Every finding on record at St. Ann's Community

Based on observations, interviews, and record review conducted during a Recertification Survey from 09/04/2025 to 09/10/2025, for one (1) (3200 Unit) of two (2) medication carts reviewed, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal laws. Specifically, there were multiple pre-poured pills in six (6) unlabeled medication cups and all the pre-poured medications were signed off as given in the Medication Administration Record prior to administering them to the residents. The findings include:The facility policy Medication-Preparation and Administration, dated 06/02/2022, included medications may not be set up in advance, medications must be administered within one (1) hour before or after their prescribed time, and to document after medications are taken by the resident.During an observation and interview on 09/09/2025 at 9:10 AM, a medication cart (3200 Unit) had six (6) unlabeled medication cups with various pills in each cup. During an interview at that time, Licensed Practical Nurse #2 stated the cups contained medications for Residents #3, #23, #33, #48, and #50 and they were able to identify all of the medications for each resident. Licensed Practical Nurse #2 stated their medication administration process included to go to resident rooms, if the resident is not in their room, the pills are put in medication cups and stored in the medication cart until the resident is located. Licensed Practical Nurse #2 stated they knew they should not administer medications to residents this way, but pre-pouring the medications and documenting them as given ensures the medication pass is completed on time. Review of the Medication Administration Audit report for 09/09/2025 revealed Licensed Practical Nurse #2 documented Residents #3, #23, #33, #48 and #50 had received their medications between 7:55 AM and 8:31 AM. During an interview on 09/10/2025 at 10:05 AM, the Director of Nursing stated nurses should be preparing medications for residents one (1) at a time and then document on the Medication Administration Record after they were given. The Director of Nursing stated pre-pouring medications and documenting as given when they have not actually been administered is dangerous as a nurse could give the wrong medications to the wrong resident. 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews, and record review conducted during a Recertification Survey from 09/04/2025 to 09/10/2025, for one (1) (Resident #34) of one (1) resident reviewed, the facility did not ensure feeding assistants had successfully completed a State-approved training course that meets the requirements before feeding residents and feeding assistants provided dining assistance only for residents who have no complicated feeding problems. Specifically, Resident #34 who had a diagnosis of dysphagia (difficulty swallowing food or liquids) was observed receiving assistance with their breakfast meal from a staff member who had not completed an approved paid feeding assistant training program. Additionally, Resident #34's care plan did not reflect the use of a feeding assistant and the staff member was not under the direct supervision of a licensed nurse. The findings include:An official communication issued by the New York State Department Health, Dear Administrator Letter #07-11 (Paid Feeding Assistants), dated 12/20/2007, included nursing homes are allowed to utilize trained individuals as paid feeding assistants to supplement existing nursing staff in ensuring residents take in adequate food and fluids. Consistent with federal regulations, each feeding assistant must successfully complete a State-approved feeding assistant training program. The nursing home must maintain documentation on each individual that successfully completes the training program and/or is utilized as a feeding assistant at the facility. Upon completion of training, the nursing home must provide each individual with a certificate indicating his or her successful completion of the feeding assistant training program. Selection of residents to be fed will be made by the charge nurse, however the determination of those residents who can safely be fed or assisted by a feeding assistant must be based upon a registered professional nurse's assessment and the resident's plan of care.An official memo issued by the Centers for Medicare and Medicaid (CMS), Quality, Safety and Oversight (QSO)-22-15-NH (Nursing Homes), dated 04/07/2022, included the waivers of regulatory requirements have provided flexibility in how nursing homes may operate and have also removed the minimum standards for quality that help ensure residents' health and safety are protected. Centers for Medicare and Medicaid are ending the specific emergency declaration blanket waivers for skilled nursing facilities. Centers for Medicare and Medicaid modified the requirements regarding training of paid feeding assistants to allow that training can be a minimum of one (1) hour in length but did not waive other requirements related to paid feeding assistants or required training content. Emergency declaration blanket waivers are to end, effective 06/06/2022. Review of the facility policy Meal Service last revised 06/03/2022, included physical assistance of the Elder/Patient with meals may not be provided by staff not credentialed to do so. Resident #34 had diagnoses including dysphagia, essential tremor (a nervous system condition characterized by rhythmic shaking that cannot be controlled), and protein-calorie malnutrition. The Minimum Data Set (a resident assessment tool), dated 09/01/2025, included the resident had moderately impaired cognition and required set-up assistance with eating. The current comprehensive care plan, reviewed on 09/09/2025, revealed the resident was on aspiration precautions (guidelines to prevent food or liquids from entering the lungs instead of the stomach) and required adaptive devices during their meal.During an observation on 09/05/2025 at 9:37 AM, Administrative Assistant #1 was providing physical assistance with feeding Resident #34. Administrative Assistant #1 was the only staff member in the dining room at that time. Review of an undated facility document provided on 09/04/2025 included paid feeding assistant training had been provided in July 2017 and August 2023, three (3) facility staff had received training, and nine (9) residents were eligible for feeding assistance, none of whom were currently using paid feeding assistants. Administrative Assistant #1 was not included on the list of paid feeding assistants who completed the approved training.During an interview on 09/05/2025 at 3:32 PM, Administrative Assistant #1 stated staff who were not a certified nursing assistant or a licensed nurse were scheduled to assist with cooking, serving, and cleaning for residents at least twice weekly. Administrative Assistant #1 did not include feeding residents as an assigned task. During an interview on 09/05/2025 at 2:45 PM, the Administrator stated if staff are not a certified nursing assistant, licensed practical nurse, registered nurse or completed the State-approved paid feeding assistant training, they cannot feed residents. They stated only three (3) staff had completed the training. During a follow-up interview at 3:52 PM, the Administrator stated Administrative Assistant #1 had received training to feed residents during the covid pandemic but had not completed the State-approved training program. 10 NYCRR 415.14(h)

Based on interviews and record review conducted during a Recertification Survey, the facility did not ensure that newly admitted resident's and/or their representatives were provided with a written summary of a Baseline Care Plan that included the minimum healthcare information necessary to properly care for the immediate needs of the resident (including but not limited to initial goals, admission orders, dietary, therapy and social services) for 9 (Residents #2, #7, #31, #40, #53, #55, #56, #57 and #58) of 11 residents reviewed. Specifically for all residents identified the facility did not provide the resident or their representative with a summary of a Baseline Care Plan in a timely manner. This is evidenced by, but not limited to the following: The current facility policy, Care Planning-Interdisciplinary, dated 7/12/22, included a baseline care plan is initiated and completed with 48 hours of admission and developed before the comprehensive assessment. Prior to the scheduled care plan meeting a copy of the residents Baseline or their Comprehensive Care Plan, a medication list, and their care card (care plan used by the Certified Nursing Assistants for daily care) will be offered to the resident and/or designated family member. A note will be written into the electronic health record to confirm this information was provided. 1. Resident #58 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and diabetes. The Minimum Data Set Resident assessment dated [DATE] included that the resident was severely impaired cognitively. Review of Resident #58's Care Plan Report (also known as a Comprehensive Care Plan or a Baseline Care Plan), dated 6/16/23, revealed no documented evidence that the Care Plan Report (utilized as a Baseline Care Plan) had been implemented within 48 hours of admission or that a written summary of their initial care needs (that included admission orders, dietary, therapy and social services) had been provided to the resident or their representative. Review of Resident #58's electronic health record from 5/25/23-present revealed no documented evidence that any summary of the resident's initial care (that included admission orders, dietary, therapy and social services) had been provided to the resident and/or the resident representative after admission to the facility. 2. Resident #56 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular heart rate), depression, and fall with a fracture. The Minimum Data Set Resident assessment dated [DATE] included that the resident was moderately impaired cognitively. Review of Resident #56's Care Plan Report, dated 10/19/23, revealed no documented evidence that the Care Plan Report or a summary of care (that included admission orders, dietary, therapy and social services) was provided to the resident or the resident representative. In a Clinical Note Report dated 12/15/23, Social Worker #1 documented that Resident #56's and the resident's family were given copies of their care plan, their care card, and a medication list at the initial family meeting on 12/13/23, 55 days after the Care Plan Report was initiated. 3. Resident #55 was admitted to the facility 2/15/24 with diagnoses including dementia, pressure ulcer of right foot, and diabetes mellitus. The Minimum Data Set Resident assessment dated [DATE] included that the resident was cognitively intact. Review of Resident #55's Care Plan Report, dated 2/15/24, revealed no documented evidence that a summary of care (including admission orders, dietary, therapy and social services) was provided to the resident or the resident representative. In a Clinical Notes Report, dated 4/15/24 Social Worker #1 documented that an initial family meeting was held on 3/27/24 and that the family was provided with copies of Resident #55's care plan, care card, and medication list (41 days after the Care Plan Report was initiated). During an interview on 5/8/24 at approximately 9:15 AM, Social Worker #1 stated that a Baseline Care Plan is done within 24 hours and that Social Work is responsible for providing it to the resident and/or family. Social Work #1 stated that there was no documentation in the electronic health record that the Baseline Care Plan had been offered until the initial care plan family meeting (for these residents). Social Worker #1 said that the Baseline Care Plan is converted to the Comprehensive Care Plan within 21 days and then that care plan is provided to the family at the initial care plan meeting (usually within 21 days) as the family would rather have the Comprehensive Care Plan instead of the Baseline Care Plan. During an interview on 5/8/24 at 11:18 AM, the Director of Nursing stated the Social Worker was responsible to make sure the resident and/or resident representative received a copy of the Baseline Care Plan. 10 NYCRR 415.11 49368

Based on observations, interviews, and record review conducted during the Recertification Survey, for one (Residents #2) of one resident reviewed the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, Resident #2 had several extended periods of time without a documented bowel movement, did not receive appropriate interventions to manage their bowel patterns, and did not have a comprehensive care plan in place to address a diagnosis of constipation. This is evidenced by the following: The facility policy and procedure, Bowel Management, date 1/28/19 included that Nursing would monitor the bowel regimen where appropriate and establish a care plan to ensure the Elder (Resident) was having regular bowel patterns. The electronic documentation system bowel management report would be reviewed daily. If an Elder had no bowel movement after more than six shifts, the staff nurse should initiate the as needed bowel regimen as ordered or notify the medical provider or supervisor. If the as needed regimen was started for no bowel movement and there were no results in 24 hours, the medical provider should be notified. Resident #2 had diagnoses including constipation, dehydration, and dementia. The Minimum Data Set Resident assessment dated [DATE] revealed the resident had moderately impaired cognition, was independent with toilet transfers, was always continent of bowel, and required assistance with toileting hygiene. Review of current physician orders included the following medications to treat constipation: sennosides-docusate sodium (stool softener + laxative) once daily, polyethylene glycol (laxative) once daily, Dulcolax (laxative) suppository daily as needed (for constipation), and magnesium hydroxide (laxative) once daily as needed (for constipation) and polyethylene glycol (laxative) once daily as needed (for constipation). Review of the current comprehensive care plan did not include measurable goals or interventions to address Resident #2's constipation or bowel management and did not address a history of, or current refusals of care. Review of the current Resident Care Summary (care plan used by the Certified Nursing Assistants for daily care needs) included to keep the toilet turned off and document bowel movements as necessary. Review of the bowel movement report (documentation of the resident's bowel movements, consistency and continence) in the resident's electronic medical record from 4/11/24 to 4/17/24 revealed Resident #2 had 16 consecutive shifts during this timeframe where no bowel movement had been recorded. Review of Medication Administration Records from 4/11/24 to 4/17/24 revealed routine medications to treat constipation were administered daily as ordered. Polyethylene glycol as needed was administered on 4/16/24 at 6:36 AM with no results documented. Review of a nurisng progress note authored by Registered Nurse #2 on 4/16/24 at 2:54 PM, revealed Resident #2 had no bowel movements and a scheduled bowel medication was administered. Review of a progress note authored by Licensed Practical Nurse #3 on 4/17/24 at 1:15 PM, revealed that polyethylene glycol and prune juice had been administered at 9:30 AM after no bowel movements had been recorded for 17 shifts and results were pending. Resident #2 was also offered a Dulcolax suppository but refused the medication. Review of the bowel movement report from 4/25/24 to 4/30/24 revealed 11 consecutive shifts during this timeframe where no bowel movement had been recorded. Review of Medication Administration Record from 4/25/24 to 4/30/25 revealed routine medications to treat constipation were administered daily as ordered. Polyethylene glycol as needed was administered on 4/28/24 at 9:32 PM with no results documented. Magnesium hydroxide as needed was administered on 4/29/24 at 6:00 PM with no results documented. Review of a nursing progress note authored by Licensed Practical Nurse #4 on 4/29/24 at 7:42 AM, revealed Resident #2 had no recorded bowel movement for 10 shifts. The resident refused bowel medications that morning but had received an as needed dose of polyethylene glycol the previous evening with no results. Review of a nursing progress note authored by Licensed Practical Nurse #5 on 4/30/24 at 6:00 AM, revealed Resident #2 had no bowel movement in 11 shifts and refused bowel medications. Review of the bowel movement report from 5/1/24 to 5/6/24 revealed no documented bowel movements for 13 consecutive shifts. Review of the Medication Administration Record from 5/1/24 to 5/6/24 revealed routine medications to treat constipation were administered daily as ordered. There were no as needed bowel medications administered during this time. During an interview on 5/2/24 at 9:52 AM, Resident #2 stated they had been experiencing constipation and was taking polyethylene glycol but could not seem to find relief. During an interview on 5/6/24 at 11:57 AM, Licensed Practical Nurse #1 stated that Resident #2 received routine medications daily to treat constipation. Upon review of the bowel movement report at that time, Licensed Practical Nurse #1 stated the resident had not had a bowel movement for 18 shifts. Licensed Practical Nurse #1 stated that the Certified Nursing Assistants were responsible for documenting when a resident had a bowel movement, and that nursing should follow the bowel protocol after nine shifts with no bowel movement. During an interview on 5/6/24 at 12:30 PM, Certified Nursing Assistant #1 stated their responsibility was to document whether a resident had a bowel movement, the characteristics of the bowel movement, and if the resident was continent or incontinent. During an interview on 5/6/24 at 12:44 PM, Registered Nurse Manager #1 stated the nurses should print the bowel movement report daily which included residents who did not have a bowel movement in the previous three days or nine shifts based on what staff documented. Registered Nurse Manager #1 stated Resident #2 was independent with toileting and that the toilet could be turned off, so staff could keep track of bowel movements. Resident #2's last documented bowel movement was on 4/30/24. Registered Nurse Manager #1 stated they would have expected the floor nurse or the supervisor to have added Resident #2 to the bowel movement list (residents who had not had a bowel movement for than nine shifts and would need the bowel protocol initiated and/or medical notified). During an interview on 5/8/24 at 10:01 AM, Licensed Practical Nurse #1 stated they were supposed to run the bowel movement report in the morning but that they did not run it that day. Licensed Practical Nurse #1 stated that it could have been a lack of documentation from the Certified Nursing Assistants or that Resident #2 may have had bowel movements that staff had not been aware of. During an interview on 5/8/24 at 10:27 AM, the Director of Nursing stated the bowel report should be reviewed every shift by the floor nurse or supervisor, and any resident who had no bowel movement in more than six shifts should be started on the bowel protocol. 10 NYCRR 415.12

Based on interviews, and record review conducted during the Recertification Survey and complaint investigation (#NY00327781), it was determined that for one (Resident #271) of six residents reviewed for unnecessary medications, the facility did not ensure that the resident was free from significant medication errors. Specifically, Resident #271 received an incorrect dose of a medication for Parkinson's disease for an extended period of time, in a dose that exceeded the recommended maximum daily dose and not as recommeded by the specialist. This is evidenced by the following: The facility policy and procedure, Internal and External Consults and Clinics, revised 7/25/22, included that any orders, reports, or notes received from an outside clinician upon return of the resident are given to nursing for review. The nursing team will read the note/recommendations and/or email the note/reconditions to the provider for review. The orders, notes, and reports are scanned into the medical record after being dated and signed off by the medical provider. The facility policy and procedure, Medical Provider Telephone Orders, revised 6/3/22, included that telephone orders may be given by a medical provider to a nurse, pharmacist or occupational therapist, physical therapist, or speech therapist. The order is read back to the medical provider who initiated it along with the elder/patient name, medical record number, location, and room number. The order must be electronically signed by the person accepting the order. Resident #271 had diagnoses including Parkinson's disease, hallucinations and delusional disorder, and a history of frequent falls. The Minimum Data Set Resident assessment dated [DATE] revealed that the resident had severely impaired cognition. An Offsite Appointment Referral for Resident #271, dated 10/2/23 and signed by the neurologist, directed to see the After Visit Summary. The After Visit Summary, dated 10/2/23 included recommendations to stop pramipexole 1.5 milligrams three times a day and to start pramipexole extended relief tablet 3 milligrams once daily for Parkinson's disease with dyskinesia (involuntary movements). Review of Resident #271's electronic health record revealed a telephone order from Physician Assistant #1 to Senior Licensed Practical Nurse #1 dated 10/2/23 for pramipexole 1.5 milligrams, 2 tablets (3 milligrams) three times daily (a total of 9 milligrams daily) starting 10/2/23. The electronic telephone order was not signed until 11/14/23 by Physician #1. Review of Resident #271's Treatment Administration Records revealed that the resident received 3 milligrams of pramipexole three times a day (for a total of 9 milligrams daily vs 3 milligrams daily as recommended) for 30 days in October 2023 and for 6 days in November 2023. In a Clinical Note Report- Medication Review dated 10/12/23, Pharmacy Consultant #1 documented a medication review had been completed. No irregularities or recommendations were identified in the review. In a Medication Incident Report dated 11/7/23 and a Facility investigation dated 11/8/23, the Director of Nursing documented that Physician #1, during a preparation for a regulatory visit, identified that the pramipexole order was entered into Resident #271 electronic health record incorrectly as 3 milligrams three times a day instead one time a day. The report included that the telephone order had been signed off by Physician Assistant #1 on 10/3/24. The Summary of Findings included that Senior Licensed Practical Nurse #1 called the Physician's Assistant about the order change after the resident's appointment with the specialist, took the verbal order regarding the medication change and entered it incorrectly. The Medication Incident Report summary included that the order had not been read back to the Physician Assistant #1 at the time of inputting the order into the electronic health record system. In a 30/60 Day Regulatory Visit Note, dated 11/8/23, Physician #1 documented that Resident #271 was seen by neurology in October and that the Neurologist wanted a reduction in the pramipexole. Physician #1 documented the dose was not decreased but mistakenly increased. During the visit, Resident #271 had said that they felt that they had been hallucinating more and that the hallucinations were worse in the past month. The note included that the resident had a fall the previous day resulting in a head laceration. When interviewed on 5/6/24 at 11:54 AM, the Director of Nursing (with Senior Licensed Practical Nurse #1 present) stated that the error occurred on 10/2/23 when the resident was seen by an off-site neurologist who recommended a medication dosage change. The Director of Nursing stated the Senior Licensed Practical Nurse #1called Physician Assistant #1 and received a telephone order. Senior Licensed Practical Nurse #1 then transcribed the medication order incorrectly for more medication instead of less. After reviewing the electronic order, the Director of Nursing stated that the order had not been signed until 11/14/23 when Physician #1 electronically signed it. The Director of Nursing stated that they (facility) had a meeting to determine the root cause analysis of the error and it was determined that it was human error. During an interview on 5/6/24 at 12:17 PM, Senior Licensed Practical Nurse #1 stated that they reviewed what the recommended dose change was on the neurology consult form with Physician's Assistant #1 during a telephone call but then transcribed a different dose. After review of the telephone order Senior Licensed Practical Nurse #1 stated the electronic order appeared not to have been signed off until 11/14/23 by Physician #1 (and not by Physician Assistant #1). On 5/7/24 at 10:28 AM Pharmacist #1 stated that the electronic health record system does provide an alert if an order exceeds the recommended dose. Pharmacist #1 stated that the alert would have occurred during the original filling of the medication. Pharmacist #1 stated that the order came in towards the end of the day and may have been missed due to alert fatigue on the pharmacist's part. Pharmacist #1 stated that they had completed the Medication Review on 10/12/23 and had missed that the pramipexole had been ordered at a dose that exceeded the recommended daily dose. When interviewed via telephone on 5/7/24 at 10:34 AM, Physician's Assistant #1 stated that the Senior Licensed Practical Nurse #1 had called them when they got the note back from the neurology consult and read the recommendations to them. Physician Assistant#1 approved the recommendation and Senior Licensed Practical Nurse #1 input the order into the electronic health record. The order should then go to their inbox to be signed. Physician's Assistant #1 recalled that they had approved the recommendation for the change but could not recall if they had signed the telephone order for it but if they had signed the electronic telephone order, their name and the date signed would be on the order. Physician's Assistant #1 stated that the process now requires the full consult note before approving and signing an order. Physician's Assistant #1 stated that the side effects from higher doses of pramipexole could include nervousness, restlessness, weight loss, and worsening Parkinson's symptoms but could not say that they saw anything acutely different with Resident #271 due to the increased dosage. Based on the following corrective actions, it was determined that the facility implemented a plan of care to correct the non-compliance effective 11/22/23 and no further plan of correction is required: - A Medication Incident Report and investigation was started on 11/7/23. - An education referral was provided to Senior Licensed Practical Nurse #1 on 11/7/23. - On 11/7/23 the order for pramipexole 1.5 milligrams, 2 tablets (3 milligrams) three times daily was discontinued. Pramipexole extended relief 3 milligrams one time daily was ordered on 11/7/23 to begin on 11/13/23. - Resident #271 was assessed by medical team on 11/7/23 and 11/8/23. - The facility policy and procedure, Internal and External Consults and Clinics, was reviewed on 11/8/23. - The medication error was reported to The New York State Department of Health on 11/9/23. - Education was provided to all nursing staff responsible for taking orders from medical team. - The medical team was provided with education regarding having nurses read back orders and/or scan/email orders to provider prior to entering orders into the electronic health record. 10 NYCRR 415.12(m)(2)

Based on observations, interviews, and record review conducted during a Recertification Survey, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for one (third-floor resident unit) of two medication rooms reviewed. Specifically, numerous controlled medications (drugs that are regulated by law due to their potential for abuse or addiction), including narcotics and opioids were observed unsecured and not in a double locked cabinet per the regulations. This is evidenced by the following. The facility policy Medications-Storage, Distributions, Administration and Wasting of Controlled Substances, dated 4/11/22 documented that controlled substances must be stored, distributed, and administered in a safe, secure manner with total compliance with all legal and regulatory requirements. The narcotics supply is to be kept under two locks at all times, and all controlled substances are to be returned to the medication room narcotic cabinet and double-locked after a medication pass. During an observation and interviews on 5/7/24 at 8:48 AM of the third-floor medication room with Registered Nurse Manager #1, the narcotic (controlled medications) cabinet double doors were open and unlocked, leaving the controlled narcotic medications unsecured. Registered Nurse Manager #1 stated the controlled medication cabinet doors should not be unlocked. Licensed Practical Nurse #1 returned to the third-floor medication room at this time and stated they had left the narcotic cabinet unlocked because they were in a hurry. The cabinet contained numerous bags of controlled substances including pain medications, narcotics, opioids and anti-anxiety medications. In an interview on 5/8/24 at 10:01 AM, Licensed Practical Nurse #1 stated that the narcotic medication cabinet doors should not be left unlocked and that the doors should only be unlocked when counting the medications with another nurse or when receiving a pharmacy delivery. In an interview on 5/8/24 at 10:30 AM, the Director of Nursing stated that the controlled medication cabinet doors should always be kept locked. 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (Complaint # NY00323662) it was determined for one (Resident #1) of three residents reviewed for abuse the facility did not ensure the resident was free from the use of verbal, mental, or physical abuse. Specifically, Resident #1 was slapped on the abdomen, yelled at, and observed having a finger pointed in their face in an intimidating manner by a staff member. This is evidenced by the following: The facility policy, Elder Abuse/Neglect/Mistreatment Policy, dated 7/22/23, defined abuse as inappropriate physical contact with an Elder of a residential health care facility, while the Elder is under the supervision of the facility, which harms or is likely to harm the Elder. Inappropriate physical contact includes, but is not limited to, striking the Elder. Additionally, verbal abuse could include a threat or physical action such as a threatening gesture or intimidation. Resident #1 had diagnoses including dementia with behavioral disturbances, anxiety disorder, and depression. The Minimum Data Set assessment dated [DATE] revealed the resident had severely impaired cognition, had no behaviors, and required the extensive physical assistance of one person for bed mobility, dressing, and personal hygiene. Review of the facility investigation dated 9/12/23, completed by the Director of Nursing (DON) revealed video footage showing Certified Nursing Assistant (CNA) #1 being rough with and slapping Resident #1. The video was provided by the resident's family member on 9/11/23. Review of video footage from a camera that had been installed by the family of Resident #1, revealed that on 9/3/23 at approximately 6:00 AM Resident #1 was lying flat in bed, partially clothed, when CNA #1, while providing care, hit the resident on the abdomen with both open hands yelling hey, stop all that [NAME] and leaning over Resident #1 pointing their right index finger in Resident #1's face in an intimidating manner. In a medical note, dated 9/11/23, the Physician documented that Resident #1 was assessed following an incident with a staff member that was brought to the facility's attention on 9/11/23. The physical exam revealed the resident was at their baseline with no concerning findings, did not appear to remember the incident, and did not appear frightened, anxious, or depressed as a result. In an interdisciplinary progress note, dated 9/11/23 Social Worker #1 documented that Resident #1 had no evidence of anxiety, depression, or psychological distress. During an interview on 9/12/23 at 8:50 AM and again at 4:06 PM, the DON stated Resident #1's family had placed a camera in their room that the facility was unaware of. The family had reviewed the video footage over the past few days and reported the incident to the DON and Administrator on 9/11/23. CNA #1 was terminated on 9/11/23. During an attempted interview on 9/12/23 at 9:45 AM, when Resident #1 was asked if any staff member had been mean to them, Resident #1 did not respond verbally, did not make eye contact, looked away from the surveyor and folded their hands together. During an interview on 9/12/23 at 4:06 PM, the Administrator and DON both stated that Resident #1's family initially installed the camera related to concerns about the Residents' toileting behaviors brought to their attention by the facility. The family decided to extend the camera monitoring for an additional week due to concerns with CNA #1 being rough with Resident #1. During an interview on 9/13/23 at 2:28 PM, CNA #1 stated they may have mushed Resident #1 in the stomach to get them to roll over but would never intentionally hit them. They stated they may have been rough, disrespectful, and intimidating but had never hit Resident #1 or any other resident. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews conducted during the Recertification Survey completed on 8/29/22, it was determined that for two (Employees #2 and #4) of five employee files reviewed, 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 (NAR) abuse screening was not completed prior to new employees beginning work. The findings are: On 8/26/22 from 10:30 a.m. to 11:55 a.m., documentation related to five recently hired employees was reviewed. The records included that employee #2 was hired as a Beauty Technician on 6/28/22. The documentation provided included a nurse aide registry abuse screening for employee #2 dated 3/8/21. Additionally, employee #4 was hired on 6/6/22 as a Care Partner and the NAR screening was dated 8/24/22. During an interview at this time, the Human Resources (HR) Manager stated that a NAR screening wasn't done originally for employee #4, and was done when the surveyors came in. During interviews on 8/26/22 at 11:27 a.m. and 3:10 p.m., the HR Manager stated that employee #2 was transferred from an affiliated facility and a nurse aide registry check was not re-run. Additionally, the HR Manager stated that there was no policy in place for a NAR check when someone transfers from one of their facilities to another. On 8/29/22 at 8:55 a.m. the facility policy NSG-07 titled 'Resident Abuse/Neglect/Mistreatment policy was reviewed. The policy included: 'Employee screening: During the pre-employment process, the Human Resources Department clears potential employees through the Nursing home Nurse Aide Registry. Additionally, the facility policy HR-24 titled 'Background Verification and Drug Testing' was reviewed and included: 'All new hires must be checked through the CNA registry prior to employment to ensure a safe environment for our residents and staff. 10 NYCRR: 415.4(b)(1)(ii)(b)

Based on observation and interviews conducted during the Recertification Survey completed on 8/29/22, it was determined that the facility did not ensure that the environment remained as free of accident hazards as possible. Specifically, on six of six resident care units, hazardous chemicals were stored in unlocked rooms and accessible to 57 residents including many with dementia and/or wandering behaviors. This is evidenced by the following: Review of facility policy Storage and handling of toxic and potentially hazardous chemicals, medications and treatment procedures, dated 12/22/94 included that the policy statement was to insure the protection and safety of elders/patients, all toxic and potentially hazardous chemical, medications, and treatment products will be store in designated locked areas when not in direct use. Section A: Cleaning Supplies #3: Return the cleaning supplies to a locked cupboard, at no time are cleaning supplies to be left out where they could be assessable to elders/patients. Section B: Treatment Items #1: Obtain treatment item from locked treatment cart, medication cart, or locked cabinet in clean utility room. #2: Use treatment item, only as directed, always keeping the item in possession unless the elder/patient is on self-administered treatment per MD order. #3: Return treatment item to locked treatment care, medication cart, or locked cabinet in clean utility room. 1.In an observation on 8/25/22 at 11:00 a.m., on the Blossom Hall resident care unit, the laundry room doors were unlocked. One and 1/2 gallons of Clothesline Fresh 11 enzyme laundry detergent was sitting on top of dryers. An observation of the soiled linen room revealed the door marked with a biohazard symbol and was unlocked. One bottle of Carbona stain and spot remover was sitting on top of washer. 2.In an observation on 8/25/22 at 11:15 a.m., on the Heritage resident care unit, the laundry room door was unlocked. One and 1/2 gallons of Clothesline Fresh 11 enzyme laundry detergent sitting on top of dryers. An observation of the soiled linen room revealed the door, marked with a biohazard symbol, was unlocked. Two bottles of Carbona stain and spot remover were sitting on top of washer. 3. Observations on 8/25/22 at 11:30 a.m. through 12:00 p.m., of the second and third floor resident care units (Peach Tree, Magnolia, Hydrangea and Cherry Grove) revealed laundry room doors that were unlocked and contained gallons of Clothesline Fresh 11 enzyme laundry detergent sitting on top of dryers or on the counter tops. 4.In an observation on 08/26/2022 at 8:30 a.m. on the Blossom Hall resident care unit, the laundry room door was unlocked. One and 1/2 gallons of Clothesline Fresh 11 enzyme laundry detergent remained sitting on top of dryers and 1 gallon sitting on the countertop. An observation of the soiled linen room door, marked with a biohazard symbol, was unlocked. One bottle of Carbona stain and spot remover was sitting on top of the washer. 5.In an observation on 8/26/2022 at 8:40 a.m., on the Heritage resident care unit, the laundry room door was unlocked. One and 1/2 gallons of Clothesline Fresh 11 enzyme laundry detergent remained sitting on top of the dryers. An observation of the soiled linen room door, marked with a biohazard symbol, revealed the door was unlocked. Two bottles of Carbona stain and spot remover remained sitting on top of washer. 6.In an observation on 8/26/2022 at 8:55 a.m. of the dirty utility room on the Magnolia unit revealed the door was unlocked and one can of Airlift fresh scent (aerosol) air freshener was sitting on the countertop. All laundry rooms contained locked cabinets that were empty and unlocked. During an interview on 8/25/22 at 11:30 am, the Social Worker stated that some residents are allowed to do their own laundry on the housing units without supervision. During an interview on 8/26/22 at 8:30 a.m., the LPN stated both the Heritage and Blossom units have residents that have dementia and have been known to wander in and out of rooms. The LPN said that the dirty utility room was unlocked and that chemicals that had a danger warning were accessible to residents. The LPN said the laundry room doors did not contain a lock and that detergents and stain removers with danger labels were accessible to residents and should be locked in the cabinets. During an interview on 8/26/22 at 8:58 a.m., the Director of Nursing (DON) stated that every unit in the building contained elders that either have dementia or wandering behaviors and that they had not realized that the cleaning chemicals utilized in the laundry and on the unit should be locked due to their hazard identifications. The DON verbalized that according to the label the chemical products identified could be dangerous if swallowed or placed in eyes. Review of Safety Data Sheet, Spartan Chemical Company, product Orange Tough 15 cleaning agent: skin corrosion/irritation category 2, serious eye damage category 1, and skin sensitization category 1. Chemical is labeled Danger with hazard statement; causes skin irritation, causes serious eye damage, may cause an allergic reaction, harmful if swallowed, inhalation of vapors or mist may cause respiratory irritation, keep out of reach of children. Review of Safety Data Sheet, Spartan Chemical Company, Clothesline Fresh enzyme laundry detergent (11), with hazard identification; acute toxicity-inhalation, category 4, serious eye damage/eye irritation category 2B, respiratory sensitization. Label identification Danger, keep out of reach of children, harmful if inhaled, causes eye irritation, may cause allergy or asthma symptoms or breathing difficulties if inhaled. Review of Safety Data Sheet, Spartan Chemical Company, Airlift Fresh Scent (aerosol), label identification, keep out of reach of children, inhalation of vapors or mist may cause respiratory irritation, may be harmful if swallowed, may cause eye irritation and may cause skin irritation. Review of Safety Data Sheet, Carbona Stain Devils: coffee, tea, wine and juice spot remover, with hazard identification; skin category 1, serious eye damage category 1 and skin sensitization category 1. Chemical is labeled Danger, harmful if swallowed, inhalation of vapors or mist may cause respiratory irritation, keep out of reach of children. 10 NYCRR 415.12(h)(1)

Based on observations, interviews, and record review, conducted during the Recertification Survey, completed on 8/29/22, it was determined that the facility did not provide a safe, clean, comfortable, and homelike environment for three of three residents reviewed. Specifically, Residents #3, #7, and #63 were observed on multiple days occupying wheelchairs with cracks, peeling material, and exposed padding. This is evidenced by: 1.Resident #7 had diagnoses including arthritis, [CONDITION(S)], anxiety, and depression. The Minimum Data Set Assessment (MDS), dated [DATE], documented that Resident #7 was cognitively intact and required the use of a wheelchair. The resident also required extensive assistance from staff for transfers. During and observation and interview on 8/24/22 at 9:22 a.m., Resident #7 was sitting in a wheelchair. The left arm fabric of the wheelchair was peeled off esposing the foam padding. Residnet #7 stated at this time that they had had the wheelchair for a quite awhile. During an observation on 8/25/22 at 10:11 a.m., Resident #7 was observed sitting in their wheelchair. The left arm rest continued to be cracked, peeling, and the foam was exposed. During an observation on 8/26/22 at 8:52 a.m., Resident #7 was observed self-propelling in the same wheelchair. The left arm rest still had cracked peeling material and exposed foam. In an interview on 8/26/22 at 10:46 a.m., Licensed Practical Nurse (LPN) #1 stated that environmental services are responsible for cleaning the wheelchairs every three months and that maintenance is responsible for fixing the wheelchairs. 2.Resident #3 had diagnoses including status post [CONDITION(S)] (stroke), [CONDITION(S)], and [CONDITION(S)]. The MDS Assessment, dated 5/23/22, revealed the resident had severely impaired cognition, required the use of a wheelchair and the assist of staff for transfers. In an observation on 8/24/22 at 10:13 a.m., Resident #3 was seated in a reclined wheelchair. The padded cushion attached to the left arm rest had a tear in the fabric along the entire length of the bottom edge exposing the white foam padding. The padded cushion attached to the right arm rest had an approximately six-inch tear along the bottom edge of the cushion exposing the white foam padding. 3.Resident #63 had diagnoses including dementia and kidney disease. The MDS Assessment, dated 7/28/22, revealed that the resident had severely impaired cognition, required the use of a wheelchair and extensive assist of staff for transfers. During observations on 8/25/22 at 3:27 p.m., and again on 8/26/22 at 3:39 p.m., with LPN #2 the left arm rest of Resident #63's wheelchair was cracked . LPN #2 stated at this time that the facility practice is to notify the Resident Care Coordinator of such equipment issues. During an observation on 8/29/22 at 10:48 am, the left arm rest on Resident #63's wheelchair remained cracked. During an interview and observation on 8/29/22 at 10:25 a.m., the Director of Nursing (DON) stated that the Certified Nursing Assistants should call maintenance for repairs on the wheelchairs. The DON stated that if the cushions are in poor repair, they should be replaced. The DON stated that the cushions on Resident #3's wheelchair were put in place by Occupational Therapy and that they would make OT aware that they needed to be replaced. In an interview on 8/29/22 at 10:47 a.m., the Facility Manager stated that they only check on the condition of the wheelchairs if they receive a notification from the nursing staff stating that the wheelchair is in disrepair. The Facility Manager stated that they do not perform audit checks for the condition of the facility wheelchairs. 10NYCRR 415.29(j)(1)

Based on observations, interviews, and record review conducted during a Recertification Survey, completed on 8/29/22, it was determined that for one (Resident #40) of one resident reviewed for position/mobility and one (Resident # 23) of one resident reviewed for pressure ulcers, the facility did not review and revise the resident's care plan (with input from the resident or resident representative to the extent possible) to reflect the resident's current needs. Specifically, Resident #40's Comprehensive Care Plan (CCP) was not revised to reflect the discontinued use of hand splints and washcloths for hand contractures and Resident #23's CCP did not reflect the history of and current presence and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The facility policy, Care Planning-Interdisciplinary, revised 7/12/22, included that the Care Plan was reviewed and updated with any change in status (minimally, quarterly). 1.Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 7/9/22, revealed the resident was severely impaired cognitively, required extensive assistance from staff for bed mobility, transfer, personal hygiene, eating and dressing and required total assistance of staff for bathing. Review of the current CCP revealed Resident #40 had contractures that required application of splints related to bilateral hand contractures. The Resident Care Card (care plan used by the Certified Nursing Assistants (CNAs) for daily care), dated 8/15/22, included for staff to ensure that gauze was in place on Resident #40's right hand between thumb and pointer finger to prevent skin breakdown and to have one rolled washcloth placed into each palm for contracture management as the resident tolerated. The Resident Care Card did not include use of foam. The Occupational Therapy (OT) Treatment note, dated, 6/16/22 summarized that the therapist discontinued the use of hand splints due to worsening hand contractures and skin breakdown. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] a. On 6/19/22 to apply gauze between fingers and palms and apply rolled wash cloths to both palms twice daily dated. b. ON 8/4/22 orders changed to include to daily remove old 4x4s drain sponges, cleanse between fingers and all open areas with [MEDICATION(S)], rinse with normal saline, dry completely, apply gauze sponges between each finger and between fingers and palms c. On 8/17/22 orders added (after cleansing and drying) to apply [MEDICATION(S)] (anti-fungal powder) to a non-adherent foam and apply to palm of both hands and must be done by two people. During observations on 8/25/22 at 11:53 a.m., on 8/26/22 at 8:87 a.m., and again on 8/29/22 at 11:57 a.m., Resident #40 was observed without hand splints, and had white gauze sticking out of the hands and between fingers. The foam (as ordered on 8/17/22) was not visible. During an interview on 8/25/22 at 3:03 p.m., the CNA stated that they used powdered gauze for Resident #40's hands. 2.Resident #23 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 6/16/22, documented that the resident was severely impaired cognitively, was at risk for developing a pressure ulcer, had one stage 3 pressure ulcer and was receiving skin and ulcer treatments. Review of the current CCP revealed that Resident #23 was at risk for skin breakdown, with preventative interventions that included but not limited to, turning and positioning every two hours while in a chair and every one hour while in bed, weekly skin checks, prompt incontinence care and treatments as ordered. The CCP did not include a history of pressure ulcers or any current pressure ulcer with related goals and interventions. Physician orders, dated 6/16/22, included instructions to cleanse natal cleft area (buttocks) with normal saline, pat dry and apply a thick layer of extra protective cream (EPC) with a Q-tip to the open area two times a day and as needed (PRN). Review of multiple Wound Care notes beginning in February 2022, revealed that a pressure ulcer was first identified on 2/3/22. Various treatments were utilized including Hydro gel (gel that promotes wound healing), Alginate (absorbs wound fluid) and foam dressing, silver [MEDICATION(S)] (cauterizes infected wound tissue), and autolytic debridement (removal of dead tissue through use of body's own enzymes). Review of the Regulatory Visit note dated 7/27/22 at 2:30 p.m., included that the pressure ulcer was resolved. Review of the Weekly Skin Observation Notes dated 7/26, 8/2, 8/9, and 8/23/22, revealed a pressure ulcer to the natal cleft area that received daily treatment. During an observation of wound treatment by the Licensed Practical Nurse (LPN) #1 on 8/26/22 at 1:13 p.m., Resident #23 had a 1cm by 0.5cm open area to the natal cleft next to a dime-sized purplish area (indicative of potential breakdown). During an interview on 08/26/22 at 3:46 p.m., LPN #2 stated that the Resident Care Coordinator (RCC) was responsible for creating and updating the care plans. LPN #2 stated that nursing staff would let the RCC know if there were any changes that would necessitate updating the care plan. During an interview on 8/29/22 at 10:10 a.m., the Director of Nursing (DON) stated that the RCC and the DON were responsible for creating and updating resident care plans. The DON stated that Resident #23 was receiving treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated that Resident #40's treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said that the CCP should have been updated to remove the splints related to Resident #23 Problem: Contractures. [10 NYCRR 415.11(c)(2)(iii)]

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for five of eight residents reviewed for Baseline Care Plans, the facility did not provide documented evidence that the resident or representative was provided a written summary of the baseline care plan that included the minimum required healthcare information necessary to properly care for a resident (Residents #32, #64, #69, #46, and #7). This is evidenced by, but not limited to, the following: The facility policy and procedure, Care Planning- Interdisciplinary, last reviewed on 12/30/17, included that a baseline care plan would be initiated and completed within 48 hours of admission and address at the minimum the following: initial goals based on admission orders [REDACTED]. A copy of the baseline care plan, the resident's care card, and a list of the resident's current medication will be provided to the resident or their representative, and a note will be written in the electronic health record to confirm that information was provided. 1. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/21/18, revealed the resident had severely impaired cognition. The Baseline Care Plan was developed within 48 hours of admission; however, the Care Plan Meeting Form, dated 5/9/18, revealed the care plan was provided on that date but did not include initial goals for the resident, a list of current medication, or dietary instructions. 2. Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/30/19, revealed the resident had severely impaired cognition. Review of the electronic medical record revealed the Baseline Care Plan, effective 1/29/18 to 2/6/18, included initial goals for care but did not include a list of current medications. The Care Plan Meeting Form, dated 2/14/18, revealed that a meeting was held on 2/16/18 to include the resident's family member and members of the interdisciplinary team, and a copy of the care plan was provided to resident/patient/family at that time. 3. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/22/19, revealed the resident had moderately impaired cognition. Review of the electronic medical record revealed a Baseline Care Plan, effective 1/15/19 to 1/24/19, included initial goals for care but did not include a list of current medications. A progress note documented by a Social Worker on 1/29/19 at 10:59 a.m. revealed that a copy of the resident's care plan was provided to the Health Care Proxy on that date. When interviewed on 2/21/19 at 10:06 a.m., the Registered Nurse Manager stated that medications were incorporated into the Comprehensive Care Plan (CCP) and a copy of the CCP was provided to the resident and/or family. When interviewed on 2/22/19 at 11:50 a.m., the Social Worker stated that the baseline care plan is started at the time of admission and rolls into the CCP. She said the CCP is given to the family or resident prior to the CCP meeting. She said that the physician orders [REDACTED]. When interviewed on 2/25/19 at 1:03 p.m., the Director of Quality and Risk Management stated that she was unable to find that physician and therapy orders were included in the baseline care plan. She said that she did not know where information would be documented regarding the contents of the baseline care plan summary that was provided to the resident or representative.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #40) of three residents reviewed for splints, the facility did not implement interventions in accordance with the resident's plan of care. Specifically, the resident was not consistently wearing his splint as care planned. This is evidenced by the following: Resident #40 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/9/19, revealed the resident's cognitive skills for daily decision making were severely impaired, the resident had upper and lower extremity impairment on both sides, and required the extensive assistance of staff for dressing, eating, and personal hygiene. The Occupational Therapy Evaluation, dated 3/26/16, revealed that the resident was to wear a left elbow Dynapro splint to help with tone management and to prevent further contractures. The (MONTH) 2019 physician treatment orders included that the resident was to have a Dynapro flex elbow splint in place always and to remove the splint for hygiene. The current Resident Care Summary (directs cares) revealed that the resident always wore a Dynapro left elbow splint and directed to remove the splint for hygiene and skin checks. During an observation on 2/19/19 at 9:37 a.m., the resident was without a splint on the left elbow. On 2/22/19 at 8:55 a.m., the resident was sleeping in bed with no splint on the left elbow. Interviews conducted on 2/22/19 included the following: a. At 8:55 a.m., the Certified Nursing Assistant (CNA) stated she was in such a hurry that she forgot to apply the resident's splint. b. At 10:06 a.m., the Registered Nurse Manager stated that the CNA was responsible for putting on the splints. She said that she expects staff to follow the care plan. When interviewed on 2/25/19 at 11:55 a.m., the Occupational Therapist said the resident wore the elbow splint for tone reduction management and to prevent further contractures. (10 NYCRR 415.11(2)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #49 and #61) of three residents reviewed for vision and hearing, the facility did not ensure that residents received proper treatment and or assistive devices to maintain hearing. Specifically, there was no follow up for missing and or broken hearing aids. This is evidenced by the following: 1. Resident #49 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/15/19, revealed the resident was cognitively intact and utilized a hearing aid or other hearing appliances. A Nursing Admission form, dated 1/31/19, revealed the resident had bilateral hearing aids. The current Resident Care Summary (directs care) revealed the resident wore glasses and to face the resident directly while speaking slowly and clearly. The Comprehensive Care Plan (CCP) revealed the resident had visual and hearing impairments and used bilateral hearing aids. Approaches included to keep adaptive equipment in good repair, check the battery regularly, and keep adaptive devices accessible. The resident was at risk for injury, and interventions included to reinforce the use of glasses and hearing aid. When interviewed on 2/19/19 at 9:13 a.m., the resident stated he had lost a hearing aid and needed to make an appointment. Interviews conducted on 2/22/19 included the following: a. At 9:29 a.m., Certified Nursing Assistant (CNA) #1 stated the resident did not wear hearing aids. She stated it would be on the Resident Care Summary if the resident wore hearing aids. b. At 1:37 p.m., Licensed Practical Nurse (LPN) #1 stated the resident does not wear hearing aids and never has. During an interview on 2/25/19 at 12:32 p.m., the Registered Nurse Manager (RNM) stated the resident's care plan included hearing aids and the care card should include that information. She stated if the resident was missing a hearing aid, it should have been documented. At 1:45 p.m., the RNM stated the resident currently had one hearing aide for the left ear, and the right hearing aid had been missing since before 12/25/18. She said that she would follow up on getting a replacement. 2. Resident #61 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/29/19, revealed the resident had moderately impaired cognition, moderate difficulty with hearing (speaker must increase volume and speak distinctly,) and utilized hearing aids. The current Resident Care Summary revealed the resident had right and left hearing aids, and when speaking to the resident ,face her directly while speaking clearly and slowly. During an observation and interview on 2/19/19 at 11:40 a.m., the resident stated her right hearing aid has been missing for over two weeks. She said she had trouble focusing on the TV without it, and staff knew her hearing aid was broken. The resident showed the surveyor her broken hearing aid, which was in a box on her tray table, and then stated she had been wondering when it was going to get fixed. When interviewed on 2/20/19 at 2:31 p.m., CNA #2 stated she called the Unit Secretary several times to schedule an appointment for the resident with the audiologist. The CNA stated the audiologist came in and fixed the resident's broken hearing aid, and the next day the other hearing aid was broken. The CNA stated she thought she had called the Unit Secretary over two weeks ago for an appointment. When interviewed on 2/21/19 at 3:20 p.m. LPN #2 stated she knew about one hearing aid being sent out for repair but was not aware the other hearing aid was broken. The LPN stated she would speak to the resident and document. She said that once she is notified of a broken hearing aid, she contacts the Unit Secretary who is responsible for scheduling appointments. During an interview on 2/22/19 at 10:06 a.m., the RNM stated the CNAs should report a broken hearing aid to the team leader and then to the Manager or the Clinical Coordinator. She said the Social Worker and family would be notified, and the resident and or family contacted to see what they would like done. The RNM said an appointment would be scheduled with the audiologist. (10 NYCRR 415.12(3)(9)(b))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #49) of three residents reviewed for accidents, the facility did not ensure the resident's environment remained free from accident hazards and each resident received adequate supervision to prevent avoidable accidents. Specifically, interventions were not re-evaluated for a resident with multiple skin tears, and there was a lack of an assessment for a decline in transfer status. This is evidenced by the following: Resident #49 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/15/19, revealed the resident was cognitively intact, had skin tears, and required extensive assistance of staff for transfers and supervision (oversight and cueing) with locomotion off the unit. The current Resident Care Summary (directs care) included the resident was independent with the power wheelchair, instructions to staff to provide frequent safety reminders while maneuvering the power wheelchair, and to remind the resident to keep the power wheelchair in P1 or P2 (speed) setting. The resident required the extensive assistance of two staff with a Vander lift (a lift using a sling where the resident does not bear weight) for transfer to a shower chair but a two-assist stand pivot transfer in and out of bed and no gait belt. The current Comprehensive Care Plan (CCP) identified the resident had vision and hearing impairments (the resident decided when to wear his glasses and or hearing aids), was at risk for injury related to poor safety awareness related to the use of a motorized wheelchair, was at risk for alterations in skin integrity related to fragile skin, and he refused to wear skin sleeves. Interventions included Physical Therapy (PT)/Occupational Therapy assessment as needed. Review of the most recent PT discharge summary, dated 9/28/18, included that the resident was independent with the power wheelchair at speed setting of P1 or P2, requires one assist for pivot transfers from power wheelchair to bed, and an Apex lift for transfers to the toilet. The resident continues to demonstrate impulsive behavior, and if staff feel he is placing himself or others at risk with his driving, then another wheelchair assessment and cognitive assessment would need to be completed. Review of the Speech Language Pathology evaluation, dated 1/3/19, revealed the resident was referred for an assessment of his speech/language and cognitive/linguistic abilities following reports of reduced safety and judgement with the power chair. Staff reported the main concern was the speed at which the resident maneuvered the chair resulting in an increased number of collisions, skin tears, and risk for striking other residents. The Montreal Cognitive Assessment (a screening instrument for mild cognitive dysfunction) revealed a score of 21 out of 30 (normal is greater than or equal to 26). The language, abstraction, and delayed recall sections were significant for deficits. There were no speech recommendations related to the power wheelchair. Review of Incident/Accident Reports, from 12/22/18 through 2/21/19, revealed 12 incidents where the resident sustained [REDACTED]. Interventions included, but were not limited to, the use of skin cream to the resident's upper and lower extremities, to continue to remind the resident regarding safety hazards, and to go slow while in the power wheelchair. Review of an Incident/Accident Report, dated 1/8/19, revealed the resident was being transferred by an Apex lift and two staff when the resident had to be lowered to the floor due to the resident's inability to stand. There were no care plan changes made. On 1/13/19, the Incident/Accident Report revealed that the resident sustained [REDACTED]. On 1/15/19, the Incident /Accident Report revealed staff were utilizing the Apex lift when the resident became weak and was lowered to the floor. Interventions included to change the resident from one assist with Apex lift to two staff assist with Apex lift and no gait belt. There was no PT referral or Registered Nurse (RN) assessment done related to the resident's transfer needs. Observations included the following: a. On 2/19/19 at 9:03 a.m., the resident was in bed and had a dressing to the left mid-forearm that was bleeding. At that time, the resident stated he had received skin tears from catching his arms on the doors. b. On 2/22/19 at 9:25 a.m., the resident was dressed in a short sleeve shirt and shorts and was operating the power wheelchair in his room. The resident was backing the chair up between the end of the bed and a dresser when the front left wheel of the chair caught on the front left corner of the dresser. The resident proceeded to go forward and back several times, catching the dresser each time and dragging the dresser with the power chair. A Certified Nursing Assistant (CNA) in the room stopped the resident and assisted the resident in backing up the chair, tucking in his left arm. When interviewed at that time, the CNA stated she does not give the resident any safety or speed reminders for the safe operation of the power chair but assists him when observed. Interviews conducted on 2/25/19 included the following: a. At 9:01 a.m., the RN stated she had revised the resident's plan of care on 1/16/19 but had not personally assessed the resident's transfer abilities. She stated she had made the change based on what staff told her the resident needed. The RN stated an assessment of the resident should have been completed before changing his transfer status to ensure the use of appropriate devices. She stated the resident does not want to go slower in the motorized chair, bangs into things, and does what he wants. b. At 11:22 a.m., the Occupational Therapist (OT) stated she had been working with the resident on his overall strength and endurance. She said that an evaluation was done by PT for the safe use of the motorized chair in (MONTH) of (YEAR) and that they would need an order to re-evaluate. The OT said she had observed the resident in the motorized chair, he displayed good safety awareness when he operated the chair in the slowest speed, and she thought the speed on the chair could be reduced. c. At 1:45 p.m., after reviewing the resident's CCP for revisions related to the skin issues, the Director of Nursing stated the resident will not wear skin sleeves but offered no other suggestions. (10 NYCRR 415.12(h)(2))

Based on observations and interviews conducted during the Recertification Survey, it was determined that for three (Cherry Grove, Magnolia Crescent, and Apple Blossom) of six residential units, the facility did not ensure that the resident environment remained as free of accident hazards as possible. The issue involved hot water temperatures that exceeded 120 degrees Fahrenheit (°F) in faucets that were accessible to residents. The is evidenced by the following: 1. During observations and an interview conducted on 9/6/17 between 3:05 p.m. and 3:52 p.m., the water temperatures at sinks in the resident rooms revealed the following: in Room #3205 (Cherry Grove) it measured 123.4°F, in Room #2203 (Magnolia Crescent) it measured 125.0°F, and in Room #1203 (Apple Blossom) it measured 123.1°F. When interviewed at that time, the Director of Maintenance stated that another maintenance staff member had reported that twice last week the water temperatures were high on the Magnolia Crescent unit, but when he went back to recheck them they were fine. He said the water temperatures are always checked first thing in the morning. 2. When interviewed on 9/7/17 at 8:30 a.m., a Certified Nursing Assistant on the Cherry Grove unit stated that sometimes the residents think the water is hot but the staff do not. She said it takes a while to get the water temperature up there, but once it does, it is hot. 3. When interviewed on 9/8/17 at 3:48 p.m., Resident #8 stated that the water can get very hot. She said the girls adjust it for her by adding cold water. She said the water was not bad that day but it is often hot and she is careful. (10 NYCRR 415.29, 415.29(a)(1), 415.29(f)(6))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen is free of unnecessary medications. The issues involved lack of Gradual Dose Reduction (GDR) of [MEDICAL CONDITION] medications (Resident #30) and continued administration of bowel medications (Resident #27). This is evidenced by the following: 1. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 8/21/17, revealed that the resident has severe impairment of cognitive function, used antipsychotic, antianxiety, and antidepressant medication, had inattention which fluctuates, is tired or has little energy nearly every day, and had no hallucinations, delusions, physical or verbal behaviors, wandering, or rejection of care. The current physician's orders [REDACTED]. The current Comprehensive Care Plan (CCP) includes that the resident is on psychotherapeutic medications with the goal that the resident's mental status and behavior will remain well controlled with the support of medication throughout the stay or through the next review. Interventions included to discuss a reduction in dosing when target behaviors are absent and/or are easily altered for specified periods of time, but no less than quarterly. There is also a care plan for behavior which included a 2/22/16 addendum that there is noted improvement with the introduction of [MEDICATION NAME] in September 2015. The current Certified Nursing Assistant (CNA) Care Card does not include any behavioral care except to ask the resident if she wants the fan pointed at her to help reduce her anxiety at times. The Nurse Practioner (NP) Visit Note, dated 11/14/16, documented that the resident is sleeping well at night and her mood is stable. The NP received an email from the resident's family member that stated mostly at dinner time, the resident has periods of anxiety and yelling, and has had to be returned to her room. The family member feels the resident is definitely better on the medications and is reluctant to taper them. Review of Medical Provider Notes from 1/6/17, revealed the resident's behaviors are well controlled but the family member does not want the medications changed. Review of the Clinical Notes Report from 1/1/17 through 9/8/17 included the following behavior documentation: a. On 1/1/17, the resident spit out Milk of Magnesia. b. On 3/6/17, the Social Worker (SW) met with resident who was pleasant and engaged. The resident occasionally switched subjects, but was easily redirected. The resident said yes to feeling down and having no energy. c. On 3/9/17, the resident was a little edgy when offered medications. She took the medications with persuading. d. On 5/19/17, the resident refused [MEDICATION NAME] (pain) stating it does not work. e. On 5/24/17, the SW met with resident and she was pleasant, but refused to complete the mood interview. The resident was at her baseline which included occasionally calling out. Review of the 4/10/17 [MEDICAL CONDITION] Nursing Note for [MEDICATION NAME] documented that the effects on the resident's target symptoms were better. No other [MEDICAL CONDITION] Notes regarding [MEDICATION NAME] were found. Review of the 4/13/17, 5/10/17, and 6/8/17 Pharmacy Recommendations included to attempt a GDR on [MEDICATION NAME], and [MEDICATION NAME], respectively. The response from the physician each time was that the family member declines to attempt a GDR. Review of the Nursing 30/60 Day Form, signed by the physician on 7/28/17, revealed the resident had chronic depression, anxiety, and paranoia and that had been reviewed several times with the family member who is a Nurse Practitioner. The family member feels [MEDICATION NAME] that the resident's mood and sense of well being are improved on the current medications and requests that no medications changes be made. Symptoms documented include that the resident feels better after getting [MEDICATION NAME] and that staff often observe anxiety, tearfulness, and wanting to go home. The psychiatric information included that the affect and mood are neutral. There is no documentation of a psychiatric consultation since admission. When observed on 9/7/17 at 11:56 a.m., the resident was sitting at a table in her wheelchair quietly waiting for lunch. At 12:07 p.m., the resident's family assisted the resident to eat lunch. Twice during that time, the resident said she wanted her shoes on (she was wearing slippers) and once she said that she feels terrible. When her family asked her how she was, she responded she feels sick. No other behaviors were noted. When observed on 9/7/17 at 3:33 p.m., the resident was awake in bed and stated she would do some paperwork. On 9/8/17 at 3:29 p.m., the resident was observed in bed awake looking at the ceiling. On 9/11/17 at 8:56 a.m., the resident was observed in a wheelchair quietly waiting for breakfast. She dozed a bit, off and on. When interviewed on 9/7/17 at 3:33 p.m., the evening shift Licensed Practical Nurse (LPN) #1 stated that once in a while the resident will cry or yell, maybe every two weeks. She said the staff do one on one with her, bring her to her room, but never have to give her an as needed medication. LPN #1 said she cannot remember documenting behaviors for the resident because she has not had any severe behavior. Interviews conducted on 9/11/17 included the following: a. At 9:00 a.m., LPN #2/days said the resident's behaviors vary between yelling for her family and being very quiet. She said the resident asked to call the police once. She said the resident does not go on and on about things. LPN #2 stated she does not see any depression, hallucinations, or delusions with the resident. She said the resident gets [MEDICATION NAME] for anxiety and is doing well. She said the anxiety is well controlled. LPN #2 said the resident's mood, behavior, and personality have been pretty stable for at least a year. b. At 9:14 a.m., the Registered Nurse Manager (RNM) stated that the resident's behaviors fluctuate. She said the resident is not combative. She said sometimes the resident will yell out that she is sick, but is easily redirected. The RNM reviewed the electronic record and stated that she believes the [MEDICATION NAME] was changed in mid to late 2015. She said [MEDICATION NAME] was started in September 2015 and has not been changed, and the as needed [MEDICATION NAME] was discontinued in April 2015. She said there were no changes with the routine [MEDICATION NAME]. The RNM said that the family does not want any changes with the resident's medications. c. At 10:07 a.m., the Director of Nursing (DON) stated that she has only worked at the facility for one month and does not know the resident. She said that [MEDICAL CONDITION] medications are reviewed at each medical visit and after a year, a GDR should be attempted in two separate quarters. d. At 10:27 a.m., NP #1 stated that she has worked at the facility for five weeks and has not seen the resident. She said it is usually up to the physician to begin a GDR and have the NP follow up. She said it is documented that the family does not want a GDR and that is an acceptable reason not to attempt a GDR. e. At 11:35 a.m. by telephone, NP #2 said that she is only working on-call now, but was working full time and did not see any behaviors displayed by the resident. She said she understood from the family member that the resident yelled at the dinner table. NP #2 said that the regulations and pharmacist instruct to do a GDR twice in a year in two different quarters. She said the family member does not want this done. f. At 12:49 p.m. by telephone, the physician stated that in her last visit note she documented that there have been no behaviors in the previous 60 days, the resident was sleeping okay and her mood was neutral. The physician said she is aware of the regulations regarding GDR and is not able to do anything about that situation. She said that the family member is a NP and has repeatedly requested no GDRs be done. She said she will not argue with a family that really feels the resident benefits from these medications for quality of life. She said, My hands are tied. Review of the June 2002 facility policy, Antipsychotic Drugs, directed that antipsychotics should not be used if one or more of the following is the only indication: wandering, poor self-care, restlessness; impaired memory, anxiety, depression, [MEDICAL CONDITION], unsociability, indifference to surroundings, fidgeting, nervousness, uncooperativeness, or agitated behaviors that do not represent danger to the resident or others. 2. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/3/17, revealed that the resident had moderate impairment of cognitive function, required extensive assist of staff for toileting and was frequently incontinent of bowels. Current physician orders [REDACTED]. The CCP, dated as last reviewed on 8/12/17, includes that the resident has a [DIAGNOSES REDACTED]. Review of the BM Report from 8/26/17 through 9/8/17 revealed that the resident had 37 BM's in that time frame and 12 of them were listed as loose. Review of the August 2017 and September 2017 Medication Administration Record [REDACTED]. Review of Nursing Progress Notes for the same time frame revealed that the resident is up on the night shift daily requesting to use the commode from one to five times during the shift. In an interview on 9/6/17 at 11:23 a.m. and again on 9/8/17 at 11:48 a.m., the CNA stated that the resident goes to the bathroom a lot. She said that the resident has several BMs a day and has for a while. The CNA said that staff will notify the nurse if the BMs are very hard or very loose like watery, but hers are not. She said that the BMs are not formed but are soft. The CNA said that the resident's bottom is very dry and slightly red because she wipes a lot but has no open areas. Interviews conducted on 9/8/17 included the following: a. At 3:34 p.m., LPN #3 stated that she checks both the No BM Report and the full BM report but she did not notice how many BMs the resident had. b. At 3:37 p.m., evening LPN #4 stated she just reviews the No BM Report for the previous six shifts. c. At 3:21 p.m., and again on 9/11/17 at 11:41 a.m., the RNM stated that during each shift the nurses are expected to review the No BM Report in the computer to see who has not had a BM in the previous six shifts. She said the report only includes who has not had a BM. The RNM said that the LPNs would not know who is having too many BMs unless the CNAs tell them. She said that the CNAs can only view their shift in the computer system when they document a resident's BMs. The RNM said that the CNAs know to notify the nurse if residents do not have a BM or if it is loose. She said the facility would have to rethink their process. When interviewed on 9/11/17 at 10:49 a.m., the NP stated that she does not cover this resident as a patient but that it is a lot of BMs. She said she would expect to be notified in order to decide to hold or cut down on the medications. The February 2015 facility policy, Bowel Management, directed that nursing will monitor the bowel regimen daily and ensure the resident is having regular bowel patterns. (10 NYCRR 415.12(l)(1))

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 895), it was determined that for two of two residents reviewed for pressure ulcers, the facility did not provide the necessary services to prevent the development of, or promote healing of, a pressure sore. The issues involved the lack of a skin assessment upon admission to the facility (Resident #12) and the lack of a Registered Nurse skin assessent and physician notification (Resident #4). This is evidenced by the following: 1. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) Assessment, dated 5/22/17, revealed that the resident is cognitively intact and had one Stage II (partial thickness/superficial loss of skin) pressure ulcer and one unstageable deep tissue (deep tissue injury is suspected due to discoloration of skin but not open) pressure ulcer. Review of a hospital discharge summary revealed that on 5/8/17, the Physician's Assistant documented during a wound/skin evaluation that the resident's skin was completely intact at that time, but that there was evidence of healed pressure injuries of both buttocks. Recommendations included a pressure relieving mattress and a barrier ointment to the buttocks to protect the skin twice daily. The Nursing Admission Note, dated 5/9/17, signed by the Licensed Practical Nurse (LPN), includes that the resident was admitted to the facility at 2:40 p.m. It does not include any documentation that a skin assessment was completed. Review of the facility admission orders [REDACTED]. It does not include any other skin care instructions or assessments. A Problem Visit Note, dated 5/10/17 and signed by the NP, included that the resident was being seen for admission to long term care. The note included that the resident was sitting in her wheelchair during the examination and that she sleeps in a recliner chair. It does not include information related to skin assessments, issues or preventive care. Review of the Physician Admission History and Physical-Long Form, dated 5/12/17, revealed that the physician noted, during an exam, deep tissue injuries to the resident's inner buttocks that were very concerning. The physician requested a specialty mattress, a chair cushion, and a skin consultation. Additionally, the physician documented that it is going to be very challenging given the resident's persistence regarding sleeping in a chair. Review of the first Wound Care Flow Sheet in the electronic medical record and signed by the NP, revealed that on 5/17/17, a skin assessment was completed that revealed a deep tissue injury of the left buttocks and a Stage II pressure ulcer of the right buttocks, measuring 2.4 centimeters (cm) x 1.7 cm that had a start date of 5/12/17. Treatments were recommended at that time. Review of the first Weekly Skin Observation Note in the electronic health record, dated 5/20/17 and signed by the LPN, included that the resident had a left heel blister, a right buttock pressure ulcer and a groin rash. During an interview on 9/8/17 at 12:50 p.m., the RN/Nurse Manager stated that she could not find any admission skin assessment. She said that the LPN completes the form and does the initial skin review, then the RN verifies the skin assessment. The RN Manager said she could not find any documentation that this was done and it should have been. During an interview on 9/11/17 at 10:40 a.m., the NP stated that skin checks should be done by nursing on admission, and if they see any concerns they should contact the skin care team and myself. She said especially if the resident was in her wheelchair at the time of the examination and unwilling to be transferred. Review of the current facility policy, Skin Care Management, directed that nursing skin observation will be completed upon admission, re-admission and intra-facility transfers. Weekly skin (head to toe) observation to be completed and documented by the nurse in the electronic health record. 2. Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/9/17, includes that the resident is cognitively intact and had no skin issues. A Nursing Progress Note, dated 6/20/17 and signed by a LPN, documented a Certified Nursing Assistant (CNA) reported a linear shaped open area to the left inner thigh that measured 4 cm x 1 cm. The LPN documented that she applied a post-op dressing and notified the nursing supervisor. The Weekly Skin Observation Form, dated 6/24/17 and signed by the same LPN, documented that there were no abrasions, bruises or pressure ulcers. The LPN documented a skin tear on the left inner thigh. The Weekly Skin Observation Form, dated 7/1/17 and signed by a RN, documented that there were no pressure ulcers or skin tears. Review of a Nursing Progress Note, dated 7/7/17 and signed by the same LPN, documented an open area on the left inner thigh, that measured 3.7 cm x 1.2 cm with 0.4 cm depth. The NP Note, dated 7/7/17, documented that she was asked to assess the resident's thigh wound as noted on 6/20/17. The NP documented that the wound was located on the medial aspect of the upper left thigh directly where the resident's briefs rub. The NP documented that the resident chronically wore two sets of briefs at a time. The NP assessed the wound on the left thigh as an unstageable pressure ulcer, measuring 3.7 cm. x 1.7 cm with 50 percent slough (dead tissue) and ordered a treatment. Interviews conducted on 9/8/17 included the following: a. At 10:50 a.m., the LPN stated that on 6/20/17 a CNA reported that when she was dressing the resident she saw an open area. The LPN examined the open area on the left inner thigh. The LPN stated she notified the supervisor of the open area and applied a dressing to protect it. The LPN stated a skin check is completed on a resident's shower day. She stated the resident is examined from head to toe. The LPN stated if a skin issue is observed the supervisor is notified, assesses the area, and calls the medical provider for a treatment order. b. At 11:10 a.m., a RN Supervisor stated she worked on 6/20/17, and she recalled the LPN calling her regarding the resident having a skin issue. She stated she did not examine the area or recall any details of that date. The RN Supervisor said that she must have been busy not to respond, because that is her responsibility. c. At 11:30 a.m., the RN Manager said that during the facility investigation, she only spoke with the involved nurses. She said that she did not speak with any CNAs to determine if anyone was aware of the open area. She said that she felt that the open area was there since 6/20/17. (10 NYCRR 415.12(c)(2))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #12) of two residents reviewed for indwelling urinary catheters (tube inserted into the bladder to drain urine, also known as a Foley catheter), the facility did not provide appropriate treatment and services to prevent potential catheter related complications. The issue involved the resident's catheter was not changed as ordered and a urology consult was not scheduled as ordered in a timely manner. This is evidenced by the following: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/17/17, revealed that the resident is cognitively intact. In an observation and interview with the resident on 9/11/17 at 11:28 a.m., the resident had a leg drainage bag attached to her urinary catheter containing a small amount of dark yellow urine. The resident said that her catheter had not been changed in a long time. She said it has been changed once since her admission to the facility. The resident said she did not know why her catheter was not changed monthly like it was before she came to the facility. She said that it was supposed to be changed last week because it was leaking and it hurt. She said that she was still waiting for that to be done. The resident said she was concerned that she now had an infection because of the leaking and her blood pressure was low. She said that she does not usually get more symptoms due to the numbness from the [MEDICAL CONDITION]. The resident said that she used to go to the urologist's office to have the catheter changed. She said that she does not go anymore because the facility will not transport her as it cost too much and she cannot afford it until her Medicaid kicks in. Review of the facility's electronic medical record revealed the following: a. Admission medical orders, dated 5/9/17 and signed by the Nurse Practitioner (NP) and the Registered Nurse (RN), directed a Foley catheter for incontinence, to use a size 18 French 30 cubic centimeters (cc) balloon, to flush daily with 60 cc of sterile normal saline and that the resident has a urology appointment on 5/30/17 at 2:00 p.m. b. In a Problem Visit Note, dated 5/10/17, the NP documented that the resident requires an indwelling catheter and that the catheter is to be changed monthly at an outside urology office. The NP will review with staff to determine if the catheter can be changed at the facility. c. In a 5/12/17 Admission History and Physical Note, the physician documented that the resident goes out for monthly Foley changes. d. A Nursing Progress Note, dated 5/14/17, included that the catheter was changed because it fell out and was replaced with a 16 French 10 cc balloon. On 6/24/17, a Nursing Note included that it was changed due to leaking. e. A new physician order, dated 9/1/17, included to change the Foley every four weeks and to use an 18 French 30 cc balloon. f. The July, August, and September 2017 Treatment Administration Records and Nursing Progress Notes, from 6/13/17 through 9/8/17, do not include any documentation that the Foley had been changed since 6/12/17. g. There is no documented evidence in the medical record that the urology consult occurred. Interviews conducted on 9/8/17 included the following: a. At 12:50 p.m., and again at 2:30 p.m., the RN Manager (RNM) said that she thought the catheter was changed on 9/1/17 because the Licensed Practical Nurse (LPN)/Clinical Coordinator (CC) was called to help and a verbal order was written. The RNM said that she could not find documentation that it was done or why. The RNM said that she called the urology office and was told that the resident's 5/30/17 appointment was cancelled. She said it was supposed to be rescheduled but it never was. She said that she did not know why it was cancelled or by whom, but that it should have been rescheduled. b. At 1:08 p.m., the LPN/CC stated that he received a verbal order on 9/1/17 from the NP to change the catheter but he could not remember why. He said that he saw that the catheter was being changed monthly prior to admission but added that the facility does not always change them monthly. c. At 1:29 p.m. and again on 9/11/17 at 10:40 a.m., the NP stated that while she was not the caregiver at the time, it is her expectation that the catheter would have been changed every four weeks per her previous routine, especially due to her history of infections. She said that she would have expected that the urology appointment was scheduled. She said if the appointment was cancelled for any reason the medical team should have been notified. The NP said if the physician orders [REDACTED]. When interviewed on 9/11/17 at 1:29 p.m., the RNM said that the resident's catheter was supposed to be changed last week after the 9/1/17 order was written but she could not find any documentation that it was done. She said that the resident's catheter was still leaking so staff would change it that day. She said medical wanted the urology appointment rescheduled and she did it that day. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #49) of four residents reviewed for nutrition, the facility staff did not ensure that the resident maintained acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrated that this was not possible. The issue involved a lack of consistent monitoring for a resident experiencing significant weight loss. The is evidenced by the following: Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment, dated 7/26/17, revealed that the resident's cognition is severely impaired, and requires supervision and set-up assistance only for eating. Review of Nutrition Progress Note, dated 5/5/17, revealed that the Registered Dietician (RD) reviewed re-weighs obtained by facility staff that appeared to support significant weight loss quantified as 13 percent weight loss in six months and 4 percent weight loss in one month. On 5/8/17, the RD documented that three re-weighs confirmed significant weight loss. In addition to Mighty Shakes (fortified milkshake containing increased calories and protein) that had already been added to meals, she suggested adding a high calorie supplement, three times daily, with medication pass to prevent further weight loss. A Medical Provider Problem Visit Note, dated 5/8/17, revealed that the resident's appetite remained fair to good, was eating 50 to 75 percent of meals, and had variability in her weights. Weight loss is also listed on the Master Problem List, dated 5/9/17. There is no mention of adding a supplement to enhance the resident's nutritional intake. Review of weight records revealed that the resident's weight was 169 pounds (lbs.) on 5/1/17, 170 lbs. on 6/1/17, 164 lbs. on 7/2/17, and 156 lbs. on 8/1/17. This reflects a loss of 13 lbs. after the initial recommendation to add the high calorie supplement. The Nutrition Progress Note, dated 7/31/17, revealed that the resident had a significant weight loss in the six month look-back period between January and July. The RD suggested adding a high calorie supplement, three times daily with medication pass, in addition to already receiving Mighty Shakes, and referenced Nutrition Notes from 5/5/17 and after for recommendations and re-weigh information. Review of Progress Notes and Nutrition Assessments revealed that there was no documentation from the RD between 5/8/17 and 7/31/17. Review of the current medical orders revealed that the high calorie supplement was ordered on [DATE] and the resident started receiving the supplement on 8/2/17. Interviews conducted on 9/11/17 included the following: a. At 10:00 a.m., the RD stated that in her Clinical Note, dated 5/8/17, she did suggest adding a high calorie supplement. She said the process for informing staff of nutritional supplement recommendations was to send an email to the Nurse Manager, Clinical Coordinator, and medical provider. She said if the team agreed with the recommendation, the medical provider would give the order to the Nurse Manager and Clinical Coordinator to be entered into the electronic record. She said that the RD can add Mighty Shakes without a medical order because it is considered a meal intervention. She said that is tried first instead of adding a medication pass supplement right away. b. At 10:55 a.m., the RD stated that she had reviewed email communications following her recommendation on 5/8/17 and there was no documentation regarding a decision whether to add the high calorie supplement. She stated that following a recommendation she typically makes a note to herself to follow-up in about a week. The RD thought that it was a period when the resident's weight had stabilized and the Mighty Shakes appeared to be working. She stated that if the resident continued to lose weight at the rate she had been losing that would have been an extra reminder to follow-up. The RD said she did not follow-up in that case. c. At 11:34 a.m., the Nurse Practitioner (NP) stated that when the RD makes a recommendation for a supplement, it is sent via email to the Nurse Manager, Clinical Coordinator, and the NP. She said that she would order the supplement if she were in-house, otherwise, nursing enters a verbal order. The NP said once the supplement was ordered she would expect that the supplement is obtained. She said if the supplement was unavailable, nursing would notify the NP, and the resident would be monitored with weekly weights. She stated that she would expect the resident's weight to plateau after starting a supplement. She said if there was no improvement in four weeks another intervention would be tried. She said if there was a sustained weight loss and no intervention was working, then she would talk to the family about hospice. Review of the facility policy for nutritional supplements, dated 1/10/12, directed that the Medical Pass Supplement be ordered for four weeks the first time. The Dietician/Technician will then do a follow-up documentation in the Integrated Note section of the chart, and determine the need to continue the supplement. (10 NYCRR 415.12(i)(1))