Nursing Admission Evaluation dated 12/31/2019 documented that the resident scored 19 denoting high risk for fall. The Facility Incident & Accident Report dated 1/05/2020 at 7:00PM documented that CNA #1 reported that Resident #1 had a skin tear on his chin. The RN Supervisor assessed the resident's chin and measured a linear tear 0.1 x 2.5 cm with no bleeding, no complaints of pain and no further injury. The attending physician was informed and ordered [MEDICATION(S)] with dressing. The Registered Nurse Supervisor (RNS) initiated an investigation. Resident #1 was unable to relate how the skin tear happened. The RNS initially theorized that the injury could have been due to a paper cut because the resident was observed to have papers and pen at the day room. The Nursing Progress Note dated 1/05/2020 at 10:48PM documented that at around 7:30PM Resident #1 was brought from the day room to the nurse's station after dinner because CNA #1 noticed bleeding under his/her chin. The RNS was called and observed the site. The MD was notified and ordered the application of [MEDICATION(S)] and a bandage over the site with 2x2 gauze daily for five days. The family was subsequently notified. Resident #1 denied pain and was unaware of how the injury happened. Safety precautions was maintained. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued and revised on 1/06/2020 with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Leave open to air for 14 days for Local Infection of the Skin and Subcutaneous Tissue. The Hospital Discharge Instructions dated 1/06/2020 documented that Resident #1 was seen for a chin laceration and multiple abrasions. Wound care instructions documented [MEDICATION(S)] daily for 3 days, stitch removal in 7 days and follow up care with the Medical Doctor (MD). Review of the Facility Investigation Summary dated 1/13/2020 revealed the following: The Nurse Practitioner on 1/06/2020 at 12:30AM reassessed the resident and called the MD that the skin tear had some depth and needed sutures. The MD agreed and the resident was sent out to the ER and came back to the facility the same day. A review of the camera footage of the 3rd floor day room on 1/05/2020 from 5:30 PM to 6:54 PM was documented and completed by the previous Director of Nursing (DON) on 01/10/2020. The footage showed that Resident #1 was seated at the table eating his dinner at around 6:15PM. The accused CNA was seated at the opposite side of the room from the resident. At 6:49 PM the resident stood up and fell to the floor. The accused CNA walked over to Resident #1, lifts him/her from the floor and back into the chair. The accused CNA then sat back in her original chair. The Employee/Payroll Change Notice dated 1/10/2020 documented that CNA #1 (accused) was initially suspended pending investigation which changed to a termination and not eligible for rehire after the investigation was completed. Attempted to call CNA #1 (Accused) but was not successful; however, the accused wrote 2 statements dated 1/05/2020 and 1/13/2020: A statement dated 1/05/2020 written by CNA #1 (Accused) documented that she did not witness any bleeding or any odd behavior during dinner time. The accused documented that the resident was drawing on a paper after dinner. A follow up statement about the incident that occurred on 1/05/2020, written by CNA #1 (Accused) on 1/13/2020, documented that at the time of the incident she was in the dayroom. She noticed Resident #1 quickly stand up from his wheelchair. The accused CNA documented that by the time she got to Resident #1, he/she had already slipped backwards and fell on his/her bottom. The accused CNA documented that she asked the resident if he/she was alright and he/she said he was okay so she picked him up. The accused CNA documented that the supervisor was notified and assessed the residents chin. The accused CNA was remorseful for her actions. An interview was conducted with the Administrator on 1/25/2021 at 2:30PM who stated that the former DON watched the camera footage and completed the investigation. The Administrator stated that the DON's account of the footage was very clear that the resident fell , and the fall was witnessed by the accused (CNA #1). The Administrator also stated that the accused admitted that she did not report witnessing the incident and was quite remorseful. He also said that the CNA did not have any history of any disciplinary action and received all the required education on abuse/neglect prevention and accident/incident reporting. The Administrator stated that the accused was terminated on 1/10/2021. 415.4(b)(I)(i)

Based on observation, interview, and record review conducted during the most recent recertification survey, the facility did not ensure that 1 resident (Resident #211) reviewed for hydration was provided the necessary care to prevent dehydration and complications related to insufficient fluids. Specifically, the resident who was being treated for [REDACTED]. Further, no measures were developed and implemented to supplement the resident's intake between meals and to monitor the resident's total daily fluid consumption. The findings are: Resident #211 is an [AGE] year-old female admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment instrument) dated [DATE] revealed that the resident had moderate impairment for decision making, was depressed, fed self with extensive assistance and had poor appetite. The nutrition assessment dated [DATE] noted that the resident's food and fluid intake was 25 to 50 per cent (%) daily, weighed 145 lbs. and required 1548 cc of fluids daily. The assessment also noted a commercial dietary supplement (2 Cal HN) would be recommended. The comprehensive care plan (CCP) in place at the time of this assessment noted that the goal for the resident was to mange and minimize potential for dehydration. The interventions to achieve this goal; encourage fluids, monitor labs and vital signs per MD order, provide and offer fluids to meet estimated needs of 1548-18[AGE] ml and provide supplemental nourishments. physician's orders [REDACTED]. The evaluation section of the CCP also noted that a health shake was added on [DATE] to meal trays to increase fluid intake and that additional intravenous fluid (IV) was provided on 12/13/19. A review of the Resident CNA Documentation Record for December 2019 showed that the resident's fluid intakes at meal times were as follows from 12/1/19 to 12/13/19: Breakfast - 9 times at or below 25% Lunch - 8 times at or below 25% Dinner- 5 times at or below 25% After the completion of the IV fluids the resident's fluid intake remained poor as evidenced by the data on the Resident CNA Documentation Record for 12/14/19 to [DATE]: Breakfast - 4 of 5 recorded meals at 25% or less Lunch - 3 of 4 meals recorded at 25% or less Dinner - 3 of 4 recorded meals at 25% or less A nurses note stated that on [DATE] the resident was diagnosed with [REDACTED].) Also, on [DATE] the dietitian documented the result of a calorie count, which showed that the resident was consuming about 382 calories and was taking fluids poorly. This documentation further stated that artificial nutrition was to be discussed with the family as a possibility. A review of the resident's clinical record to include care plan and dietary and nurses notes revealed no plan, offering and/or monitoring of supplemental fluids between meals to adequately supplement the fluid intake at meal times. On [DATE] at 12:06 PM the meal observation revealed that the resident was offered 4 oz juice, 4 oz health shake, 8 oz milk, 8 oz tea and a bowl of broth. She consumed 2 oz juice and 2 oz health shake and refused the other fluids and most of the solids (pureed foods). The registered Dietitian was interviewed on [DATE] at 12:50 PM. She stated that nursing should offer extra fluids between meals and that the amount of supplements consumed at meal times was included in the total amount of fluids recorded for the meals. The Registered Nurse Manager (RNM)(#3) was interviewed on [DATE] at 1:10 PM. This interview revealed no evidence of a plan and monitoring of the resident's fluid intake between meals. The RNM stated that all residents were offered fluids between meals. 415.12(i)(1)(j)

Based on observations, interviews and record review conducted during the recent recertification survey, the facility did not ensure that emergency equipment was readily available for 1 of 2 residents screened for respiratory care. Specifically, a resident with a [MEDICAL CONDITION] did not have an Ambu bag (a hand-held device that provides positive pressure to residents who are not breathing) at the bedside. (Resident #158). The findings are: Resident #158 was admitted with [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION] with 3 liters of continuous oxygen via a [MEDICAL CONDITION] collar. The resident was observed for [MEDICAL CONDITION] care on [DATE] at 10:00 AM with Licensed Practical Nurse (LPN) #1 and the Unit Manager. The ambu bag was not observed at the bedside. After a thorough search of the room neither staff could locate the equipment. The nursing care plan for [MEDICAL CONDITION] care initiated on 12/15/19 listed interventions that include; ensure emergency kit with secondary airway, ambu bag and suction machine are present in room. The LPN and the Unit manager could not state whose responsibility it is to check the room for the necessary equipment and ensure it is always in the room. 415.12(k)(6)

Based on observation, interview and record review conducted during the recertification survey the facility did not ensure that drugs were stored under proper temperature controls. Specifically, one of four refrigerators had temperatures below the manufacturers' specifications for the drugs stored inside (36 degrees Fahrenheit). The findings are: On [DATE] at 11:30 AM the fourth-floor refrigerator was observed with Registered Nurse (RN) #1 and Nurse Manager #1. The temperature was between 35 degrees Fahrenheit (F) and 36 F. The refrigerator was storing: - [MEDICATION NAME] solution - Affluria flu virus vaccine - [MED] [MED] vials and pre-filled injection pens - [MED] eye drops - [MEDICATION NAME] vials Review of the drug manufactures' published information for storage documented the drugs were to be stored at 36 F to 46 F and discard if they became frozen. The Refrigerator Temperature Log had temperatures below 36 F on 13 out of 15 days. - 12/01/19 - 28 F at 5:00 AM; 31 F at 5:00 PM - 12/02/19 - 32 F at 5:00 AM; 26 F at 5:00 PM - 12/03/19 - 28 F at 5:00 PM - 12/04/19 - 32 F at 5:00 AM; 28 F at 5:00 PM - 12/05/19 - 32 F at 5:00 AM; 32 F at 5:00 PM - 12/06/19 - 30 F at 5:00 AM; 32 F at 5:00 PM - 12/07/19 - 30 F at 5:00 PM - 12/08/19 - 28 F at 5:00 AM; 28 F at 5:00 PM - 12/09/19 - 30 F at 5:00 AM; 29 F at 5:00 PM - [DATE] - 28 F at 5:00 AM - 12/11/19 - 20 F at 5:00 AM - 12/14/19 - 32 F at 5:00 AM - 12/15/19 - 30 F at 5:00 AM The Log included the following directions: Acceptable temperature: Upon opening door, below 41 degrees F. If temperature is above 41 degrees F upon opening, notify maintenance. It did not include directions for low temperatures. In interviews on [DATE] at 11:30 AM RN #1, the Nurse Educator and the Nurse Manager #1 stated they did not know what the temperature range should be. Nurse Manager #1 stated she was not aware staff had noted temperatures below 36 F on her unit. In an interview on [DATE] at 2:45 PM with Licensed Practical Nurse (LPN) #2 she stated she saw and logged temperatures below 36 F from [DATE] to 12/9/19. She did not notify the Nurse Manager. On [DATE] at 03:15 PM LPN #1 stated she saw the temperature was 32 F on 12/2/19 and 31 F on 12/1/19. She did not tell Maintenance or the Nurse Manager because the Log did not say what to do if the temperature was low. During an interview on [DATE] at 3:00 PM with the Assistant Maintenance Director he stated he was not aware there were issues with the refrigerator. The facility's Medication Refrigerator Temperature Log policy dated 3/10/13 revealed the following; 1. The nurse checks the temperature daily by looking at the thermometer inside of the medication refrigerator. 2. Records the current temperature on the medication refrigerator temperature log. 3. Informs the Supervisor and Maintenance Department if the temperature is not between 36 and 46 degrees Fahrenheit. 415.18(3)(1-4)

Based on observation, record review and interview conducted during a recertification survey the facility did not ensure that care was provided in a manner that maintained dignity for 3 of 4 residents (#27, #61,158). Specifically, residents' drainage bags were not concealed to prevent direct observation by others. The findings are: Review of the facility Ostomy Care Policy and Catheter Care Policy revised on 07/26/2014 included a procedure to provide privacy covers over the drainage bags only when residents leave the room. Resident # 27 had [DIAGNOSES REDACTED]. The resident's [MEDICAL CONDITION] care plan included an intervention to provide dignity by applying a cover over the [MEDICAL CONDITION] drainage bag when the resident is out of their room. Observations on 12/11/2019 at 11:16 AM, on 12/13/19 at 10:33 AM and 12/16/2019 at 10:52 AM revealed that Resident #27 was in bed with the [MEDICAL CONDITION] drainage bag and tubing in clear view from the door with no privacy bag. Resident #61 had [DIAGNOSES REDACTED]. The 10/12/2019 Quarterly Minimum Data Set (MDS, an assessment tool) revealed that the resident had an indwelling catheter. The resident's urinary catheter care plan included an intervention to maintain the resident's dignity at all times. Observations on 12/12/2019 at 07:50 AM and 12/12/2019 at 11:50 AM as well as on 1[DATE]19 at 08:59 AM revealed Resident #61's urinary drainage bag to be uncovered and in clear view of others in the hallway. Resident #158 had [DIAGNOSES REDACTED]. The 11/08/2019 MDS revealed that the resident had an indwelling urinary catheter. The resident's urinary catheter care plan included an intervention to apply a privacy bag whenever the resident is out of bed. Observation on 12/18/2019 at 10:19 AM revealed Resident #158's urinary drainage bag hanging on the left side of the bed without a privacy bag and visible from the hallway. In an interview with the Certified Nursing Assistant (CNA) #1 on 1[DATE]19 at 11:21 AM she stated that they were trained to cover the resident's drainage bags only when they are outside of their room. In an interview with the Registered Nurse Manager #2 on 12/16/2019 at 10:52 AM she stated that based on facility policy they only use a privacy bag when a resident is outside of their room. 415.5(a)

Based on observation, record review, and interview conducted during a recertification survey, the facility did not ensure the care plan for nutrition was reviewed and revised based on comprehensive assessment to address weight loss for 1 of 7 residents (Resident #75) reviewed for nutrition. Specifically no new interventions were initiated to address the resident's continued unplanned weight loss. The findings are: Resident #75 has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS; a resident screening and assessment tool) of 3/25/17 was reviewed. The assessment indicated the resident has severely impaired cognition; is totally dependent on one person for eating, has no swallowing problem, height was 60 inches and weight was 135 lbs., at the time of the assessment. There was no known significant weight loss/gain, and the nutrition approach was mechanically altered/ therapeutic diet. According to the weights (in pounds) recorded on the subsequent MDS assessments completed on the following dates revealed: - 03/25/17 - 135 - 07/16/17 - 131 - 10/26/17 - 128 - 11/10/17 - 123 - 02/07/18 - 121 The dietary supplement order history documented in the electronic medical record indicated Glucerna (nutritional supplement) 4 oz. twice daily had been ordered since 3/8/17. The weight monitoring record indicated the resident's weight was 135.2 lbs at that time. and the resident had since lost 14 lbs with no new interventions to prevent further weight loss. The nutrition care plan last updated on 2/18/18 indicated that the resident was at nutrition risk due to therapeutic low concentrated sweet (LCS) diet, mechanically altered (pureed) with nectar thick liquids. Interventions included, but are not limited to, provide LCS, pureed, nectar thick liquids diet per physician's orders [REDACTED]. twice daily. The dietary progress note dated 11/10/17 indicated that the resident had been hospitalized for [REDACTED]. During the hospital stay, the resident lost 5 lbs. (a total of 11 lbs. since June 2017). The dietary progress note of 11/15/17 indicated that the resident continued to lose weight slowly and would consider increasing Glucerna if any further weight loss occurred. The Dietetic Technician (DTR) and the Registered Dietitian were interviewed on 3/6/18 at 2:29 PM and stated that there have been no new dietary interventions to prevent further weight loss. The DTR stated that they put a sugar-free Health Shake on her tray in the morning but the resident was not drinking it so it was discontinued. The resident was observed during lunch on 3/5/18 at 12:25 PM in the unit dining room. The resident ate a small amount of the pureed Brussels sprouts and chili and ate most of the mashed potato. Further observation of the resident eating lunch on 3/6/18 at 12:15PM revealed she had to be fed by staff. The resident had eaten all the mashed potatoes, a small amount of the pureed turkey and all her soup. Following surveyor intervention on 3/6/18, a 3-day calorie count was initiated and fortified mashed potatoes and super cereal were added to prevent further weight loss. 415.11(c)(2)(i-iii)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that each resident's medication regimen was free from unnecessary medications for 1 of 6 residents reviewed for unnecessary medications and [MEDICAL CONDITION] medications (Resident # 51). Specifically, trial gradual dose reduction (GDR) was not attempted in the presence of documented evidence that the resident's behavior had improved and that non-pharmacological interventions including redirection were documented as effective in addressing the resident's behavior. The finding is: Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment and screening tool) of 7/28/17 indicated that the resident has severely impaired cognition; showed physical behavioral symptoms directed toward others (staff) and other behaviors including combativeness during cares, hitting and scratching staff and resisting cares occurring 1 to 3 days; and received antipsychotic medications for 6 days during this assessment period. The physician's orders [REDACTED]. The evaluation section / monitoring notes of the care plan to address behavior and [MEDICAL CONDITION] drug use initiated on 8/28/17 revealed that on 10/12/17, the resident displayed rejection of care and was scratching staff which occurred sometimes; 11/15/17, the resident scratched the staff during care; 11/21/17, it was documented in this evaluation section that the resident's behavior had improved; and on 12/6/17- scratching the staff during care and was restless. During these episodes, the staff successfully redirected the resident. The Quarterly MDS dated [DATE] and indicated that the resident remained severely cognitively impaired and did not show any behavioral problems. This MDS further documented that the resident received antipsychotic medications for 7 days during this assessment period. A medication regimen review was conducted on 12/6/17 and the consultant pharmacist recommended to the physician to consider a plan for trial GDR and discontinuation of the atypical antipsychotic medication used for dementia, [MEDICATION NAME] 0.5mg TID. A notation written by the physician on the medication review form stated that he disagreed with the recommendation as this medication helped with the resident's agitation. The psychiatric nurse practitioner (NP) progress notes dated 12/12/17 documented the following: no observed symptoms of mania, delusions, [MEDICAL CONDITION] or paranoia; had a good sleep/hygiene; fair appetite; calm; no evidence of a movement disorder or disturbance. The resident's moods and behaviors were generally stable with episodic agitation. Further review of the behavior monitoring notes of 2/13/18 documented that the resident's behavior had improved, will continue to monitor the resident and continue the plan of care. Effective interventions to address the resident's behaviors included redirection, 1:1 care and a backrub. Resident #51 was observed for five days (3/1, 3/5, 3/6, 3/8 and 3/9) at various times during the recertification survey to display a persistent, sad facial expression. At no time were physical aggression and other behaviors directed toward self and other residents were manifested. The resident did not appear to be in any distress. The resident appeared to be well-nourished and well-hydrated. The psychiatric Nurse Practitioner (NP) was interviewed on 3/9/18 at 3:30 PM as to why GDR for [MEDICATION NAME] was not conducted per the pharmacist's recommendation and in the presence of documented evidence that the resident's behavior had improved. The NP stated that the resident has unspecified [MEDICAL CONDITION] as documented on her progress notes. The Licensed Practical Nurse Unit Manager was interviewed on 3/9/18 at 2:00 PM and stated that the resident's behavior had improved significantly since admission in July 2017. 415.12(l)(2)(i)(ii)

Based on record review and interviews conducted during a recertification survey, the facility did not provide the care and treatment in accordance with professional standards of practice for 1 of 6 residents reviewed for falls (Resident #368). It was determined that x-rays were not performed in a timely manner as ordered by the physician to establish [DIAGNOSES REDACTED]. The resident was sent to the hospital for evaluation and management 12 hours after the incident occurred. The hospital x-ray revealed a [MEDICAL CONDITION] femur. The finding is: Complaint #NY 628 Resident #368 is a [AGE] year old female and has [DIAGNOSES REDACTED]. The Significant Change MDS (Minimum Data Set; a comprehensive resident assessment and screening tool) of 5/9/17 indicated that the resident scored 3 out of 15 on the BIMS (Brief Interview for Mental Status; used to test memory recall and orientation) which indicated that the resident had severely impaired cognition; required extensive assistance of two persons with bed mobility, transfer, dressing, toilet use and personal hygiene and was totally dependent on one person with locomotion on and off the unit. The comprehensive care plan for Risk for Falls initiated on 6/29/17 documented that the resident was a fall risk secondary to history of falls, impaired functional mobility, visual impairment, environmental hazards and pain. Interventions included, but were not limited to, maintain a well-lit, uncluttered environment, maintain bed in lowest position, observe resident for restlessness, and provide required staff assistance. The care plan for ADL Functioning updated on 6/29/17 had interventions including to provide the resident extensive assistance of two persons with bed mobility, transfer to and from bed to chair, dressing, toilet use and personal hygiene. The CNA Care Plan and Accountability Record initiated on September 2017 and remained current, had instructions that the resident required extensive assistance of two persons with bed mobility, transfer to and from the bed and to the chair, dressing and personal hygiene. The facility investigation report documented that on 9/3/17 at 11:30 PM, the resident was found sitting on the floor next to her bed. The resident was unable to state why she fell or what she was trying to do when she attempted to get out of bed. The unit Licensed Practical Nurse (LPN #1) notified the Registered Nurse supervisor (RN #1). RN #1 assessed the resident while the resident was on the floor and determined that the resident had pain and limited movement of the left hip and thigh. After assessing the resident, RN #1 gave directions to the unit nursing staff to move the resident back to bed. The physician was notified by RN #1 at 11:55 PM and ordered to do an x-ray in the morning. According to this report, a stat (as soon as possible) x-ray was entered into the radiology services company at that time to rule out fracture and pain of the left hip. A review of the radiology services policy and procedure dated 2/16/17 stated that x-rays requested on a stat basis, will be done in 4 hours, from time of schedule until the service is performed. The nursing progress notes of 9/4/17 documented that the resident's representative was notified of the resident's fall at 8:15 AM. The x-ray company was called at 8:30 AM to confirm the request. At 11:30 AM, the resident complained of increased pain and was medicated with Tylenol 650 mg with little effect. The pain level remained a 10 on a scale of 0-10 on the verbal pain scale. A slight external rotation to the left lower extremity was noted with swelling present. (External rotation of the lower extremity following a fall or injury usually suggests [MEDICAL CONDITION] extremity). This progress notes further documented that the day shift RN supervisor (RN #2) notified the attending physician regarding the fall and ordered to transfer the resident to the medical center for evaluation. The resident was transferred by ambulance to the medical center at 12:00 PM on 9/4/17, approximately 12 hours after the incident. The medical center's Discharge Summary report dated 9/4/17 documented that the resident had a mechanical fall in the nursing home and x-ray of the hip revealed a [MEDICAL CONDITION] femur. In a signed statement dated 9/4/17 by the assigned day shift CNA (#2), it was revealed that while she was applying anti-embolic stockings (part of dressing activity) without assistance, the resident complained of pain on the legs but did not specify which leg. After finishing care, CNA #2 then transferred the resident from the bed to the wheelchair without assistance, and wheeled the resident to the hallway near the nursing station. (At this that time, x-rays have not been done to rule out [MEDICAL CONDITION].) CNA #2 stated that the resident was then taken to the dining room by another staff member for breakfast. CNA #2's statement further documented that she was instructed by the day shift LPN #2 to put the resident back in bed because the resident will be getting an x-ray. In a signed Employee Statement of CNA #2 on the Confidential Quality Assurance Document dated 9/12/17, provided by the facility and without having to request this record, on 9/4/17 CNA #2 was educated for not following the CNA care guide for the resident's ADLs and for not obtaining reports from the nurse prior to providing cares to the resident. Following review of the investigation report, it was determined that the facility and the radiology services company did not adhere to the stat x-ray time frame as outlined on the above radiology services policy and procedure timeline grid to ensure that the resident received timely evaluation and management to rule out [MEDICAL CONDITION] femur. The attending physician was interviewed on 3/09/18 at 12:55 PM and stated that he was informed on the evening of 9/3/17 that the resident had a fall and that the resident did not complain of pain. The physician further stated that he never received a call back from nursing that the resident was in pain. He stated that he does not mind the staff calling him back anytime, day or night, and should have sent the resident out (to the hospital) if he knew the resident was in pain. RN #1 was interviewed on 3/09/18 at 1:06 PM and stated that on the night of 9/3/17, she called the doctor and reported that the resident had a fall and had pain on the left hip area. RN #1 further stated that the doctor ordered to do an x-ray in the morning which was contrary to the investigation report of 9/3/17 that a stat x-ray request was put into the radiology services company. RN#1 stated that the resident was medicated with Tylenol after the resident complained of pain on her left hip area with good effect and instructed the nursing staff on the night shift to keep the resident in bed. 415.11(c)(3)(i)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that ongoing communication of the amount and type of hospice care were coordinated with the facility for 1 of 1 resident reviewed for hospice and end of life (Resident #145). The finding is: Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. Review of the Hospice Plan of Care initiated on 8/9/17 included the following entry: Aide 3-5 week 13 and bath, personal care, toileting, assist with ambulation, transfers, meal prep, laundry, housekeeping as determined by assessed by psychosocial needs and self-care deficits. The Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) dated 12/9/17 indicated the resident was receiving hospice care. The facility care plan for Hospice Care initiated on 12/27/17 and updated on 1/3/18, identified goals were to provide pain management, maintain the resident's dignity and respect the family's wishes regarding care. Interventions included, but are not limited to, assess for comfort and provide calm environment, ensure preferences for end of life by encouraging discussion, encourage family involvement, ensure the physician/physician assistant provide pain management, hospice nurse visits, play Spanish music, hospice care services for 1:1 support and companionship. The Registered Nurse (RN) Unit Manager was interviewed on 3/05/18 at 1:32 PM regarding when the hospice aide comes to the facility. She stated that the aide usually comes two times per week for a few hours each time. When asked what days the aide comes in, the RN unit manager stated she was not sure and was unaware if there was a schedule as to when the aide would come. The Social Worker was interviewed on 3/05/18 01:35 PM regarding the schedule of the hospice aide and stated that she was unaware of the aide's schedule. During further interview with the Social Worker on 3/05/18 at 2:06 PM, she stated she reviewed the hospice service contract and it indicated they would provide aides 5 days per week 4 hours per day. She further stated they reported the reason they could not provide the services as they claim, was because they have difficulty getting aides. Observation of the resident 03/05/18 at 2:22 PM revealed he was sleeping in bed. There was no music playing. His roommate's TV was on but the roommate was out of the room. He had a small CD player next to him on his over bed table. The RN unit manager was further interviewed on 3/6/18 at 9:30 AM and she stated the hospice aide reports to her and communicates with her. When shown the hospice aide's attendance sheet, she stated she was unaware that the aide was not signing in and out and not documenting what she does each time she comes. The hospice aide was interviewed on 3/6/18 at 12:00PM and stated that she comes mostly twice per week for 1.5 to 2 hrs. per day. While she is here, she changes the bed, bathes the resident, and feeds him. She stated her schedule varies depending on what is going on with the other residents she cares for. She stated that the hospice agency tells her when and where she needs to go and that she doesn't have a set schedule for coming to the facility. When asked if she signs in and out and documents what she does, she stated she documents on a form that hospice keeps and she signs in and out on the touch pad at the reception desk (in the facility). Review of those documents, received from the hospice agency, indicated that between 8/14/17 and 10/18/17, the hospice aide was coming 4 times per week for 4 hours. There was no documentation of a hospice aide care between 10/18/17 and 11/21/17. From 11/21/17 through 2/8/18, the aide was coming between 1 to 3 times per week, mostly twice per week. There was a week when she came in 3 times for 1.5 hours each time. The time spent varied between 1.5 and 3.5 hours. The facility Director of Nursing (DON) was interviewed on 3/06/18 at 10:39 AM regarding discussions with hospice about the contract and the plan of care to provide a hospice aide 3-5 times per week. The DON stated she was unaware that the hospice aide had not been signing in and out of the facility and not documenting what she does while she is here with the resident. 415.12

Based on record review and interviews conducted during a recertification survey, the facility did not provide the care and treatment in accordance with the comprehensive person-centered care plan for 1 of 6 residents reviewed for falls (Resident #368). It was determined that the level of assistance with regards to transfer and mobility, was not provided in accordance with the resident's comprehensive assessment and care plan for activities of daily living (ADL). Specifically, the assigned Certified Nursing Aide (CNA #1) dressed, transferred and moved the resident from bed to chair without assistance. The finding is: Complaint #NY 628 Resident #368 is a [AGE] year old female and has [DIAGNOSES REDACTED]. The Significant Change MDS (Minimum Data Set; a comprehensive resident assessment and screening tool) of 5/9/17 indicated that the resident scored 3 out of 15 on the BIMS (Brief Interview for Mental Status; used to test memory recall and orientation) which indicated that the resident had severely impaired cognition; required extensive assistance of two persons with bed mobility, transfer, dressing, toilet use and personal hygiene and was totally dependent on one person with locomotion on and off the unit. The comprehensive care plan for Risk for Falls initiated on 6/29/17 documented that the resident was a fall risk secondary to history of falls, impaired functional mobility, visual impairment, environmental hazards and pain. Interventions included, but were not limited to, maintain a well-lit, uncluttered environment, maintain bed in lowest position, observe resident for restlessness, and provide required staff assistance. The care plan for ADL Functioning updated on 6/29/17 had interventions including to provide the resident extensive assistance of two persons with bed mobility, transfer to and from bed to chair, dressing, toilet use and personal hygiene. The CNA Care Plan and Accountability Record initiated on September 2017 and remained current, had instructions that the resident required extensive assistance of two persons with bed mobility, transfer to and from the bed and to the chair, dressing and personal hygiene. The facility investigation report documented that on 9/3/17 at 11:30 PM, the resident was found sitting on the floor next to her bed. The resident was unable to state why she fell or what she was trying to do when she attempted to get out of bed. The unit Licensed Practical Nurse (LPN #1) notified the Registered Nurse supervisor (RN #1). RN #1 assessed the resident while the resident was on the floor and determined that the resident had pain and limited movement of the left hip and thigh. RN #1 then gave instructions to the unit staff to move the resident back to bed. RN #1 then notified the physician at 11:55 PM and ordered to do an x-ray in the morning. A request for stat (as soon as possible) x-ray was then requested to the radiology services at that time to rule out [MEDICAL CONDITION] hip. Further review of the facility's Detailed Incident Investigation report dated 9/3/17 indicated that the resident stayed in bed during the night shift. According to this report, the resident complained of discomfort on the left hip area and was medicated with Tylenol with good effect. The resident remained in bed and was frequently rounded by LPN #1, CNA #1 and RN #1 throughout the night and the resident did not complain of further pain and discomfort. The nursing progress notes of 9/4/17 documented that the resident's representative was notified of the resident's fall at 8:15 AM. the representative arrived approximately an hour later and noted a change in the resident's left lower extremity. The x-ray company was then called at 8:30 AM to confirm the request. At 11:30 AM, the resident complained of increased pain and was medicated with Tylenol 650 mg with little effect and the pain level remained a 10 on a scale of 0-10 on the verbal pain scale. The day shift RN #2 assessed the resident and noted a slight external rotation to the left lower extremity with swelling present. This progress notes further documented that RN #2 notified the attending physician regarding the fall and the pain and to request to transfer the resident to the medical center for evaluation. The resident was transferred by ambulance to the medical center at 12:00 PM on 9/4/17, approximately more than 12 hours after the incident. The medical center's Discharge Summary report dated 9/4/17 documented that the resident had a mechanical fall in the nursing home and x-ray of the hip revealed a left femoral fracture. Following review of the facility investigation report, it was determined that the facility and the radiology services company did not adhere to the Stat x-ray time frame as outlined on the above radiology services policy and procedure to ensure that the resident received timely evaluation and management to rule out [MEDICAL CONDITION] femur. In a signed statement dated 9/4/17 by the assigned day shift CNA (#2), it was revealed that while she was applying anti-embolic stockings (part of dressing activity) by herself, the resident complained of pain on the legs but did not specify which leg. After finishing care, CNA #2 then transferred the resident from the bed to the wheelchair without assistance, and wheeled the resident to the hallway near the nursing station. (At this that time, the x-rays have not been done to rule out [MEDICAL CONDITION]. The resident should have been kept in bed until all the x-rays were completed and the [DIAGNOSES REDACTED]. CNA #2 stated that the resident was then taken to the dining room by another staff member for breakfast. CNA #2's statement further documented that she was instructed by the day shift LPN #2 to put the resident back to bed because the resident will be getting an x-ray. In a signed Employee Statement of CNA #2 on the Confidential Quality Assurance Document dated 9/12/17, provided by the facility and without having to request this record, CNA #2 was educated for not following the CNA care guide for the resident's ADLs and for not obtaining reports from the nurse prior to providing cares to the resident. CNA #2 was called by phone for an interview on 3/9/18, left a message, but did not return the call up to the time of the survey exit. RN #1 was interviewed on 3/9/18 at 1:06 PM and stated that on the night of 9/3/17, she called the doctor and reported that the resident had a fall and had pain on the left hip area. RN #1 further stated that the doctor ordered to do an x-ray in the morning. She stated that the resident was medicated with Tylenol after the resident complained of pain on her left hip area with good effect and instructed the nursing staff on the night shift to keep the resident in bed. 415.11(c)(3)(ii)

Based on observation, record review and interview, the facility did not ensure that prompt efforts were made to resolve a resident's grievance regarding environmental factors in her room for 1 of 1 resident reviewed for grievance and accident hazards(Resident #37). The findings are: Resident #37 is a long-term care resident in the facility and was admitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (a resident assessment tool) completed on 8/28/16 indicated that the resident scored 9 out of 15 on the BIMS test (Brief interview for Mental Status; used to measure orientation and memory) which suggested that the resident had moderately-impaired cognitive skills for daily decision-making. The Social Service Progress Note of 9/30/15 documented that the resident was complaining of water leaking into her room during heavy rain. According to this documentation, the resident has been complaining about the leaking window for over a year with no resolution to the problem. The psychiatric consultation record dated 9/20/16 indicated that the resident complained to the psychiatrist about the water leaking into her room and nobody has taken interest to fix it. Observation of the resident's room was conducted on 11/14/16 at approximately 11:00 AM. A large window next to the resident's bed was noted with copious amounts of water leaking from the heavy rain outside. The water was dripping into the heater situated below the window, as well as on to the floor, next to the resident's bed. The resident was interviewed on 11/16/16 at 10:30 AM and stated that the window has been leaking for a long time now and she doesn't think they are going to fix it. 415.3(c)(1)(ii)

Based on observation, record review and interview, the facility did not ensure that a resident was provided with a safe, clean, comfortable and homelike environment for 1 of 1 resident reviewed for grievances and accidents. Specifically, the resident complained of the window in her bedroom that has been leaking for over a year when it rains. The findings are: Resident #37 is a long-term care resident in the facility and was admitted on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (a resident assessment tool) completed on 8/28/16 indicated that the resident scored 9 out of 15 on the BIMS test (Brief interview for Mental Status; used to measure orientation and memory) which suggested that the resident had moderately-impaired cognitive skills for daily decision-making. The Social Service Progress Note of 9/30/15 documented that the resident was complaining of water leaking into her room during heavy rain. According to this documentation, the resident has been complaining about the leaking window for over a year with no resolution to the problem. The psychiatric consultation record dated 9/20/16 indicated that the resident complained to the psychiatrist about the water leaking into her room and nobody has taken interest to fix it. Observation of the resident's room was conducted on 11/14/16 at approximately 11:00 AM. A large window next to the resident's bed was noted with copious amounts of water leaking from the heavy rain outside. The water was dripping into the heater situated below the window, as well as on to the floor, next to the resident's bed. The resident was interviewed on 11/16/16 at 10:30 AM and stated that the window has been leaking for a long time and she doesn't think they are going to fix it. The resident stated that she was offered another room once before but when she checked to see the room, there was some noisy medical equipment in the room for the other resident. The resident stated that she would be unable to sleep in that room and no other solutions were provided. During further interview, the resident stated she likes to sit in a chair by the window and do her word games but she was unable to do so because of the water leaking from the outside especially during the rain. The housekeeping director was interviewed on 11/18/16 at 10:45 AM regarding what housekeeping had been doing to address the leaking window. the housekeeping director stated that he has one of his housekeeping staff go into the room and put towels down and a wet floor sign to address the potential for slipping. The room was observed on 11/14/16 in the morning and there were no towels on the floor nor was there a wet floor sign to address the potential for slipping. The floor was wet from the rain at that time. 415.5(h)(1)