Every finding on record at St Camillus Residential Health Care Facility

Based on observations, record review, and interviews during the recertification survey (complaint #2643650) the facility failed to treat each resident with respect and dignity and in a manner and environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality. Specifically, during a confidential group meeting thirteen (13) of thirteen (13) residents stated they experienced long call bell response times and multiple observations were made of long call bell response times.Findings include:The facility policy Resident Rights, last reviewed 5/14/2024, documented residents had a right to a dignified existence, self-determination, communication with and access to persons and services both inside and outside of the facility. The facility policy Meeting Resident Needs, revised 12/20/2023, documented the nursing staff response to resident needs (including call bells) was expected to occur regardless of credential, title or resident assignment; response to resident needs should take priority over other routine tasks; licensed nursing staff would monitor unit response to call lights and direct staff as needed to ensure that resident needs were met; and when a resident activated their call bell, or verbally requested assistance, response should be within 10-15 minutes. The following call bell wait times were observed on the call bell monitor located at the nurses' station: -On 01/05/2026 at 9:39 AM, Resident #105's call bell light was on for 70 minutes; -On 01/05/2026 at 9:39 AM, Resident #123's call bell light was on for 39 minutes; -On 01/06/2026 at 3:21 PM, Resident #123's call bell light was on for 36 minutes; and -On 01/08/2026 at 8:28 AM, Resident #18's call bell light was on for on 40 minutes. The following observations and interviews regarding Resident #102's call bell were made on 01/07/2026: -at 10:10 AM, the call bell monitor located at the nurses' station documented the call bell was on for 70 minutes. Certified Nurse Aide #7 entered the room briefly, turned off the call bell and exited the room. Certified Nurse Aide #7 stated they answered Resident #102's call bell and the resident wanted their table moved and to get up. They were going to report it to the aide that was assigned to the resident. -at 10:12 AM, Resident #102 was lying in bed. They stated they thought their light had been on for about an hour and needed to go to the bathroom. The aide who just answered the bell said they would get their aide to come help them. -at 10:20 AM, the call bell light was back on. -at 10:29 AM, Medical Secretary #9 entered Resident #102's room, turned off the call bell light, and exited the room. Resident #102 was in bed and stated the aide that was just in said they had to go get their aide, which meant they were going to have to put their light back on. -At 10:32 AM, the call bell light was back on. -At 10:42 AM, the call bell light was off, and staff were in the room assisting the resident to the bathroom. During a follow up interview on 01/07/2026 at 2:20 PM, Certified Nurse Aide #7 stated all aides were responsible for call bells and they should be answered within 10-15 minutes. If they answered a call bell for someone not on their assignment and they needed something easy they would meet that need. If that resident was requesting care or their shower, they would not have time to provide that due to having their own assignment, but they would let the resident's assigned aide know. If someone requested to be toileted, they helped with that as they would not want a resident to be incontinent. They were unaware how long Resident #102's call light was on. They did not have time to help the resident get up as they had to give a shower to another resident. During an interview on 01/08/2026 at 8:57 AM, Medical Secretary #9 stated when answering a call light, they turned the call bell light off if they could not fulfill the resident's need, and the find the person who could. Answering call bells was everyone's responsibility and the goal was to answer them within 5-10 minutes. During an interview on 01/08/2026 at 9:34 AM, Licensed Practical Nurse Manager #10 stated call bells should not go unanswered for more than 10 minutes and anything over 30 minutes was excessive. Anyone could answer a call bell and if the need could not be met it should be reported to whomever could meet that need. During an interview on 01/09/2026 at 10:56 AM, Registered Nurse Clinical Coordinator #8 stated they expected call bells to be answered within 15 minutes. Everyone could answer call bells and if a resident was requesting to use the bathroom they should be taken, even if that resident was not assigned to the person answering the bell. They checked the call bell monitor and noticed long wait times in the past. They stated a 40 and 70 minute call bell wait time was excessive. No one should wait that long. 10NYCRR 415.3 (c)(1)(i)

Based on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for four (4) of seven (7) medication carts (Unit 2 East and West, Unit C, and Unit D) and one (1) of three (3) medication rooms (Unit 2) reviewed. Specifically, the Unit 2 [NAME] cart had insulin pens that were not labeled with the open or expiration dates, and expired medications; the Unit 2 East cart had insulin pens that were not labeled with open or expiration dates; the Unit C cart had insulin pens, nasal sprays, and inhalers not labeled with open or expiration dates and expired medications were left in the cart; the Unit D cart had insulin pens and inhalers that were not labeled with open or expiration dates; and the Unit 2 medication room had supplies directly on the floor under the sink.Findings included:The facility policy Medication Administration, revised 06/20/2019, documented all multidose vials/containers were labeled with the facility provided medication sticker and included the expiration date, which was 28 days from the open date. Licensed nurses checked the expiration dates prior to administration of any multidose vial containers to ensure the medication was not expired; if expired the medication was discarded immediately. The facility policy Insulin Administration, revised 01/02/2020, documented the licensed nurse checked the expiration date of insulin pens prior to administration. During an observation and interview with Licensed Practical Nurse #24 on 01/07/2026 at 1:29 PM, the top drawer of the Unit 2 [NAME] medication cart had two lispro insulin pens and one Lantus insulin pen without an open date or expiration date on the label. Licensed Practical Nurse #24 stated insulin pens were labeled when opened and expired in 28 days. They were not sure why they were not labeled as they were given on the evening shift. Whoever opened the insulin pen was responsible for labeling the pen. If they saw insulin or any medication that was expired or not labeled, they discarded it and notified the unit manager. There was a vitamin C container that expired in 12/2024. Licensed Practical Nurse #24 stated no one was on vitamin C and was not sure why it was still in the cart. Every nurse was responsible for making sure medications were discarded when expired. During a follow-up observation and interview with Licensed Practical Nurse #24 on 01/07/2026 at 2:08 PM, in the Unit 2 medication room there was a box and bag stored on the floor under the sink. Licensed Practical Nurse #24 stated they had agency nurses that did not know things could not be kept on the floor. During an observation and interview with Licensed Practical Nurse #36 on 01/08/2026 at 9:35 AM, the top drawer of the Unit 2 East cart had Lantus insulin pen that was not labeled with the open or expiration date. Licensed Practical Nurse #36 stated all insulins were labeled with open date as they were not as effective after 28 days. They were not sure why it was not labeled. The second drawer had a budesonide inhaler that was opened on 11/18/2025. Licensed Practical Nurse #36 stated they were not sure if inhalers needed to be labeled when opened or when they expired. They administered the inhaler to the resident that day as they did not think that inhalers expired and were used until they were gone. During an observation and interview with Licensed Practical Nurse #52 on 01/08/2026 at 10:23 AM, the first drawer of the Unit D cart had eye drops that expired 01/2022, a Lantus insulin pen and a lispro insulin pen were not labeled with the open or expiration date. Licensed Practical Nurse #52 stated the eye drops should not have been in the cart and was unsure why they were. They must have been overlooked the last time they looked through the cart. Insulin pens should be labeled with an open date and the expiration date; they were only good for 30 days after they were opened and then were thrown out. They stated they must have been too busy when they opened the insulin pens and forgot. They were sure they would have noticed when they gave the insulin to the resident. The third drawer of the cart had a Trelegy Ellipta inhaler that was not labeled with the open or expiration date. Licensed Practical Nurse #52 confirmed the packaging of the inhaler stated to discard six weeks after open date. They did not write the open date on the inhaler because there were only 30 doses, and it would be discarded all the doses were gone. During an observation and interview with Licensed Practical Nurse #30 on 01/08/2026 at 2:53 PM, the first drawer of the Unit C cart had two lispro insulin pens that were labeled with the open date or expiration date. Licensed Practical Nurse #30 stated insulin pens were only good for 28 days after they were opened. They should have been dated, but they were like that when they started their shift. The first drawer also had four nasal sprays that were not labeled with an open date or expiration date. Licensed Practical Nurse #30 stated nasal sprays were only good for 28 days. However, they never dated them and always went by the date the medication was ordered as the opened date. Additionally, in the first drawer of the cart there were atropine 1% eye drops that were opened on 09/12/2025 and expired 10/01/2025. Licensed Practical Nurse #30 stated that the resident no longer took eye drops and they should have been discarded as they were old. In the second drawer of the cart there were two Trelegy Ellipta inhalers and one Incruse Ellipta inhaler that were not labeled with an open date or expiration date. Licensed Practical Nurse #30 stated they never labeled when the medication was opened, they went by how many doses were left in the inhaler and discarded when it was empty. During an interview on 01/09/2026 at 12:09 PM, Assistant Director of Nursing #37 stated insulin should be labeled because it expired 28 days after it was opened. It should not be administered if it was expired or not labeled with the open date. Licensed practical nurses checked their carts before their shift and after, so it was ready for the next shift. The carts were checked daily. If there was an outdated medication it needed to be discarded. 10NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification survey (complaint #652393) the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen. Specifically, in the main kitchen food in the cooler was not labelled, expired food was not discarded, the dish machine was not functioning properly while in use, and food service equipment was unclean. Findings include:The facility policy Food Safety and Procurement, last reviewed 03/2025, documented food would be discarded based on food labels or upon evidence of spoilage. Food which was not properly labeled and dated was discarded. Food service staff would monitor the refrigerators daily and discard outdated food. Strategies to control food borne illness included equipment and utensil cleaning and sanitizing, including the dish machine.The facility procedure Daily Cleaning Assignments, last reviewed 02/2020, documented the refrigerators and ovens would be cleaned daily.The facility procedure Weekly Cleaning Assignments, last reviewed 02/2020, documented the ovens would be deep cleaned weekly.The facility policy Cleaning Schedules, last reviewed 02/2020, documented any food spills in the oven would be cleaned up immediately and ovens would be cleaned daily or biweekly as needed. Refrigerator food spills would be cleaned up daily.The following observations were made in the main kitchen:- on 01/05/2026 at 9:32 AM a bag of meat, cheese slices, a white bag of food, and a meat salad were not labelled in the upstairs walk-in cooler, preparation refrigerator, and salad refrigerator. The upstairs walk-in cooler contained expired food including two large containers of sour cream with an expiration date of 11/30/2025, and two cases of milk with an expiration date of 01/02/2026.The sandwich cooler, preparation cooler, and salad cooler had accumulated debris and residue.-on 01/07/2026 At 9:30 AM, the ovens had dried on, burnt food spillage on the bottom. At 9:45 AM, staff were washing breakfast dishes while the dish machine was not functioning properly. The dish machine temperature was checked or recorded for the day, and the temperature dial did not move above 120 degrees Fahrenheit during the wash and sanitation cycles.During an interview on 01/07/2026 at 9:45 AM, Executive Chef #12 stated the dish machine temperature was taken daily at 11:00 AM. They stated dishes should not be used if the dish machine was not cleaning or sanitizing at the required temperature.During an interview on 01/07/2026 at 9:50 AM, Food Service Director #13 stated dishes should not be used if the dish machine was not cleaning or sanitizing at the required temperature because they are not sanitized to kill germs.During an interview on 1/8/2025 at 11:56 AM, Food Service Team Lead #11 stated they usually recorded the dish machine temperature daily after the machine warmed up, around 9:45 AM. They were running late that morning and forgot. During an interview on 01/08/2026 at 12:08 PM, Food Service Director #13 stated Team Lead #11 recorded the temperatures in the morning after warming the dish machine up and the missing temperature check yesterday was an oversight. Food in the coolers were rotated based on the first in first out method and all staff were trained in this method. The refrigerators and ovens were cleaned based on the cleaning schedule. All food should be labelled and dated once they were removed from the original case. During an interview on 01/08/2026 at 2:38 PM, Licensed Practical Nurse #15 stated they found outdated and spoiled milk in the unit refrigerator in the past but discarded it without serving it. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification survey, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of ten (10) staff (Certified Nurse Aide #35 and Environmental Services Worker #48) reviewed for influenza vaccinations; and five (5) of eight (8) residents (Residents #66, #87, #195, #244, and #268) reviewed for transmission based precautions. Specifically, Certified Nurse Aide #35 and Environmental Services Worker #48 declined the influenza vaccine and were observed wearing their masks below their nose while in resident areas; and Resident's #66, #87, #195, #244, and #268 were on droplet precautions for diagnoses of influenza and/or COVID-19 and staff were observed not wearing appropriate personal protective equipment when entering their rooms.Findings include:InfluenzaThe facility policy Staff influenza Vaccination, policy, revised 12/16/2022, documented influenza immunization would be offered to all staff when it becomes available each season annually, unless the immunization is medically contraindicated, or the individual has already been immunized during this time. Staff who declined to receive the vaccination with no medical contraindication must execute a signed declination of influenza vaccination and be compliant with wearing a mask during flu season.Influenza records were requested for 10 random staff and received on 01/08/2026.Environmental Services Worker #48 signed the facility's declination for the influenza vaccine on 12/12/2025.Certified Nurse Aide #35 signed the facility's declination for the influenza vaccine on 12/15/2025.During an observation on 01/05/2026 at 12:28 PM, Certified Nurse Aide #35 was walking in the hallway on the 2nd floor with their mask below her nose.During an observation on 01/06/2026 at 2:06 PM, Environmental Services Worker #48 was observed walking through the C-Unit with their mask below their nose.During an observation on 01/07/2026 at 10:37 AM, Certified Nurse Aide #35 was observed at the nurse's station with their mask below their nose talking to a resident. During an interview on 01/08/2026 at 11:14 AM, Certified Nurse Aide #35 stated they declined their influenza vaccine and was supposed to wear a mask while working. They stated the mask frequently slipped down and they were supposed to wear the mask to help prevent the spread of germs.During an observation on 01/09/2026 at 09:03 AM, Certified Nurse Aide #35 was observed walking through the 2nd floor dining room with their mask below their nose, there were 11 residents seated in the dining room. When Certified Nurse Aide #35 saw the surveyor, they pulled their mask above their nose.During an interview with Registered Nurse/ Infection Preventionist #37 on 01/09/2026 at 12:09 PM, they stated they observed Certified Nurse Aide #35 not wearing their mask appropriately and needed to tell them to put it on correctly all the time. If staff declined the influenza vaccine, they should wear a mask while working to prevent the spread of infection.Droplet Precautions/Personal Protective Equipment The facility Droplet Precaution signage documented everyone must: Clean hands when entering and leaving room. Medical and staff must use gown, glove, and eye cover if contact with secretions is likely.1.Resident #66 tested positive for influenza A and COVID -19 on 01/05/2026. During an observation on 01/06/2026 at 12:39 PM, the resident had a droplet precautions sign outside of their room and Licensed Practical Nurse #50 was observed entering their room and without eye protection.2. Resident #87 tested positive for COVID -19 on 01/01/2026. During observations on 01/05/2026 at 10:11 AM and 12:38 PM, the resident's had a droplet precautions sign outside of their room. The isolation caddy outside of the room included gowns, masks, but did not contain any eye protection.3. Resident #195 tested positive for influenza A and COVID -19 on 12/31/2025. During an observation on 01/06/2026 at 8:38 AM, the resident had a droplet precaution sign outside of their room and Licensed Practical Nurse/ Assistant Unit Manager #49 was standing at the resident's bedside talking to them. They were not wearing a gown or gloves and just had their prescription glasses on. During an interview Licensed Practical Nurse/ Assistant Unit Manager #49 stated they should have worn a gown, gloves, and a face shield in case they were exposed to any secretions. They stated this was an oversight and they knew better. 4. Resident #244 tested positive for influenza A on 01/02/2026. During an observation on 01/06/2026 at 1:32 PM, the resident had a droplet precautions sign outside of their room and Certified Nurse Aide #51 entered the resident's room and did not wear eye protection.5. Resident #268 tested positive for influenza A on 01/03/2026. During an observation on 01/06/2026 at 12:36 PM the resident had a droplet precautions sign outside of their room and Licensed Practical Nurse #50 was observed entering the resident's room and did not wear eye protection. During an observation on 01/06/2026 at 1:24 PM, Certified Nurse Aide #51 was observed entering the resident's room and did not wear eye protection.During an interview on 01/06/2026 12:50 PM Licensed Practical Nurse #50 stated they entered Resident #66's and Resident #268's rooms and did not wear eye protection. Both residents were on droplet precautions. They stated they should wear eye protection when going in the rooms as they could be exposed to secretions.During an interview on 01/06/2026 at 1:37 PM Certified Nurse Aide #51stated Residents #244 and #268 were on droplet precautions and they did not wear eye protection when entering their room. They stated they did not think they would be exposed to possible secretions, so they did not have to wear eye protection. During an interview on 01/09/2026 at 1:31 PM Registered Nurse/ Infection Preventionist #37 stated any residents who tested positive and/or were suspected of having influenza or COVID -19 were placed on droplet precautions and staff were expected to wear a gown, gloves, and eye protection when providing care and during any close contact due to the risk of secretions from droplets. It was the responsibility of all nursing staff to ensure the proper personal protective equipment was available and the facility had plenty of personal protective equipment.10NYCRR 415.19(a)(b)

Based on observations, record review, and interviews during the recertification and abbreviated survey (2643650) the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for one (1) of four (3) residents (Resident #17) reviewed. Specifically, Resident #17 had brown debris underneath long, untrimmed fingernails; had foul breath; was unshaven; and did not receive their shower as plannedFindings include: The facility policy Activities of Daily Living (ADLs) Supporting, effective 12/22/2023, documented residents were provided with the necessary services to maintain good grooming, nutrition, personal, and oral hygiene when the resident was unable to carry out activities of daily living. Hygiene included bathing, dressing, grooming, oral care, mobility, toileting, communication, eating, and drinking. The facility policy Shaving, effective 12/29/2023, documented nursing facility would ensure a resident who was unable to carry out required grooming received the necessary services to maintain good grooming, including the management of facial hair for both men and women. The facility policy Oral Care, effective 12/29/2023 documented nursing facility would ensure that a resident who was unable to carry out required oral care received the necessary services to maintain good oral hygiene. The facility policy Grooming Fingernails, revised 12/21/2023, documented residents who required assistance with fingernail grooming would be provided with the necessary staff assistance to maintain fingernails in a clean and neat appearance consistent with resident preferences. Resident #17 had diagnoses including kidney disease and and diabetes. The 12/18/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, did not reject care, required partial/moderate assistance for oral care, and was dependent for most activities of daily living. The Comprehensive Care Plan initiated 9/22/2025, documented the resident had a deficit in activities of daily living related to muscle weakness and immobility. Interventions included supervision for oral care and partial/moderate assistance of one for bathing and dressing. The undated Resident Profile (care instructions) documented the resident transferred with a mechanical lift; was dependent on two for toileting, dependent for personal hygiene, and required supervision with oral hygiene, and bathing/showers. Their shower day was on Tuesday during the 7:00 AM-3:00 PM shift. The certified nurse aide shower task documented not applicable on 12/23/2025 and 12/30/2025. Resident #17 was observed with jagged fingernails and brown debris behind and around their fingernails, bad breath, and was unshaven on 01/05/2026 at 10:29 AM; 01/06/2026 at 2:10 PM; and 01/07/2026 at 9:49 AM During an interview on 01/07/2025 at 9:49 AM Resident #17 stated they were not sure what day their shower was. They never refused their shower and did not remember the last time they had a shower. They wanted their hair washed and combed, their nails cleaned and cut, their teeth brushed, and to be shaved. They especially wanted a shave as they were always clean shaven. During an interview on 1/07/2026 at 10:05 AM, Certified Nurse Aide #23 stated they were responsible for providing hygiene care for residents on shower days and as needed. Showers were provided weekly with hygiene care. On shower days care included washing the resident, washing hair, brushing teeth, and clipping nails. On other days, the residents were provided a bed bath which included washing the body and the groin area, combing hair, brushing teeth, and providing nail care. Nails should be cut and cleaned even if it was not their shower day. Oral care should be completed twice a day to prevent heath issues and residents shaved for dignity reasons. Resident #17 was scheduled for their shower on 01/06/2026. The resident did not receive a shower that day because they required a mechanical lift to get into the shower and staffing was limited, so they gave the resident a bath in bed. They did not notice the resident's nails that morning and should have. They did not shampoo the resident's hair because the resident did not get a shower. They did not provide oral care, nail care, or shave the resident because they were busy. During an interview on 01/09/2025 at 12:09 PM, Assistant Director of Nursing stated they expected the scheduled shift to complete the resident's weekly shower. Showers were completed by the certified nurse aides, however, licensed practical nurses could assist. If a resident refused a shower, the assigned certified nurse aide should notify the charge nurse or team lead. The charge nurse or team lead should approach the resident and if the resident still refused document a progress note and pass on to the next shift. The next shift or next day the shower was offered again. At times care was not completed, including showers, because of short staffing. 10 NYCRR 415.12(a)(3)

Based on observations, record review, and interviews during the recertification survey the facility failed to ensure the development and implementation of a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for two (2) of three (3) residents (Residents #195 and #6) reviewed. Specifically, Resident #195's person-centered comprehensive care plan did not include the use of an anticoagulant (blood thinner) and Resident #6's person-centered comprehensive care plan did not include the use of insulin (used to treat high blood sugars) or an anticoagulant.Findings include:The facility policy Comprehensive Care Plans, revised 10/17/2022, documented the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that would include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in a comprehensive assessment. The comprehensive care plan would be reviewed and revised based on changing goals, preferences, and needs of the resident and in response to current interventions by the interdisciplinary team after each assessment, inclusive of the comprehensive and quarterly review assessments. 1) Resident #195 had diagnoses including history of blood clots, embolism (a blood clot that blocks a blood vessel), and long-term use of anticoagulants. The 12/29/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment and was on an anticoagulant. The 12/22/2025 physician order documented Eliquis (blood thinner) 5 milligram tablet by mouth two times a day for history of a deep vein thrombosis (blood clots). There was no documented evidence of a person-centered comprehensive care plan that included the use of an anticoagulant or monitoring for symptoms of anticoagulant use. During an interview on 01/09/2026 at 9:28 AM, Licensed Practical Nurse #26 stated they were unsure if an anticoagulant medication should be on the care plan, and they would have to ask the nurse manager. They thought it would be helpful if Resident #195's anticoagulant medication was included in their care plan because they had hematuria (blood in the urine) and sustained a fall so staff should have been aware they were on a blood thinner. During an interview on 01/09/2026 at 9:42 AM, Registered Nurse Manager #4 stated they were unaware Resident #195's anticoagulant medication was not included in their care plan, and it must have been an oversight. Resident #195 was on Eliquis twice a day, had a history of falls, and had recent hematuria. It was important for anticoagulant therapy to be included on the care plan so staff were aware and could monitor for bleeding. 2) Resident #6 had diagnoses including diabetes and atrial fibrillation (irregular heart rhythm). The 12/18/2025 Minimum Data Set assessment documented the resident was cognitively intact and received insulin and an anticoagulant daily. Physician orders documented: -on 12/11/2025, heparin sodium (blood thinner) 5000 units subcutaneously (under the skin) two times a day for deep vein thrombosis prophylaxis (preventative treatment for blood clots). -on 12/11/2025, insulin aspart (short acting insulin) inject subcutaneously per sliding scale before meals for diabetes. Notify registered nurse or provider if (blood sugar) was greater than 400 or less than 70 (milligrams/deciliter). -on 12/12/2025, Lantus (long-acting insulin) 30 units subcutaneously at bedtime for diabetes. There was no documented evidence of a person-centered comprehensive care plan that included the use of insulin and monitoring for hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar), or the use of an anticoagulant and monitoring for potential side effects. During an interview on 01/08/2026 at 3:19 PM, Certified Nurse Aide #25 stated they looked at resident's care plans often because it told them everything about the resident and how to safely care for them. They were unsure if medications like an anticoagulant or insulin were included in the care plan, but they thought if Resident #6 was diabetic and on insulin the care plan should include things to monitor for like low or high blood sugar, dizziness, or sweating. They were unsure what to monitor for when a resident was on an anticoagulant medication. During an interview on 01/09/2026 at 9:28 AM, Licensed Practical Nurse #26 stated registered nurses were responsible for initiating and updating care plans. If a resident was a diabetic, it should be in their care plan so staff would know to monitor for signs of hyperglycemia or hypoglycemia. Resident #6's care plan should have included their diabetes diagnosis, they required a fingerstick before meals and at bedtime, and they received insulin. They were unsure if an anticoagulant medication should have been included in Resident #6's care plan but they thought it was important so staff would know to monitor for bleeding or bruising. During an interview on 01/09/2026 at 9:42 AM, Registered Nurse Manager #4 stated the registered nurses were responsible for initiating and updating care plans because licensed practical nurses were not allowed to touch them per the facility policy. All staff were expected to look at resident care plans because the care plan told them everything about the resident and how to care for them. They were not aware Resident #6's care plan did not include insulin or anticoagulant medication use, but it should have so staff knew to monitor for bleeding, and signs of hypoglycemia or hyperglycemia. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure that residents who required dialysis (used to filter waste products from the blood when the kidneys do not work properly) received such services consistent with professional standards of practice for one (1) of one (1) resident (Resident #134) reviewed. Specifically, Resident #134 received hemodialysis treatments at a community-based dialysis center and did not have on-going assessments and oversight before and after dialysis treatments including assessment of the dialysis access site, and consistent ongoing communication and collaboration between the facility and the dialysis center. Additionally, the resident was not always provided a lunch meal on their dialysis days.Findings include:The facility policy Coordination of Dialysis Treatment, revised 1/19/2018, the Dialysis Care Coordination Form accompanied the residents to their treatment. The goal was to facilitate communication between the facility and the dialysis center for the purpose of incorporating pertinent resident information into the resident's plan of care. The nurse manager, charge nurse, or designee was responsible for completing the Dialysis Care Coordination Form and ensuring the form accompanied the resident to the dialysis center for each dialysis treatment. Upon return from dialysis, the licensed practical nurse immediately monitored the status of the resident's access site to observe for bleeding or other complications and followed up as indicated and documented the status of the access site in the resident's health record. The licensed practical nurse also reviewed the Dialysis Care Coordination Form and if it had no feedback from the dialysis center, they called the dialysis center for a verbal update. The unit secretary filed the completed dialysis form in the Correspondence Section of the medical record after review by clinical staff. Resident #134 had diagnoses including end-stage renal (kidney) disease. The 10/31/2025 Minimum Data Set assessment (a health status assessment tool) documented the resident was cognitively intact, did not reject care, and required hemodialysis treatments.The Comprehensive Care Plan initiated 08/18/2025 documented the resident needed hemodialysis related to renal failure. Interventions included dialysis three times a week on Monday, Wednesday, and Friday and not to draw blood or take blood pressure in arm with graft. There was no documented evidence of the location of the dialysis access site, a plan for monitoring of the dialysis access site access site, or completion if pre and post dialysis assessments.The 12/05/2025 updated physician order documented the dialysis three times a week, send communication book and completed form to dialysis. Upon return from dialysis check communication book for any correspondence from dialysis and if nothing documented, contact the dialysis center and document on the form. The communication book must be signed by a registered nurse and placed in the documents area of the chart. The nurse must monitor the residents access site upon return from dialysis for bleeding, edema, or any other complication. There was no documented evidence the dialysis site was monitored or that pre or post dialysis assessments were completed. There were no communication summaries for the month of November 2025.The dialysis communication book dated December 2025-January 2026 documented:-Outpatient dialysis daily treatment summaries were completed by the dialysis facility and included pre and post dialysis weights, blood pressures, any medications administered, or labs obtained for all dialysis days (12/01/2025 no dialysis as resident had a bowel movement), 12/12/2025, 12/15/2025, 12/29/2025, and 01/07/2026). There was no documented evidence the information was reviewed by the facility upon the resident's return. There was no communication to the dialysis center from the facility on 12/01/2025, 12/15/2025, or 12/29/2025. There was no documentation from the facility after the resident returned from dialysis the resident or their access site was assessed on 12/12/2025, 12/15/2025, 12/29/2025, or 01/07/2026. There were multiple entries in the communication book that were not completed, signed, or dated. During an observation on 01/05/2026 at 10:02 AM, Resident #134 was sitting by the elevator with a transportation aide wheeling them onto the elevator to dialysis. Resident #134 asked staff for their lunch. The resident stated they were never sent to dialysis with their lunch, and they got hungry at dialysis. Certified Nurse Aide # 35 looked in the refrigerator and was not able to locate the lunch then went to the resident's room and brought the lunch from the room to the resident. The resident asked for their communication book that was supposed to be hooked to the back of the wheelchair. Certified Nurse Aide #35 went to the room and got the communication book that was in a black bag and hung it on the back of the wheelchair. During an observation and interview on 01/06/2026 at 12:00 PM, Resident #134 stated they went to dialysis on Monday, Wednesday, and Friday, was picked up at 10:00 AM and returned between 3:00-3:30 PM. Most days they were not sent with a lunch, and they wanted one because they were hungry. By the time they got back to the facility, it was almost dinner and when they did have a bagged lunch they were not as hungry. An (arteriovenous) fistula (a surgically created connection between an artery and a vein for dialysis access) was observed on their left arm. The resident stated most days the nurse did not come in their room when they returned from dialysis, and they never looked at their access site dressing. The resident reported removing the dressing earlier that day and placed it on their wheelchair where it was observed as dry without drainage. The resident stated facility staff never looked at their dialysis site. Sometimes the nurse did take their blood pressure when they returned but not often. During an observation on 01/07/2026 at 10:04 AM, Resident #134 was observed by the elevator in a wheelchair with their coat on and communication binder in a black back hung to the back of the wheelchair. The resident did not have a lunch or bag meal. During an interview on 01/07/2026 at 12:35 PM, the dialysis center nurse stated Resident #134 received dialysis in their center on Monday, Wednesday, and Friday. In the month of December, the resident was seen 12/01/2025 but was sent back to the facility as they had a bowel movement and wanted to be cleaned up. They rescheduled for 12/02/2025 and was seen 12/03, 12/05, 12/08, 12/20, 12/12, 12/15, 12/17, 12/19, 12/26/12/29, and 12/30. The resident was sent to the hospital from dialysis on 12/21/2025 and remained in the hospital until 12/25/2025 and did not receive dialysis at the center while in the hospital. In January 2026, the resident received dialysis on 01/02, 01/05 and was in the facility currently. The nurse stated Resident #134 rarely came to dialysis with the communication form completed, therefore they had no knowledge as to medication changes or changes in medical status. The resident rarely had a lunch and did not have one at the time of their treatment 01/07/2025. During an interview on 01/08/2026 at 11:14 AM, Certified Nurse Aide #35 stated they often were assigned Resident #134 who went to dialysis on Monday, Wednesday, and Friday at 10:00 AM. They helped get the resident cleaned up, toileted, and dressed before dialysis. They sent the resident with a bagged lunch on 01/05/2025 after the resident had asked for it. It came up on the resident's breakfast tray, and they located it in the resident's room and brought it to the resident. Resident #134 asked for their binder on 01/05/2025 and they retrieved the binder and placed it in a bag located on the back of the resident's wheelchair. During an interview on 01/08/2026 at 11:08 AM, Licensed Practical Nurse #36 stated Resident #134 was sent out for dialysis, and they did not do anything special for the resident. They did not complete any paperwork because that was only completed for in-house dialysis residents. They did not do anything when the resident returned from dialysis as they were unaware that anything had to be done upon returned. They were not sure if the resident was sent with a bagged meal and had not seen one as the certified nurse aides normally assisted the resident with dialysis preparation. During an interview on 01/09/2025 at 12:09 PM, the Assistant Director of Nursing stated there was a communication book that went with Resident #134 to all dialysis treatments. Nursing completed the binder before sending the resident to dialysis, so the center was aware of any new orders. The dialysis center completed the binder with treatment findings, blood pressure, weights, and any concerns. The nurse assigned to the resident upon return should check the resident's vitals and their access site to make sure they were not bleeding, and they were stable after treatment. 10NYCRR 415.12(k)

Based on observations, record review, and interviews during the recertification survey the facility failed to ensure accommodation of resident food preferences for one (1) of two (2) residents (Resident #4) reviewed. Specifically, Resident #4 did not receive double portions at meals as planned. Findings included:The facility policy Accommodation of Needs and Preferences and Homelike Environment, revised 12/2017, documented the facility would identify and provide reasonable accommodation of resident preferences. The facility policy Management of Resident Dining, revised 06/2025, documented food and drink would be provided per the meal ticket. The supervisor would monitor each meal on the tray line to ensure tray accuracy, including portion size of the resident tray.Resident #4 had diagnoses including food insecurity. The 12/13/2025 Minimum Data Set assessment documented the resident was cognitively intact and had diagnoses of protein calorie malnutrition and depression.The 12/10/2025 hospital discharge summary documented Resident #4 was treated for starvation ketoacidosis.The Comprehensive Care Plan initiated 12/11/2025 documented Resident #4 was to receive double portions at meals. The 12/11/2025 Diet Technician #17 progress note documented Resident #4 was a new admission and wanted double portions. The 12/13/2025 Registered Dietitian #16 nutrition assessment documented Resident #4 received double portions for nutrition supplementation and had increased calorie and protein needs to heal wounds.During an interview on 01/05/2026 at 10:00 AM, Resident #4 stated they requested double portions with meals when they were admitted and often did not receive them. They stated they were often still felt hungry after eating the meals and had to rely on other snacks on the unit.During an observation on 01/07/2026 at 12:06 PM, Resident #4 received six (6) ounces of beef stew and one-half (1/2) cup of mashed potatoes. Resident #4's lunch meal ticket, dated 01/07/2026, documented the resident was to receive 12 ounces of beef stew and one (1) cup of mashed potatoes and was verified by Registered Dietitian #19.During an interview on 01/08/2026 at 9:55 AM, Certified Nurse Aide #18 stated residents could have doubles portions if they asked, and they let the dietitians know if they received these requests. They had called the kitchen many times to receive extra food for residents who were still hungry after a meal. Resident #4 complained of hunger after meals and would eat ice cream or something on the unit after they finished the meal. During an interview on 01/08/2026 at 10:11 AM, Licensed Nurse #15 stated Resident #4 often asked for extra food portions at meals, and this was an ongoing issue for them. During an interview on 01/08/2026 at 12:08 PM, Food Service Director #13 stated anybody could have double portions, and when nursing called about missing portions, they brought the extra food to the unit right away. The kitchen staff knew who was on larger portions because it was either underlined or highlighted on the tray ticket. During an interview on 01/08/2026 at 10:25 AM, Registered Dietitian #19 stated Resident #4 was supposed to receive double entree breakfast, lunch and dinner, double starch at lunch and dinner, and double sides at breakfast. 10NYCRR 415.14(d)(3)(4)

Based on observations, record review, and interviews the facility failed to ensure that when a restraint was indicated, the least restrictive alternative for the least amount of time was used and included ongoing re-evaluation of the need for the restraint for one (1) of one (1) resident (Resident #13) reviewed. Specifically, a crisscross lap belt (a nylon belt around the waist and hooked to the back of the wheelchair) was implemented for Resident #13 and there was no documented evidence the device was determined to be the least restrictive alternative or the need for the device was periodically reevaluated. Findings include: The facility policy Restraints, revised 11/2017, documented the use of restraints for staff convenience, for purposes of discipline, or as substitutes for direct care, activities, and other services was prohibited. Restraint use was limited to circumstances in which the resident had medical symptoms that warranted the use and used only to protect the health and safety of the resident, and to assist the resident to attain and maintain optimum levels of physical and emotional functioning. The use of restraints would be re-evaluated throughout the resident's length of stay. The Interdisciplinary Team would review on an on-going basis to identify opportunities for use of restraint alternatives, less restrictive restraint, and/or restraint removal. The Restraint Evaluation Form, and corresponding Individualized Restraint Reduction Planning Form would be completed with each restraint assessment. A registered nurse was responsible to obtain medical orders and parameters of use, track dates for periodic reassessment with quarterly care planning to assist in the verification of on-going usage, complete the physical device evaluation form, and individualized restraint reduction form. Resident #13 had diagnoses including brain injury, dementia, and difficulty with walking. The 12/09/2025 Minimum Data Set assessment documented the resident had severely impaired cognition; used a manual wheelchair; had no upper or lower extremity impairment; required partial/moderate assistance with chair to bed and toileting transfers, walking 10 feet, and walking 50 feet with two turns; was independent in their wheelchair; had no falls since the prior assessment; and used a truck restraint daily. The 11/4/2020 Restraint Risk Education Form documented the resident used a crisscross restraint for impulsivity and poor safety awareness and was signed by the resident's representative. The 01/23/2024 physician orders documented crisscross lap belt, do not release during meals, release every 2-3 hours and as needed for care. The Comprehensive Care Plan initiated 01/18/2023 and revised 10/29/2025, documented the resident used a physical restraint, crisscross belt related to long standing traumatic brain injury. Interventions included discuss and record with the resident /family/ caregivers, the risk and benefits of the restraint, when restraint should/ would be applied, routine while restrained, any concerns or issues regarding restraint use; ensure the resident was positioned correctly with proper body alignment while restrained; ensure valid consent prior to initiating restraint; monitor/ document/report as needed any changes regarding effectiveness, of restraint, less restrictive device, if appropriate; any negative or adverse effects noted, including decline in mood, change in behavior, decrease in activity of daily living self-performance, decline in cognitive ability or communication. Contracture formation, skin breakdown, and signs/ symptoms of delirium, falls/ accidents/ injuries, agitation or weakness; and release every 2-3 hours, release as needed for care and may release when closely supervised by staff. The 12/01/2025 Evaluation for Physical Restraint Form completed by Registered Nurse Unit Manager #28 documented the resident had a crisscross belt, they were unable to release it upon request, the device impaired the resident's pre-existing functional ability, and the device was a restraint. The restraint protocol documented to complete the restraint evaluation form, update care plan and plan of care, obtain medical order with medical necessity and parameters of release, periodic re-assessment/ plan to reduce and/or eliminate. There was no documented evidence the crisscross belt was determined to be the least restrictive device, medical symptoms warranted the ongoing use of a physical restraint, or a plan to reduce and or eliminate the restraint was attempted. Resident #13 was observed with a crisscross belt applied around their waist and attached to the back of their wheelchair: - On 01/05/2026 at 10:13 AM and 12:32 PM, while in their room. -On 01/06/2026 at 10:04 AM, while in their room. -On 01/07/2026 at 12:13 PM, while in their room. -On 01/08/2026 at 9:08 AM, while in their room and at 9:45 AM, while self-propelling their wheelchair in the hallway. During an interview on 01/07/2026 at 2:05 PM, Certified Nurse Aide #29 stated if a resident had a restraint it was listed on the care instructions and included when staff were to release the device. Resident #13 had a crisscross belt, and they were unable to release it on their own. Staff applied the device when the resident was in their wheelchair and removed it every 2 -3 hours and during care. They thought the resident had the crisscross belt related to their diagnosis and impulsivity with safety awareness. It served as a reminder to the resident to not stand, as it did not allow them to stand up. They stated the resident had the device for a while and never seen another device attempted. The resident was able to transfer from their chair to toilet or their bed with assistance of one. During an interview on 01/08/2026 at 9:44 AM, Physical Therapist #32 stated they were currently working with Resident #13 on mobility, walking, and safety. The resident was able to walk with assistance of one but was impulsive. The crisscross belt was initiated by nursing in 03/2020. The resident was unable to remove the device on their own, it prevented the resident from rising fully to their feet and was used for safety. They were unsure what alternatives were attempted in the past prior to the initiation of the crisscross belt. Nursing staff were responsible to provide education to the resident/family, obtain consent, and ensure ongoing monitoring/ need for the device. During an interview on 01/01/2026 at 11:23 AM, Licensed Practical Nurse #30 stated Resident #13 had a restraint while they were up in their chair. Staff were to remove the device every 2-3 hours, during care, and as needed. They resident was unable to remove their crisscross belt, and staff monitored their positioning while they were in the chair to ensure they were seated up right. The resident had the device for a couple of years, and it was used for safety. The resident was impulsive and attempted to stand on their own. The crisscross belt prevented the resident from standing and served as reminder to sit down and ask for help. They were unsure if any other devices had been attempted prior to initiation of the crisscross belt or any different devices since the resident was their unit. During an interview on 01/09/2026 at 10:17 AM, Registered Nurse Unit Manager #28 stated Resident #13 had a crisscross belt used for safety purposes. The device was used to remind the resident not to stand without help as they were impulsive. it was considered a restraint, as it prevented the resident from standing. The resident had the device in place since they started as the unit manager. They completed the quarterly evaluation to determine if the device was a restraint. They stated there were no attempts to trial any different devices or re-assessment for the reduction of the device. They stated they had not read the facility's restraint policy. During an interview on 01/09/2026 at 11:24 AM, the Director of Nursing stated Resident #13 had a crisscross belt, which was considered a restraint. The resident had the device in place for some time. The device should be reviewed quarterly, annually, and anytime there was a significant change in the resident's status to determine if it was still considered a restraint, if the device remained appropriate to use, and to determine if it was the least restrictive device. It was the responsibility of the nurse manager to evaluate if the restraint was still needed. They should monitor the resident at least quarterly for a restraint holiday (the resident was assigned to one staff member to see how they did without the restraint in place). The findings of the restraint holiday should be documented in the resident's chart. They stated if the nurse manager had any questions regarding the facility policy they should ask nursing administration for clarification. They were unaware there were no attempts to trial different devices or re-assess for reduction. During a telephone interview on 01/09/2026 at 12:02 PM, Physician #34 stated Resident #13 had an order for a crisscross belt, which was in place for some time. The device was used for safety reasons as the resident could be impulsive related to their diagnosis. They were unaware if any different devices were attempted to be used or if a restraint reduction was attempted. They expected the least restrictive device to be used and attempt to assess for reduction of the device if possible. 10NYCRR 415.4(a)(2-7)

Based on observations, interviews, and record review during the recertification survey (complaint #652367) the facility failed to ensure the interdisciplinary team determined a resident's ability to safely administer their own mediations, if clinically appropriate, for two (2) of three (3) residents (Residents #108 and #260) reviewed. Specifically, Resident #108 had a prescribed nasal spray on their bedside table and Resident #260 had unprescribed elderberry supplements on their bedside table. There was no documented evidence of assessments and/or physician orders for the residents to safely self-administer medications.Findings included:The facility policy Self Medication, revised 06/18/2008, documented the procedure for self-administer of medications included identifying the resident who may be appropriate for self-medication, a physician order was obtained, and a resident self-medication administration record was completed. A self-medication pill holder that the resident was comfortable with was sent to pharmacy and filled with one week's worth of medication. The pill holder was kept in the medication cart or in the resident's locked drawer. 1) Resident #108 had diagnoses including acute and chronic respiratory failure and aspergillosis (a fungal lung infection caused by inhaling certain mold spores). The 12/24/2025 Minimum Data Set assessment documented the resident had intact cognition and required set-up to moderate assistance for most activities of daily living. The 12/17/2025 physician order documented ipratropium bromide nasal solution 0.03% (blocks mucous production) sprayed twice in both nostrils four times a day for allergies. During observations on 01/05/2026 and 01/07/2026 ipratropium bromide nasal spray was on the resident's overbed table without licensed staff present. There was no documented evidence of a provider order for self-medication administration or a self-medication administration assessment. The 01/07/2026 Medication Administration Record documented ipratropium bromide nasal solution, two (2) sprays in both nostrils four times a day at 9:00 AM, 12:00 PM, 5:00 PM, and 8:00 PM. Licensed Practical Nurse #3 documented they administered Resident #108's ipratropium bromide nasal spray at 9:00 AM. During an interview and observation on 01/07/2026 at 11:01 AM, Licensed Practical Nurse #3 stated residents administered their own medication after an assessment and a provider order was obtained. Medications should not be at the bedside if the resident did not have an order or assessment. They confirmed the nasal spray was on Resident #108's overbed table. They stated they did not get an order for the resident to self-administer medication, but they should have. The nasal spray should not have been on the resident's overbed table. During an interview on 01/07/2026 at 11:08 AM, Registered Nurse Unit Manager #4 stated residents should not have medications at their bedside until they were assessed for appropriateness, and a provider order was entered. Resident #108 did not have an order for self-medication administration. The resident should not have the nasal spray at the bedside as it was a medication. Nasal spray should be kept in the locked medication cart. 2) Resident #260 had diagnoses including heart disease and syncope (temporary loss of consciousness) and collapse. The 12/15/2025 Minimum Data Set assessment documented the resident had moderate cognitive impairment, one-sided upper extremity mobility impairment and required set-up/clean-up assistance for most activities of daily living. The discontinued physician order documented elderberry zinc/vitamin C/immune mouth/throat lozenge, place and dissolve one tablet buccally (cheek) one time a day for supplement was discontinued on 03/04/2025. The 03/21/2025 Nurse Practitioner #6 progress note documented due to polypharmacy (use of multiple medications), vitamin C, vitamin D, vitamin B-12, triamcinolone, and elderberry tablets were discontinued. Elderberry supplement was observed on Resident #260's bedside table on 01/05/2026 at 9:48 AM and 01/06/2026 at 8:58 AM. There was no documented evidence of a physician order for elderberry supplements. There was no documented evidence of a physician order for self-medication administration or a comprehensive care plan for the ability to self-administer medications. During an interview and observation on 01/07/2026 at 10:18 AM, Licensed Practical Nurse #5 stated Resident #260 was not taking any supplements, including elderberry supplements. The resident did not have orders to self-administer any medications. Licensed Practical Nurse #5 confirmed Resident #260 had elderberry supplements on their bedside table. The resident should not possess medications that were not ordered. They stated they did not notice the supplements at the bedside. During an interview on 01/07/2026 at 10:25 AM, Resident #260 stated they have taken the elderberry supplements every day since they were admitted . Their child brought the supplements into them. During an interview on 01/07/2026 at 10:48 AM, the Director of Nursing stated residents should not have medications at the bedside. They could only have them if there was a provider order and they proved they could take them safely. Elderberry supplements and nasal spray were medications and therefore should not have been at the residents' bedside without the provider order and an assessment. It was a huge safety issue for medications to be left at the bedside. 10 NYCRR 415.3(f)(1)(vi)

Based on observation, record review, and interview during the abbreviated survey (NY00331278), the facility did not ensure each resident received adequate supervision and the environment remained as free of accident hazards as possible to prevent accidents for 1 of 3 residents reviewed (Resident #2). Specifically, Resident #2 obtained and ingested medications from the medication cart and it was unclear whether licensed practical nurse #3 left the medication cart unlocked when it was unattended or whether the lock malfunctioned. After ingesting the medications, the resident required hospitalization and treatment with activated charcoal (emergent treatment for an overdose) and intravenous fluids. This resulted in actual harm to Resident #2 that was not immediate jeopardy. Findings included: The undated Medication Cart policy documented the facility required medication carts to be locked at all times when staff were not actively standing at the cart. Staff were expected to understand and adhere to the facility policy. Resident #2 had diagnoses including vascular dementia with psychotic disturbance, Stage 4 chronic kidney disease, and depression. The 1/5/2024 Minimum Data Set assessment documented the resident's cognition was moderately impaired, they exhibited behavioral symptoms not directed towards others, was independent with transfers, and received antipsychotic and antidepressant medications. The 10/11/2023 comprehensive care plan documented the resident was verbally and physically aggressive, had a history of depression and a psychosocial well-being problem related to lack of acceptance of their current condition. Interventions included to administer antidepressant and antipsychotic medications, encourage participation, and allow time to answer questions and to verbalize feelings. The 1/9/2024 nurse practitioner #1's progress note documented they were alerted the resident was found with an open bottle of acetaminophen (pain reliever) in their hand and the bottle up to their mouth. They were not sure how many pills the resident ingested. When they arrived on the unit, the resident was vomiting, and pieces of capsules were seen. The resident expressed suicidal ideation stating they took the pills because they wanted to die. The resident was sent to the hospital. The 1/9/2024 at 11:40 AM, Incident Report completed by registered nurse Manager #2, documented the resident obtained 3 bottles of pills from the medication cart, took an unknown amount, and stated they wanted to kill themselves to get out of the facility. Licensed practical nurse #3, who was assigned to the medication cart, was suspended pending the outcome of the investigation. A statement attached to the report dated 1/9/2024, by licensed practical nurse #3 documented they last saw the resident sleeping in their room around 11:00 AM, at around 11:20 AM, they went on break, thought they had locked the medication cart, and they routinely double checked the cart before leaving. The undated incident overview completed by registered nurse Manager #2 documented on 1/9/2024 at approximately 11:30 AM, the resident was found seated next to medication cart with a bottle of acetaminophen and stated they wanted to kill themselves. Licensed practical nurse #3 left the unit around 11:20 AM and the resident got into the cart at around 11:35 AM. After the medication cart was examined, 3 bottles were found missing. A bottle of probiotics and a bottle of iron were found in the resident's room and the medications were confiscated. All bottles were one quarter full and there was no way of telling how many the resident took. The resident started to vomit, pills were seen in the vomit, and the resident was sent to the hospital. It was determined the root cause of the incident was the medication cart was left unlocked, allowing the resident to take medications from the top drawer. The 1/11/2024 hospital discharge summary documented the resident was admitted with an intentional overdose of acetaminophen, iron, and probiotics. The resident received activated charcoal per poison control as well as intravenous fluids. Psychiatry was consulted and the resident was found without insight into their decisions given their dementia diagnosis. On 1/18/2024, the resident was observed at 1:30 PM, wheeling themselves in their wheelchair up to staff near the dining room. An unidentified staff person offered and obtained coffee for the resident. During an interview on 1/19/2024 at 9:00 AM, licensed practical nurse #3 stated they were trained when hired to lock the medication cart anytime they were away from it, and it was their normal routine to check the medication cart drawers to ensure they were locked. They assumed they had locked the cart when they left for break on 1/9/2024 and could not remember if they checked the drawers after locking the cart. They were allowed to return to work on 1/13/2024 after being retrained on locking the medication cart at all times. On 1/16/2024, they had an issue with the medication cart not locking properly. On that date, after they pushed the lock on the medication cart to lock it, the drawers were still able to open when they pulled on them. They notified maintenance on that date and when maintenance got to the unit, they had gotten the medication cart to lock and could not get the issue to happen again in front of the maintenance staff. The maintenance staff instructed them to notify them if there were any further issues with the medication cart. Licensed practical nurse #3 stated they reported the medication cart lock not working to the oncoming evening shift licensed practical nurse when they gave report. They stated on 1/16/2024 when the medication cart lock was not working, they took a video on their phone and showed the video to the Director of Nursing on 1/17/2024. They had not had an issue with the medication cart since 1/16/2024 and the cart they had an issue with was removed from service on 1/18/2024. During an interview on 1/19/2024 at 9:15 AM, registered nurse Manager #2 stated the resident was focused on leaving the facility and had behaviors. On 1/9/2024, the resident refused medications, was agitated, and was pacing at times which was typical for them. Later in the shift, they heard staff yell, and they found the resident seated next to the cart. At that time, someone had already removed a pill bottle from the resident's hands. Registered nurse Manager #2 immediately reported the incident to the Director of Nursing, the Assistant Director of Nursing, and nurse practitioner #1. They assessed the resident, and the resident told them they wanted to kill themselves because they wanted to get out of the facility. The resident then started vomiting. They called 911 and searched the resident's room where 2 more bottles of pills were found. They interviewed all staff on duty at the time of the incident, was not sure how the resident got into the medication cart and assumed licensed practical nurse #3 left the cart unlocked. They inspected the medication cart after the incident and the cart was locked. Registered nurse Manager #2 stated nurses were trained upon hire that when they were away from the cart or the cart was not in sight, it was to be locked and they expected the cart to be locked. On 1/18/2024, licensed practical nurse #3 reported to them the medication cart was not locking properly on 1/16/2024. During an interview on 1/19/2024 at 11:15 AM, the Director of Nursing stated they did not check the medication cart at the time of the incident on 1/9/2024 because there were no concerns with the lock malfunctioning at that time. On 1/17/2024, licensed practical nurse #3 showed them a video of the medication cart not locking appropriately on 1/16/2024. They and licensed practical nurse #3 tried to recreate the drawers not locking and could not. They reported the concern to the Administrator and as far as they knew, maintenance had gone around and checked that all medication carts were functioning appropriately. They stated in addition to maintenance and the oncoming nurse, licensed practical nurse #3 should have reported the lock malfunctioning to a supervisor. On 1/18/2024, they again tried to get the medication cart drawers to open when the cart was locked, and they were not able to recreate the issue. The medication cart was removed from the unit and a new cart provided. During a telephone interview on 1/22/2024 at 12:26 PM, nurse practitioner #1 stated it was the facility's policy that the medication cart be kept locked at all times and residents should not have access to an unlocked cart. Accidental ingestion of an over-the-counter analgesic could have affected the resident's liver and they were not sure what the outcome would have been for probiotics and iron and was why they sent the resident to the hospital for an evaluation. Activated charcoal was typically given for an overdose. During a telephone interview on 1/23/2024 at 10:47 AM, licensed practical nurse Assistant Manager #5 stated they were alerted by someone from maintenance a resident was in the medication cart drawer and attempting to take medication on 1/9/2024. Licensed practical nurse Assistant Manager #5 yelled for help and then took the bottle of medication away from the resident. They noticed the top drawer of the medication cart was open, so they closed it and pushed the lock in. 10 NYCRR 415.12(h)(1)

Based on interviews during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure residents had the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States for all 241 residents of the facility. Specifically, mail from the United States Postal Service (USPS) was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community. Findings include: The facility policy, Resident Rights, reviewed and revised 10/18/2022, documented the nursing facility recognized and supported the residents' right to exercise their rights as a resident of the facility and of the United States. The policy summarized the rights of resident as stipulated under the Federal and State law. During a resident group interview on 11/13/2023 at 3:40 PM, ten anonymous residents stated personal mail was not delivered to them on Saturdays. During an interview on 11/15/2023 at 11:45 AM, unit secretary #1 stated they would go to the mailroom and get the mail for the unit. They delivered the mail to the residents when they worked Monday through Friday. They stated mail did not come to the unit on Saturdays and was held until Monday and passed out then. During an interview on 11/15/2023 at 11:48 AM, registered nurse (RN) #2 stated that packages or food delivery service would be delivered to the supervisor's office and brought to the unit for residents, but parcel mail was not delivered to residents on Saturdays. During an interview on 11/16/2023 at 2:27 PM, central supply staff #3 stated that mail came in the building through the glass windows by the front door. The business office would separate out their items. Central supply staff #3 stated they would get a phone call stating the mail was ready for pick up and they would get the mail from the bucket and sort out the parcels by unit. The sorted mail was placed in the appropriate unit mailbox. They stated the unit secretaries were responsible for getting the mail from the unit mailboxes every day. They stated If the mail was still in the mailbox at the end of the day at approximately 4:00 PM, they took the mail to the unit. Central supply staff #3 stated mail was delivered to the facility on Saturdays but neither members of the business office nor central supply worked on Saturday. Mail was not sorted on Saturdays and residents did not receive mail on Saturdays. They stated it was important for residents to receive mail on Saturdays, especially during the holidays and birthdays. During an interview on 11/17/2023 at 2:26 PM, the Administrator stated when mail arrived the business office took their items out and the remainder went to central supply. If mail was delivered on Saturday, it would be distributed Monday. They stated residents should get mail the day it was delivered. During a telephone interview on 11/17/23 at 2:28 PM, the Director of Central Supply and Purchasing stated mail was delivered to the facility Monday through Saturday and on Saturday the front desk would sort the mail for distribution. During an interview on 11/17/23 at 2:51 PM, operator/receptionist #5 stated they worked the front desk every Saturday. The process for mail on Saturday was USPS would deliver a white postal bin and the facility would provide a return white postal bin for outgoing mail. If the parcels appeared official in appearance, they went into a white filing cabinet with a lock and was locked until Monday. They stated mail, such as magazines, business-related post cards, or junk mail stayed in the bin on the counter until Monday. The business office came and got the mail from the locked cabinet on Mondays. 10NYCRR 415.3(c)(l)(i)

Based on observation, interview, and record review during the recertification and abbreviated (NY00321818 and NY00317835 and NY00321978) surveys conducted 11/13/2023-11/20/2023, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 5 of 6 resident units (Units B, C, D, 2, and 3). Specifically, Unit 3 had mattresses and furniture in disrepair; Units B, C, D, 2, and 3 served resident meals directly on trays; and the medication room and the kitchenette were unclean on Unit 3. Finding include: The facility policy Resident Rights dated 10/18/2022, documented the residents had the right to a dignified existence that included a safe, clean, comfortable, and homelike living environment. The facility policy Standards for Resident Dining, dated 10/9/2018 documented the dining area tables should be properly set with placemats on the units, condiments, etc. Residents served in their rooms should have meals taken to the rooms covered and assist with set up within reach of resident. Unit 3 Mattresses/Furniture The following observations were made on Unit 3: - on 11/13/2023 at 10:30 AM and 11/14/2023 at 8:15 AM in room [ROOM NUMBER] there were broken dresser drawers placed on top of the dresser. - on 11/13/2023 at 10:57 AM, 11/14/2023 at 8:30 AM, and 11/15/2023 at 1:04 PM in room [ROOM NUMBER] there was a mattress with a large rip over half of its side. - on 11/13/2023 at 3:33 PM and 11/14/2023 at 8:48 AM in room [ROOM NUMBER] there was a mattress on the floor with a rip down half of the side. - on 11/14/2023 at 8:47 AM a chair between rooms [ROOM NUMBERS] had dark brown drips down the back. - on 11/15/2023 at 9:28 AM, 11/16/2023 at 10:46 AM, and 11/17/2023 at 12:53 PM a chair to the right of the kitchenette had a square rip in the seat with protruding foam. During an interview on 11/15/2023 at 12:50 PM licensed practical nurse (LPN) #21 stated the dresser in room [ROOM NUMBER] had been broken for nearly one year. They had reported it to the secretary but could not recall when. They stated when items were in disrepair it could take months to get them fixed. They stated they observed many mattresses with large tears that did not get replaced. They stated torn mattresses could be an infection control issue. During an interview on 11/16/2023 at 12:44 PM LPN #19 stated they notified the secretary when there was broken equipment. They stated they never filled out work orders but called maintenance when items were broken. They stated it normally took several days for a repair but not usually more than one week. If a mattress was ripped it could be an infection control issue. During an interview on 11/16/2023 at 1:53 PM, LPN Assistant Unit Manager #24 stated when equipment was broken a work order was completed by the secretary and they have also completed work orders. They stated they were not aware of the ripped mattresses and that work orders were normally addressed within a day or two. They stated the dresser had been broken for a month or two, but it took longer to get a dresser replaced because the facility does not provide dressers. Resident Meal Service The following observations were made on Unit 2: - on 11/13/2023 at 1:24 PM lunches arrived on the Unit 2 cart for hallway tray service. Residents were served their lunch meals directly on the trays without staff removing the food items. - on 11/15/2023 at 1:21 PM, Resident #38 was eating their meal with all food items remaining on the tray. Resident #38 stated they always ate on the tray, and it was how their meals were served to them. The following observation were made on Units C and D: - on 11/13/2023 at 1:16 PM, all residents in the dining room on D Unit had their lunches served directly on trays. - on 11/15/2023 at 8:50 AM, Resident #60 on C Unit was eating breakfast in their room with all food items served directly on a meal tray. - on 11/15/2023 at 1:36 PM, all residents in the dining room on D unit had their lunches served directly on trays. - on 11/16/2023 at 1:01 PM, all residents in the dining room on D unit had their lunches served directly on trays. The following observations were made on Unit 3: - on 11/13/2023 at 1:16 PM, multiple residents in the dining room were being served their lunch meal directly on a tray. - on 11/13/2023 at 1:57 PM, Resident #100 was being fed their meal directly from a tray. - on 11/14/2023 at 9:15 AM, multiple residents were in the dining room eating breakfast served directly on a meal tray. - on 11/15/2023 at 10:57 AM, Resident #36 was eating their breakfast meal served directly on a tray. Multiple residents were eating their meals directly from trays. The following observations Unit B observations included meals served on trays on the following dates: - on 11/13/2023 at 12:28 PM, all residents were eating from meal trays in the B unit dining room. - on 11/14/2023 at 8:55 AM, Resident #223 was served breakfast on a meal tray. - on 11/14/2023 at 12:23 PM, Resident #223 was served lunch on a meal tray. - on 11/14/2023 at 12:24 PM, Resident # 116 was served lunch that was set up on their beside table on a meal tray in their room. - on 11/14/2023 at 12:27 PM, Resident #135 was served lunch on a meal tray in their room. - on 11/15/2023 9:05 AM, Resident #223 was served breakfast on a meal tray in their room. - on 11/15/2023 at 9:15 AM, Resident #116 was served breakfast on their bedside table on a meal tray in their room. - on 11/15/2023 at 9:21 AM, Resident #135 was served breakfast on a meal tray. - on 11/15/2023 at 12:52 PM, Resident #223 was served lunch on a meal tray in their room. - on 11/15/2023 at 1:00 PM, Resident #116 was served lunch on a meal tray in their room. - on 11/15/2023 at 12:50 PM, Resident #135 was served lunch on a meal tray that was set up on the bedside table while they were up in their wheelchair. - on 11/16/2023 at 9:00 AM, Resident #135 was served breakfast on a meal tray while in bed. - on 11/16/2023 at 9:04 AM, Resident #116 was served breakfast on a meal tray in their room. - on 11/16/2023 at 9:06 AM, Resident #223 was served breakfast on a meal tray in their room. - on 11/16/2023 at 12:50 PM, Resident #116 was served lunch on a meal tray which was on the bedside table while they were up in their wheelchair. - on 11/16/2023 at 12:52 PM, Resident #223 was served lunch on a meal tray in their room. - on 11/16/2023 at 12:55 PM, Resident #135 was served lunch on meal tray. During an interview on 11/16/2023 at 9:31 AM, certified nurse assistant (CNA) #34 stated all meals were always served on trays. This was not homelike. Before COVID they had placemats and served out of the kitchenette with steam tables. That was much better because if items were missing, they could just go to the kitchenette to get the items. They stated there had been talk of using the kitchenettes again, but no actual plans had been disclosed to the unit staff. During an interview on 11/16/2023 at 9:38 AM, licensed practical nurse (LPN) #9 stated meal service was always served on the tray, and was not homelike. They used to service out of the kitchenette, but switched to trays after COVID. There were better ways to serve that were more homelike. During an interview on 11/16/2023 at 11:28 AM, CNA #18 stated meal service was always served on the tray and was not homelike. During an interview on 11/16/2023 at 11:37 AM, registered nurse (RN) #2 stated serving meals on the tray was not 100% homelike. The brain injury unit was always served on trays. 2nd floor was done on the hot trays in the kitchenette, but that was before COVID. During an interview on 11/16/2023 at 11:47 AM, RN #10 stated the food was always served on trays. It used to be served from hot plates. Hopefully, we go back to that and only use a plate. Tray service was not homelike, typically people would not eat on a tray at home. They said the steam tables were coming back but did not know when given all the other construction that was occurring. During an interview on 11/16/2023 at 1:53 PM, LPN #24 stated meal service was always served on the tray and was not homelike. They stated in the past meals were served from the kitchenette and were not served on trays. They stated they did not eat on a tray at home. Since changing to serving off carts, meals were served on trays. During an interview on 11/17/2023 at 11:43 AM, Registered Nurse (RN) Manager #29 stated it was important for residents to have a homelike environment because this was their home, and they should be given that same comfort level. Meals on trays are not homelike and it would be more homelike if the plates were taken off the trays before placed in front of the resident. During an interview on 11/17/2023 at 2:00 PM, the Director of Nursing (DON) stated that all meals were served on trays and did not think it was homelike to be served like that. They were working on alternate ways like using the steam tables in the future to make it more homelike. During an interview on 11/17/2023 at 2:28 PM, certified nurse aide (CNA) #26 stated it was important for residents to have a home like environment because it was their home and quality of life is important. It was homelike to place the plates and the drinks in front of the residents rather than on a tray. Medication rooms and the Unit 3 kitchenette The signed email from Chief Information Officer #54 dated 11/16/2023 documented the cameras were installed in the medication rooms for the B Unit on 11/2/2023 and Units 2 and 3 on 11/4/2023. During an observation on 11/13/2023 at 11:29 AM, the Unit 3 medication room had a white powder coating the floor beneath a camera mounted in the ceiling. During an observation on 11/13/2023 at 11:35 AM, the Unit 2 medication room had a white powder coating the floor beneath a camera mounted in the ceiling. Other debris was present and the floor throughout the medication room was visibly soiled. During an observation on 11/14/2023 at 10:08 AM, the B (Baker) Unit medication room floor had white debris under the camera mounted in the ceiling. A work order dated 10/6/2023 at 10:42 AM documented the sink on the 3rd floor dining area was clogged. During an observation on 11/13/2023 at 11:09 AM, the right door was ajar under the sink beside the ice dispenser in the 3rd floor dining room. The interior of the cabinet was stained and soiled by a black substance, and flies were present. During an interview on 11/13/2023 at 11:09 AM, the Director of Maintenance stated there was a leak in the cabinet beneath the sink of the 3rd floor dining room and they must not have finished cleaning it up. During an interview on 11/20/2023 at 10:41 AM, CNA #18 stated that housekeeping was responsible for cleaning the medication rooms. During an interview on 11/20/2023 at 11:09 AM, housekeeper #55 stated they tried to clean the medication rooms daily, but because the rooms were normally locked, they may not get to those every day. They stated when cleaning those rooms they would sweep, mop, wipe down the counters, remove the garbage, and the cleaning was not documented. Housekeeper #55 stated the water leaking under the sink in the 3rd floor dining room had been an ongoing issue for about 3 years and it was due to something not draining properly because it was not level. They stated they often put down paper towels, but they did not clean under the cabinet because they thought it was screwed shut. They stated they did not have any problems with pests within the facility, but if they saw something they would report it to the unit secretary. During an interview on 11/20/2023 at 2:59 PM, the Director of Environmental Services #43 stated the medication rooms were supposed to be cleaned daily, and depended on if they could get nursing staff to unlock the room. They stated they thought the cabinet below the sink in the 3rd floor dining room was locked and that would prevent that area from being cleaned. They stated the facility did not have any pest issues, and an outside company came every other week to treat any areas of concern. The Director of Environmental Services #43 stated it was important for the medication rooms to be cleaned for the health of the residents and it was not timely if the room had not been cleaned for two weeks. They stated this was the resident's home, and it was not dignified if it was not clean. During an interview on 11/20/2023 at 3:32 PM, the Director of Maintenance stated they had no idea how long the leak had been present beneath the sink of the 3rd floor dining room and they did not believe anything regarding that was documented. They stated they were not aware of any pest issues in the facility, but those were taken care of by environmental services. 10 NYCRR 415.29(j)(1) 43754 48446 48895

Based on observation, record review, and interviews during the recertification and abbreviated (NY00327307, NY00321978, NY00321818 and NY00317835) surveys conducted 11/13/2023-11/20/2023 the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 10 of 10 residents who expressed concerns regarding lack of sufficient staffing and not receiving care in a timely manner. Specifically, during a confidential group meeting (resident council) residents stated their call bells could sometimes take an hour to an hour-and-a half to be answered, and that there were not enough certified nurse aides (CNAs) to assist dependent residents with personal hygiene and toileting tasks. Additionally, deficiencies related to staffing levels were identified in the areas of ADL Care Provided for Dependent Residents (Residents #36, #100, #120, #141, and #183) and the area of Quality of Care (Resident #146); and one discharged resident (Resident #304) that was not provided incontinence care timely due to lack of sufficient staffing. Findings include: The facility policy Staffing, effective date 10/20/2022, documented the facility would provide sufficient nursing staff (on a 24-hour basis) with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain/maintain the highest practical physical, mental, and psychosocial well-being of each resident. The Facility Assessment, last updated 5/2023, documented the facility was licensed for a total of 284 skilled nursing beds. Within the total beds, two units (KB and B) were sub-acute, and there was a 20-bed certified brain injury unit. The remaining 182 beds accommodated long term care residents as well as a small sub-group of longer-stay rehabilitation residents. Most of the long-term care residents required assistance with mobility, bathing, dressing, and grooming. Sufficient staff were available to meet residents' needs, and staffing was evaluated routinely and was adjusted as needed. The certified nurse aide (CNA)/licensed practical nurse (LPN) staffing was supplemented with agency nursing staff and overtime to help achieve and maintain desired staffing patterns. Recruitment and retention strategies remained ongoing. The facility identified resources needed to provide competent care to its residents, and one of the areas included staff stability, where the facility would continue the Nurse Aide Training Program (NATP), agency diversification, and enhanced recruitment and retention strategies. During the entrance conference on 11/13/2023 the Administrator stated the facility census was 241 residents. Refer to citation F 684 Quality of Care Wound treatments not completed 10/23/2023 and 10/24/2023, Resident #146: Resident #146 had an unstageable (full-thickness pressure injuries in which the base is obscured by dead tissue) right heel pressure wound, and an unstageable right buttock wound and there was no documented evidence treatments were completed as ordered. During an interview on 11/13/2023 at 1:02 PM, Resident #146 stated their wounds were improving, but their treatments were not always done. They stated it was hard to keep the area on their sacrum clean because they had loose stools at times and felt like the facility did not have enough staff to do everything they needed to do. During a telephone interview on 11/16/23 at 5:00 PM, LPN #48 stated if a resident had a wound treatment order it was located on the TAR and whoever completed the treatment should sign the TAR or document that it was completed by someone else. They stated if they were working with Resident #146 that meant they were the only nurse passing medications and doing treatments on the unit. They stated they might not have documented the treatment was completed because there was not enough staff on the unit. Refer to Citation F 677 ADL Care Provided for Dependent Residents Resident #141 was not provided with a shower, oral hygiene, and fingernail care. Resident #183 was assisted with shaving. Resident #36 was not assisted with oral hygiene. During an interview on 11/16/2023 at 1:53 PM, LPN #24 stated CNAs could not always do care because of staffing issues. They stated sometimes there were only 3 scheduled CNAs on the day shift, and they could not always complete showers, nailcare, or oral care. During an interview on 11/16/2023 at 1:53 PM, licensed practical nurse (LPN) Unit Manager #24 stated CNAs were responsible for assisting residents with care including shaving female residents for dignity reasons. They stated Resident #183 should be shaved and had been shaved previously. LPN Unit Manager #24 stated they observed Resident #183 with a significant amount of facial hair on their lip and chin hair between 11/13/2023 and 11/16/2023, and they requested a CNA shave the resident earlier that morning. They stated that care was often missed because they were short-staffed. CNAs could not always complete resident care because of staffing issues. They stated sometimes there were only 3 CNAs scheduled on the day shift so residents could not always get showers, nailcare, or oral care completed. If oral care was not provided it could lead to gingivitis, tooth loss, infection, cavities, pain, and even being unable to chew foods. Incontinence care not provided timely 10/31/2023, Resident #304: Resident #304 was admitted to the facility with diagnoses including encephalopathy, unspecified and morbid obesity. The 10/31/2023 Minimum Data Set (MDS) assessment documented the resident had intact cognition, was dependent of two or more for toileting hygiene and toilet transfer, was always incontinent of bowels and used a wheelchair. The comprehensive care plan (CCP), initiated 10/26/2023, documented Resident #304 had a self-care deficit in toileting hygiene and was dependent of 2 requiring substantial or maximal assistance. The evening staffing for the KB unit on 10/31/2023 documented: - 1 LPN (LPN #37). - 4 CNAs: CNA #40 (float, 3PM - 11PM), CNA #36 (4PM - 7PM), CNA #35 (float from unit B, 7PM - 11PM), and CNA #65 (float, 7PM - 11PM). During an interview with licensed practical nurse (LPN) #37 on 11/16/2023 at 4:16 PM, who was the medication nurse for the KB unit, they stated they recalled an incident with Resident #304 on 10/31/2023. The resident's family was visiting on the evening shift when they heard shouting down the hall. The family was telling certified nurse aide (CNA) #40 the resident needed incontinence care. CNA #40 was telling the family member they needed a second staff to assist. The family member had stated they had been waiting for an hour for CNA #40 to find a second staff person for the resident to be changed. They (LPN #37) called the nursing supervisor because they were assisting another resident who had vomited. During an interview with registered nurse (RN) supervisor #38 on 11/16/2023 at 4:46 PM, stated LPN #37 had called them on 10/31/2023 to let them know a family member had interacted with CNA #40 about Resident #304 needing incontinence care, they were upset that incontinence care had not been provided for an hour, and that the family member had left the facility before the resident's care could be provided. CNA #40 had stated to them per the resident's care plan, the resident was a two person assist with incontinence care. The family member called the facility after they got home to inform them Resident #304 needed incontinence care. They (RN supervisor #38) stated CNA #40 was a float staff and they had been very short staffed that shift, so they assisted with incontinence care to Resident #304. During an interview with RN unit manager #41 on 11/17/2023 at 9:50 AM they stated if a family member ever expressed a care concern or had a confrontation with a CNA, the CNA should notify the nurse on the unit. If a second CNA was not available to assist with incontinence care per a residents' care plan, there was always the RN supervisor available to assist as the second staff person. Resident Group Meeting 11/13/2023: During a confidential resident group interview on 11/13/23 at 3:37 PM, ten anonymous residents stated that their call bell would sometimes take anywhere from 1- 1 1/2 hours before it was answered due to short staffing. They reported the following examples because of call bells not being answered timely due to inadequate staffing: - Residents had to stay on bedpans for a long period of time due to staff forgetting about them. - A resident had to help their roommate to the bathroom, because staff did not answer their call bell. - Residents did not receive showers on their scheduled shower days. - Residents had to ask for snacks, and when they did, staff never returned to their rooms. - Meal trays were not being served timely by unit staff once they arrived on the units. Facility staffing during day observations 11/13/2023 - 11/17/2023: Facility staffing documented the following nursing schedule for 11/13/2023-11/17/2023: Monday 11/13/2023, day shift (7 AM - 3 PM) staffing was scheduled for the following: - KB unit had 1 Nurse Manager (NM), 3 LPNs, and 5 CNAs (3 worked, 7:30 AM - 7 PM, 6 AM-2 PM, and 7 AM - 2PM, respectively) for 30 residents. - B unit had 1 NM, 2 LPNs, and 5 CNAs (1 worked 7 AM-12:30 PM) for 32 residents. - C unit had 3 LPNs, and 5 CNAs (2 worked 6 AM - 2 PM, and 7 AM - 7:30 PM, respectively) for 44 residents. - D unit had 1 NM, 3 LPNs, and 5 CNAs (3 worked, 7:30 AM - 3 PM, 10 AM-11 PM, and 8 AM - 2PM, respectively) for 42 residents. - 2nd floor had 1 NM, 2 LPNs, and 3 CNAs for 29 residents. - Brain Injury had 1 NM, 1 LPN, and 2 CNAs for 10 residents. - 3rd floor had 2 NMs, 3 LPNs, and 3 CNAs (2 worked 7 AM - 7 PM, and 11 AM-3 PM, respectively) for 55 residents. Tuesday 11/14/2023, day shift (7 AM - 3 PM) staffing was scheduled for the following: - KB unit had 2 NMs, 1 ANM, 3 LPNs, and 4 CNAs (2 worked 7 AM-3 PM, and 11 AM-3 PM, respectively) for 35 residents. - B unit had 1 NM, 2 LPNs, and 5 CNAs for 33 residents. - C unit had 1 NM, 2 LPNs, and 5 CNAs (1 worked 7 AM - 7:30 PM) for 43 residents. - D unit had 1 NM, 1 ANM (Assistant Nurse Manager), 2 LPNs, and 4 CNAs (1 worked 7:30 AM - 3 PM) for 42 residents. - 2nd floor had 1 NM, 2 LPNs, and 3 CNAs (2 worked 6 AM - 2 PM, and 7 AM - 2 PM, respectively) for 28 residents. - Brain Injury had 1 NM, 1 LPN, and 2 CNAs for 10 residents. - 3rd floor had 1 NM, 1 ANM, 3 LPNs, and 4 CNAs (1 worked 6 AM - 2 PM) for 54 residents. Wednesday 11/15/2023, day shift (7 AM - 3 PM) staffing was scheduled for the following: - KB unit had 1 NMs, 1 ANM, 2 LPNs, and 3 CNAs for 36 residents. - B unit had 1 NM, 2 LPNs, and 3 CNAs for 32 residents. - C unit had 1 NM, 3 LPNs (1 worked 11 AM-11:30 PM), and 1 CNA that worked 6 AM-2 PM for 42 residents. - D unit had 1 NM, 1 ANM, 3 LPNs, and 4 CNAs for 41 residents. - 2nd floor had 1 NM, 2 LPNs, and 3 CNAs (1 worked 6 AM - 2 PM) for 29 residents. - Brain Injury had 1 NM, 1 LPN, and 2 CNAs for 10 residents. - 3rd floor had 1 NM, 1 ANM, 2 LPNs, and 4 CNAs (1 worked 11 AM - 3 PM) for 54 residents. The facility did not provide staffing for Thursday 11/16/2023, day shift. Friday 11/17/2023, day shift (7 AM - 3 PM) staffing was scheduled for the following: - KB unit had 1 NMs, 1 ANM, 2 LPNs, and 1 CNAs for 36 residents. - B unit had 1 NM, 1 LPN, and 3 CNAs (1 worked 11 AM-3 PM) for 26 residents. - C unit had 1 NM, 2 LPNs (1 worked 7 AM-2 PM), and 1 CNA for 44 residents. - D unit had 1 NM, 1 ANM, 1 LPN, and 5 CNAs (1 worked 7:30 AM-3 PM) for 42 residents. - 2nd floor had 1 NM, 2 LPNs, and 3 CNAs (2 worked 6 AM - 2 PM and 11 AM-3 PM, respectively) for 33 residents. - Brain Injury had 1 NM, 1 LPN, and 2 CNAs for 16 residents. - 3rd floor had 1 NM, 1 ANM, 2 LPNs, and 3 CNAs (1 worked 6 AM - 2 PM) for 54 residents. During an observation and interview on 11/15/2023 at 12:28 PM, CNA #23 on Unit 3 stated they completed Resident #120's care and did not have time to do nail care. They stated the resident should have had nail care completed, however there was not enough staff to complete all the resident tasks. Resident #120's nails were long with brown debris underneath the nails. During an interview on 11/15/2023 at 12:30 PM, LPN #21 on Unit 3 stated they felt the facility was short staffed every day. There were three wings and they split a cart for one wing. Sometimes one nurse covered all three wings. They could not pass medications timely. Sometimes when the unit was short staffed, residents were not turned and repositioned. During an interview on 11/16/2023 at 11:28 AM, CNA #18 on Unit 3 stated good staffing for the day shift was 5 or 6 CNAs. Usually, they only had 3 or 4 staff on day shift, which was not enough. There were times they were not able to complete care, because of insufficient staffing. The facility used agency staff. They had been asked to work overtime even when they worked 6 to 7 days a week. Evenings was the worst shift to staff, and staff were offered a larger shift differential for evenings. During an interview on 11/16/2023 at 1:53 PM, LPN #24 on Unit 3 stated CNAs could not always do care because of insufficient staffing issues. The unit prioritized residents with skin issues. There were sometimes 3 CNAs on the day shift, and they could not always give residents their showers, oral care, or nail care. During an interview on 11/20/2023 11:01 AM, nurse practitioner (NP) #32 stated in the past, residents had told them they sat in urine for long periods of time and their call bells had been unanswered for long periods of time. NP#32 stated they had seen difficulties with staff trying to feed all the dependent residents timely. There seemed to be more resident falls on the weekends and evenings due to less staff. If CNAs did not give showers, do oral care, or nail care there could be the potential for open wounds, missed skin checks, dental caries, thrush, and residents not wanting to eat. If treatments were not done, residents could get wounds, or worsening wounds. Sitting in urine could cause urinary tract infections and excoriations. During an interview with the staffing coordinator/scheduler on 11/20/2023 at 12:00 PM they stated they had staff ratios for each unit, and it changed daily, based on call-outs. If a staff person was going to call out for their shift, they needed to do it 2 hours before their shift started. They made a list of CNAs who called out more to see if they needed to be spoken to or suspended. The facility offered money incentives (bonuses) for staff to pick up extra shifts. Mondays were difficult days to fill staffing because they typically had more call-outs, and if staff had just worked the weekend they did not want to work on Mondays. Evening shift was harder to staff because they had less staff. They had an active agency staff list they used to fill staffing vacancies. They tried to get any staff they could to fill shifts. Float staff had certain units they liked better, and they tried to put them on their preferred units, but that was not always the case. During an interview on 11/20/23 at 2:15 PM, the Director of Nursing (DON) stated staffing was addressed daily and needs were determined based on a combination of census and acuity. The facility had 2 full-time staffing coordinators. Call-outs tended to average 6-8 staff per day. Staff were tracked and held accountable for their call-outs and discipline notices were sent. They tried to make deals with staff and offer shift switches to cover shifts, but call-outs were the biggest problem. Some staff had told the DON that they were short staffed at times. Sometimes meal trays were not delivered on time because of kitchen staffing. During an interview with the Administrator on 11/20/2023 at 2:43 PM they stated staffing started out manageable but the call-outs were the problem. Mondays were tough days and the RN Unit Managers sometimes had to work as an LPN passing medications. LPNs had to work as aides. Some families had concerns that CNAs did not do something or did not provide care timely for residents. Float CNAs on the evening shifts were anxious at times because of family complaints about resident care. Continuity of care was important, and the more float CNAs, the less continuity of care. 10 NYCRR 415.13(a)(1)(i-iii) 48895

48446 48895 Based on observation, record review, and interview during the recertification and abbreviated (NY00326461, NY00326492, and NY00317835) surveys conducted 11/13/2023-11/20/2023, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, accurate, and at an appetizing temperature for 3 of 3 meals reviewed (11/14/2023 and 11/15/2023 lunch meals, 11/16/2023 breakfast). Specifically, food was not palatable or served at appetizing temperatures and meal trays were missing items, Findings include: The facility's policy Management of Resident Dining dated 2/25/2020 documented that it was the responsibility of the cook staff to verify that all food sent to the units for meal service was palatable and at a proper holding temperature. Resident interviews and observations included the following: - on 11/13/2023 at 10:48 AM, Resident #135 stated the food was not good and was mushy. The sandwiches did not taste good, and the chicken salad was not good. - on 11/13/2023 at 11:09 AM, Resident #183 stated the food was always cold. - on 11/13/2023 at 11:38 AM, Resident # 223 stated the food was not hot, was not delivered on time, and did not taste good. - on 11/13/2023 at 12:04 PM, Resident #38 stated they frequently received food that was unappetizing. The sandwiches were soggy due to watery vegetables being plated with the bread. - on 11/13/2023 1:07 PM, Resident #146 stated the food was not good and gave them gastrointestinal distress. They stated they wanted more protein meals, they ate the broth from bean soup and wax beans, and the food had a lot of gravy/sauce, and they would like more sandwich options. The resident stated they did not feel the meal met their needs. - on 11/13/2023 at 2:01 PM, Resident #223 stated their lunch was cold, and items were different than the menu, but this was the norm. - on 11/14/2023 at 9:49 AM, Resident #116 was eating their breakfast meal and stated their eggs were rock hard. During an observation on 11/14/2023 at 1:29 PM, the last tray from the lunch cart on the Unit 3 was selected as a test tray and a replacement was ordered for the resident. Certified nurse aide (CNA) #66 stated the meal did not look good. The top portion of the lasagna was blackened and burned. The meal ticket documented a supplemental dessert that was not included on the tray. During an observation on 11/15/2023 at 8:55 AM, breakfast carts arrived on Unit 3 and were missing all liquids and lids for coffee. Staff was observed looking for lids in the kitchenette. During an observation and interview on 11/15/2023 at 9:21 AM, Resident #135 stated dinner the previous evening was Salisbury steak and tasted like soapy water. Resident #135 stated they were afraid they would get sick if they ate it. They requested a prepackaged peanut butter and jelly sandwich. During an interview on 11/15/2023 at 11:03 AM, LPN #24 stated that orange juice did not come with the breakfast tray delivery today and was substituted with apple, cranberry, or beverage of choice. During an observation and interview on 11/15/2023 at 11:09 AM, Resident #179 was eating breakfast from a tray in their room. They stated they were missing their brown sugar for their oatmeal and their orange juice. CNA #53 answered the call bell and returned with brown sugar. He had been asking for orange juice since 9:30 AM. The CNA stated there was no orange juice in the facility and offered apple or cranberry juice which the resident declined. During an observation on 11/15/2023 at 12:55 PM, Resident #223 was missing chocolate ice from their lunch tray. During an observation on 11/15/2023 at 1:09 PM, Resident #135 was eating lunch in their room and stated they would eat the prepackaged peanut butter and jelly sandwich. They stated they were not going to eat anything else because the food was not good. They stated they loved squash, but it did not taste like squash and did not seem cooked. During an interview and observation on 11/15/2023 at 1:21 PM, Resident #38 stated the squash was served on the plate with the sandwich and the bread was soggy. Resident #38 lifted the sandwich to show the watery runoff from the squash under the sandwich, which had absorbed into the bottom slice of bread. During an observation on 11/15/2023 at 1:27 PM, the following temperatures were measured in the main kitchen on the meal service line: squash 140 degrees Fahrenheit (F), soup 159 F, and ham sandwich 52 F. At 1:36 PM the last cart left the kitchen for Unit 3. At 2:04 PM the last tray to be served on Unit 3 was selected as a test tray and a replacement tray was ordered for the resident. The meal ticket documented double portions of soup, ham salad, squash, mandarin oranges, 2 supplemental shakes, 1 supplemental dessert, 1 apple juice (nectar thick), 1 water (nectar thick), margarine, salt, and pepper. The tray included 1 serving of soup, 2 ham salad sandwiches,1 portion of squash, 2 applesauce, 1 supplemental shake, thickened cranberry juice, thickened lemon-flavored water, buttery spread, salt, and pepper. The tray did not include the supplemental dessert or double soup portions. At 2:08 PM the following temperatures were measured with licensed practical nurse (LPN) Assistant Unit Manager #24 present, the squash was 91 F, the ham sandwich was 70 F, the soup was 141 F, and the supplemental shake was 45 F. During an observation and interview on 11/15/2023 at 1:28 PM, Resident #179 stated they did not like ham salad on wheat bread and were not offered a substitute. They only ate salad, Mighty Shake (supplement), and pears. The resident's meal ticket documented the fruit as mandarin oranges. During an observation on 11/16/2023 at 8:39 AM the following temperatures were measured from the main kitchen steam table: oatmeal 165 F, scrambled eggs 162 F, and pancakes 142 F. At 9:07 AM the cart left the kitchen and at 9:09 it was delivered to the second floor. At 9:20 AM, CNA #34 was delivering the last tray from the cart which was selected as a test tray. The following temperatures were measured with unit secretary #1 present: eggs 116 F, milk 48 F, and coffee 132 F. The meal ticket documented crispy rice cereal and apple cinnamon oat cereal was provided. During an interview on 11/16/23 at 9:31 AM, CNA #34 stated they used to serve meals out of the kitchenette from steam tables which was much better because if items were missing, they could just go to the kitchenette to get the items. They stated if there were missing items they called down to the kitchen. They stated the food sometimes looked appealing but not always. During an interview on 11/16/23 at 9:38 AM, LPN #9 stated hot foods were served with cold foods, or warmed plates with cold sandwiches. Hot foods were not always served hot, and cold foods were not always served cold. They stated items were frequently missing. During an observation on 11/16/2023 at 12:50 PM, Resident #116 was missing cottage cheese and Resident #135 was missing yogurt from their lunch trays. During an interview on 11/16/2023 at 12:44 PM, LPN #19 stated many times residents said the food was cold. They stated food was often cold and even burnt. During an interview on 11/17/2023 at 10:43 AM, registered dietitian (RD) #86 stated substitutions were approved by the RD. The kitchen should let the RD know that an item needed to be substituted, and they would review what items were on hand and pick an appropriate substitution. Pears were a substitution for mandarin oranges, and they were served two days in a row for lunch. Approved substitutions were sent via email to the units by the general manager of the kitchen. The units were to relay the information to the residents. During an interview on 11/17/23 at 2:00 PM, the Director of Nursing (DON) stated they expected the food be appealing and for the residents to want to eat the food. Hot foods should be served hot and cold foods should be served cold. The food should be enjoyable for the residents to eat. During an interview on 11/20/2023 at 11:33 AM, diet technician #69 stated that when serving and checking trays they did look at the quality of the meal and they thought the lasagna was okay for service and was not burned. They stated they only checked the temperature of the meal when they did meal audit test trays which they tried to do about once a week. During an interview on 11/20/2023 at 12:05 PM, Chef Manager #62 stated each position on the tray line checked the tray to the point they were at, the checker at the end of the line checked the complete tray when loading the trays onto the cart for delivery to the units. Nursing staff should check when they passed trays, and they were the final check. They stated when trays were checked they looked at the following: the right diet, if it was up to temperature, appearance, taste, correct portion, and correct items on the tray. Chef Manager #62 stated it was important for the residents to get a quality meal that looked appetizing, was served at the appropriate temperature, and matched the menu because this was the resident's home. During an interview on 11/20/2023 at 12:59 PM, cook #68 stated they checked the temperature of the food as it was placed on the line, and again at the end of the meal service. They stated the hot food needed to be 165 F or over, and cold items needed to be 47 F and below. They stated the squash that was served at 91 F was not acceptable. Cook #68 stated the lasagna that was served was burned, but they tried to take the burned layer off before it was served. 10NYCRR 415.14(d)(2) 49448

Based on record review and interview during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure they provided the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #353) reviewed. Specifically, Resident #353 was discharged from the facility to home and did not receive a Notice of Medicare Non-Coverage (NOMNC) CMS-10123 (Centers for Medicare and Medicaid Services) for Medicare Part A as required. Findings include: The CMS form instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 documents a Medicare provider or health plan (Medicare Advantage plans and cost plans, collectively referred to as plans) must deliver a completed copy of the NOMNC to beneficiaries/enrollees receiving covered skilled nursing, home health (including psychiatric home health), a comprehensive outpatient rehabilitation facility, and hospice services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care was not being provided daily. Resident # 353 was admitted to the facility with diagnoses including chronic respiratory failure, non-Hodgkin's lymphoma (type of lymphatic cancer), and heart failure. The 8/15/2023 Minimum Data Set (MDS) assessment documented it was a discharge assessment-return not anticipated, Skilled Nursing Facility Prospective Payment System (SNF PPS) Part A discharge (end of stay) assessment. The start of the most recent Medicare stay was 7/24/2023 and the end of the most recent Medicare stay was 8/15/2023. The discharge status was not documented. The resident's Admission Record documented the resident's child was the responsible party and emergency contact. The resident was discharged to home with home care services. The form CMS-20052 SNF Beneficiary Protection Notification Review for Resident #353 documented Medicare Part A skilled services start date was 7/24/2023 and the last covered day of Part A services was 9/28/2023. The facility initiated a planned discharge on 8/15/2023 from Medicare Part A services when benefit days were not exhausted. A NOMNC form CMS-10123 was not provided to the resident and there was no documented explanation as to why the form was not provided. During an interview on 11/20/2023 at 11:18 AM registered nurse (RN) MDS Director stated they provided NOMNC CMS-10123 letters two days prior to the Medicare discharge date s. It was important to receive the letters so the resident could decide if they wanted to appeal. The form was sent via certified mail and then would be uploaded into the electronic charting system. They stated they were unaware the form was needed for Resident #353 when they were discharged home, and the resident was not provided with the form. 10NYCRR 415.3(g)(2)(iii)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00312845, NY00317835, NY00321300, NY00321978, NY00326461, NY00326492, NY00326914, and NY00327307) conducted 11/13/2023-11/20/2023, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming, personal hygiene, and oral hygiene for 5 of 7 residents (Residents #36, #100, #120, #141, and #183) reviewed. Specifically, Residents # 36 and #100 were not assisted with oral hygiene; Resident #120 did not receive fingernail hygiene; Resident #141 was not provided with a shower, oral hygiene, and fingernail care; and Resident #183 was not assisted with removal of facial hair. Findings include: The facility policy Denture Management revised 5/22/2017, documented residents with dentures were assessed and dentures were cleaned and stored to maintain integrity of the dentures. There was no documented policy on the provision of oral hygiene. The facility policy Grooming Fingernails revised 8/12/2008, documented residents' nails were to be kept clean and neat to support self-esteem and dignity. Nails were to be assessed weekly on their shower day by certified nurse aides (CNAs) and refusal of care was to be reported to the Team Leader or Charge Nurse. The facility policy Meeting Resident Needs revised 3/13/2019, documented CNAs would identify any unmet resident needs and address them (positioning, toileting, personal care needs) and anticipate upcoming resident needs and address them proactively. 1) Resident #141 was admitted to the facility with diagnoses including benign neoplasm meninges (tumors in the brain and spinal cord), muscle weakness, and was receiving palliative care (optimizes quality of life with a serious illness). The 10/20/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required supervision and set up with eating, and extensive assistance of one for bathing, dressing, and personal hygiene. The comprehensive care plan (CCP) updated 10/20/2023 documented the resident had an ADL deficit related to rhabdomyolysis (a breakdown of muscle tissue). The resident was dependent for eating, hygiene, and oral hygiene. The undated care instructions (Kardex) documented the resident required assistance of two for transferring and showering and was dependent for oral and personal hygiene. The resident was to receive a shower weekly on Monday evenings and as needed. The Kardex documented showering was resolved/cancelled on 10/13/2023. During an observation and interview on 11/13/2023 at 10:17 AM, the resident had long fingernails on both hands. The resident stated they had not received a shower or had their teeth brushed in a long time. They stated they would like their teeth brushed, their nails clipped, and a shower. They had asked staff and a doctor had come to clip their toenails, but no one would clip their fingernails. During an observation and interview on 11/14/2023 at 10:47 AM, the resident had long fingernails on both hands. The resident stated they asked for their fingernails to be cut many times, but they were not cut. They stated they had asked for a shower and to have their teeth brushed for months. They stated they cleaned their teeth with straws. The resident stated they did not receive a shower on 11/13/23 (Monday) but would have taken one if it was offered. During an observation on 11/15/2023 at 8:35 AM, the resident had long fingernails on both hands. Several straws were observed on the floor next to their bed. During an interview on 11/15/2023 at 12:30 PM licensed practical nurse (LPN) #21, stated CNAs were responsible for completing residents' personal hygiene needs. They stated if a resident refused care the CNA should tell the LPN who would report it to the Unit Manager. LPN #21 stated they observed Resident #141 putting straws in their teeth. They stated hygiene needs could not be met because they were short staffed and having 1 or 2 CNAs to care for 20 residents was not acceptable. They stated getting a shower was important and it made residents feel better and not feel depressed. They stated showers also helped keep the resident's peri area clean and decreased the potential for a urinary tract infection. They stated clean and short fingernails would help to limit infection. They stated oral care was necessary to prevent cavities, tooth loss, and infection. During an observation and interview on 11/16/2023 at 9:34 AM, the resident had long fingernails on both hands. The resident stated they still had not had a shower, had their teeth brushed, or their fingernails clipped. At 11:21 AM, the resident was cleaning their teeth with a straw, had stubble on their face and stated they would shave if they could reach the razor. They stated their fingernails were long and jagged and they would like them clipped. During an interview on 11/16/2023 at 11:28 AM CNA #18, stated that CNAs were responsible for hygiene needs which included shaving, clipping, and cleaning fingernails, unless the resident was a diabetic, assisting with oral hygiene care, and showering. CNA #18 stated they were usually assigned to Resident #141 and had never given them a shower as they were scheduled for evening showers. They had not provided oral care to the resident because the resident refused when asked, and they asked the nurse to care for the resident's fingernails last Friday. They stated they were supposed to tell the nurse when a resident refused care and they did not. If a resident did not get personal hygiene care they could get an infection, cavities, and have issues with mouth pain. The CNA reviewed the shower schedule and there were two schedules listed for the resident. One schedule documented a Monday shower during the day shift, and the other documented Tuesday on the day shift. CNA #18 stated they thought the resident was an evening shower which was why they had not given them a shower on their shower day. During an interview on 11/16/2023 at 1:53 PM, LPN #24 stated CNAs could not always do care because of staffing issues. They stated sometimes there were only 3 scheduled CNAs on the day shift, and they could not always complete showers, nailcare, or oral care. They stated the last shower for Resident #141 was documented on 11/3/2023 and it was documented yesterday that the resident was independent with brushing their teeth. LPN #24 stated the resident was not independent and they expected the resident to be assisted and set up. They stated if oral care was not provided, they could get gingivitis (gum disease), tooth loss, infection, cavities, pain, and may even be unable to chew foods. During an interview on 11/17/2023 at 9:33 AM, the resident stated they had never refused oral care, fingernail care, or a shower. During an observation and interview on 11/20/2023 at 9:40 AM, the resident was in bed cleaning their teeth with a straw. They stated they were only given their toothbrush one day last week and had to clean their teeth with a straw because they could not reach their toothbrush and toothpaste. They stated they were happy that it was Monday and their shower day. 2) Resident #183 was admitted to the facility with diagnoses including muscle weakness with a history of falling, high blood pressure, and kidney disease. The 10/13/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, did not reject care, required extensive assistance of one for most ADLs, and had functional limitation in range of motion for both arms. The comprehensive care plan (CCP) updated 10/3/2023 documented the resident required assistance with ADLs related to impaired balance. Interventions included set up assistance for eating, oral care, and personal hygiene; and substantial assistance of one for showering and lower body dressing. The undated care instructions (Kardex) documented the resident required set up for oral care and personal hygiene and substantial assistance of 1 for showering. Resident # 183 was observed: - on 11/13/2023 at 11:09 AM, sitting in a chair in their room with a significant amount of light-colored hair on their lip and chin. - on 11/14/2023 at 11:00 AM and 11:15 AM, sitting in a chair in their room with a significant amount of light-colored hair on their lip and chin. - on 11/15/2023 at 8:28 AM sitting in a chair in their room with a significant amount of light-colored hair on their lip and chin. During an interview on 11/16/2023 at 10:46 AM, certified nurse aide (CNA) #20 stated that Resident #183 should be shaved if they would like because it was not dignified to have facial hair. They were assigned to the resident on Monday and today and provided care, however, they did not shave the resident because the resident did not ask. They stated they should have asked the resident if they wanted to be shaved. During an interview on 11/16/2023 at 1:53 PM, licensed practical nurse (LPN) Unit Manager #24 stated CNAs were responsible for assisting residents with care including shaving female residents for dignity reasons. They stated Resident #183 should be shaved and had been shaved previously. LPN Unit Manager #24 stated they observed Resident #183 with a significant amount of facial hair on their lip and chin hair between 11/13/2023 and 11/16/2023, and they requested a CNA shave the resident earlier that morning. They stated that care was often missed because they were short-staffed. 3) Resident #36 was admitted to the facility with diagnoses including diabetes, and below knee amputations of both legs, and dementia. The 8/29/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, did not reject care, required extensive assistance of one for dressing and personal hygiene, and was totally dependent on transferring with a mechanical lift. The comprehensive care plan (CCP) updated 8/29/2023 documented the resident had a self-care deficit related to amputations of the left leg above the knee and the right leg below the knee. Interventions included set up for eating, extensive assistance of one for grooming, and total assistance of 2 for dressing lower extremities, and a mechanical lift for transferring. The undated care instructions (Kardex) documented the resident required extensive assistance of 2 for mobility and personal hygiene was to be provided every day and evening shift and as needed on the night shift. The resident required 2 staff for care due to accusatory behaviors. The 8/14/2023 dental consult documented a periodic oral exam was completed. The resident's dental hygiene was fair, and the recommendation was to assist the resident with oral care twice a day. During an observation and interview on 11/14/2023 at 8:59 AM, the resident had significant plaque on their teeth. They stated they did not receive assistance with brushing their teeth. During an observation and interview on 11/15/2023 at 10:06 AM, the resident had food between their lower teeth. They stated they would like to have their teeth brushed. During an interview on 11/16/2023 at 1:53 PM, licensed practical nurse (LPN) #24 stated CNAs could not always complete resident care because of staffing issues. They stated sometimes there were only 3 CNAs scheduled on the day shift so residents could not always get showers, nailcare, or oral care completed. If oral care was not provided it could lead to gingivitis, tooth loss, infection, cavities, pain, and even being unable to chew foods. They stated they expected all residents to be offered oral care and if they refused the CNA should notify the LPN so the resident could be reapproached. During an observation and interview on 11/17/2023 at 12:33 PM, the resident was in their room with food particles in their lower teeth. The resident stated they had not had their teeth brushed for as long as they could remember and would like them brushed. During an interview on 11/17/2023 at 12:55 PM, CNA #20 stated they completed care for Resident #36 in the morning. They stated they did not complete oral care for Resident #36 because the resident refused oral care. They did not tell the nurse and should have. Oral care was important to prevent cavities and problems with the mouth. They stated to complete oral care they needed a toothbrush and toothpaste, or a swab and mouthwash and supplies were kept in the room or bathroom. They stated they were not able to locate a toothbrush, toothpaste, mouthwash, or mouth swabs in the bathroom or in any of the drawers in the resident's room. During an interview on 11/17/2023 at 2:46 PM, LPN #24 stated they wanted to know when anyone refused care. They stated they would expect oral hygiene supplies to be in every resident's room for ease of performing oral care. During an interview on 11/20/23 at 11:01 AM, nurse practitioner (NP) #32 stated if a resident did not have oral care completed, they could get dental caries (cavities), thrush (yeast infection of the mouth), and may not want to eat which could cause weight loss. 10NYCRR 415.12(a)(3)

Based on observation, record review, and interviews during the recertification survey conducted 11/13/2023-11/20/2023, the facility did not ensure residents were provided an ongoing program to support their choice of activities, designed to meet their interests and support their physical, mental, and psychosocial well-being for 2 of 2 residents (Residents #53 and #190) reviewed. Specifically, Resident #53 was not provided preferred activity when their television was non-functional; and Resident #190 was not provided meaningful activities that met their interests and preferences. Findings include: The facility policy, Resident Rights, reviewed and revised 10/18/2022, documented the nursing facility was committed to protecting and supporting the rights for each resident including freedom of choice to make their own, independent decisions through support of resident choice, such as to choose activities and schedules, participation in organizations and activities of their choice, and right to reasonable accommodations of needs. The facility policy, Assessment, Provision, and Documentation of Activity, reviewed and revised 10/20/2022, documented that every effort would be made to promote residents' participation in preferred, meaningful activities, which included care plans that are individualize and structured per the resident's interest, and reflect adequate level of stimulation. The facility would ensure residents' preferences for activities were identified and current, participation in those activities were maximized, and necessary accommodations were in place to enhance the resident's participation. The undated facility activity calendar for November documented the following activities: -11/13/2023 at 2:30 PM, Team Scattergories in the Chapel Garden. -11/14/2023 at 10:45 AM, Catholic mass in the Chapel Garden; 2:00 PM-4:00 PM, Woofs from the Dogs of [local dog rescue] on the 2nd and 3rd floor lounge, and room to room. -11/15/2023 at 2:30 PM, Bingo in the Chapel Garden. -11/16/2023 at 10:45 AM, Protestant services in the Chapel Garden; 2:00 PM, Let's Get Physical Exercise Group in the Chapel Garden. -11/17/2023 at 2:30 PM, Music in the Chapel Garden. -11/18/2023 and 11/19/2023, 1:1 visits - Lounge & Room to Room. The undated 2nd floor activity calendar for November 2023 documented the only activity added for the 2nd floor residents was on 11/17/2023 at 10:45 AM, morning exercise in the lounge. No additional activities were documented for the 2nd floor residents between 11/13/2023-11/19/2023. 1)Resident #53 was admitted to the facility with diagnoses including macular degeneration (vision loss), hearing loss, and muscle weakness. The 6/27/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact; required extensive assistance of one for most activities of daily living (ADLs); had moderate difficulty hearing; had impaired vision; felt it was very important to listen to music they liked, to keep up with the news, and go outside to get fresh air when the weather was good; and it was somewhat important to do their favorite activities. The 6/20/2023 recreation assessment documented that Resident #53 had poor/hard of hearing, poor vision, and was independent, but needed help with set up. It was very important they had music they liked, they kept up with the news, and got to go outside. The resident was a loner, and the TV was all the activity material the resident needed. The comprehensive care plan (CCP) revised on 6/26/2023 documented the resident was alert and able to make decisions regarding their preferences of care. Interventions included adapting programs as needed to promote success, introduce to peers with similar interest, offer and invite resident to preferred activities of interest, provide leisure materials for independent leisure time, and visit one on one as needed. The CCP revision on 7/27/2023 documented the resident was independently capable of pursuing their own leisure. Interventions included checking in for any needs or supplies such as large print reading materials and large print word puzzles. The resident's leisure interests were watching TV and listening to music. The 8/30/2023 activity participation documented Resident #53 was alert and oriented, they rarely wheeled their chair, they were a very private person and was hesitant to reveal their interests. The resident had refused all recreation groups to date. They stayed in their room and watched TV and used their phone to contact family. The 11/7/2023 health status note documented that resident was moved to an alternative room. The facility census documented the resident was returned to their original room on 11/9/2023. The undated resident activity log for November documented there were 38 activity categories for residents. The activity log categories included games, movie, nail care, sensory stimulation, social, strolls, and religion. The November 2023 activity log documented Resident #53 was offered 2 communication visits on 11/7/2023 and 11/14/2023. During an interview on 11/13/2023 at 11:40 AM, Resident #53's family member stated the resident sat in their room all day. The resident was moved to an alternative room and since then they did not have a working television. They stated they used the remote to turn on the television, without success. The resident had a hearing amplifier that was used for one-on-one situations but not in group settings. They stated the resident liked books on tape if someone could set it up for them as the resident could not see if the lights were on or use the buttons. During observations on 11/13/2023 at 11:40 AM, 11/14/2023 at 10:35 AM, 11/15/2023 at 11:31 AM, and 11/16/2023 at 9:06 AM, Resident #53 was seated in a wheelchair in the center of their room with no activity materials and the television was off. During an interview on 11/15/2023 at 11:07 AM, certified nurse aide (CNA) #8 stated there was a monthly activities calendar and the activities were the same for the whole facility and were held downstairs. They did not know if the activities were adapted to the needs of the resident as they had never seen an activity occur. They had seen the other unit CNAs facilitate drawing and coloring one time in the last month. Resident #53 preferred to stay in their room. They were not sure if any activities were available that met Resident #53's needs and abilities. During an interview on 11/15/2023 at 11:31 AM, Resident #53 stated that when they went to the temporary room on 11/7/23 they were not able to bring the television with them. Upon returning to their original room on 11/9/2023 the remote was no longer working for their television and they could not use it. They stated they were without their television from 11/7/2023 to 11/14/2023. During an interview on 11/16/2023 at 10:45 AM, licensed practical nurse (LPN) #9 stated that there was a calendar of events posted and activities were centrally located downstairs. Tuesdays and Thursdays were church services, Wednesdays was bingo, and Fridays there was musical entertainment. The recreation staff would come to the unit and asked the residents if anyone wanted to attend the posted activity. If residents were at different ability levels there would be two different activities, versus adapting one for all residents. LPN #9 had not seen activities staff go into Resident #53's room or provide them with activities to their ability level. LPN #9 stated there were not enough activities for the residents and it was important to have activities, because they had nothing to do. The resident became anxious doing nothing. If nursing did not provide activity, there would not be any. The residents just sat in front of the television in the dining room all day. During an interview on 11/16/2023 at 11:37 AM, registered nurse (RN) #2 stated sometimes recreation would come to the unit, but it would not be planned, and they would just show up and see if anyone was interested in an activity. They stated if a resident was deaf or blind, they would not have something for them specifically to do for activities. RN #2 stated recreation had books on tape, as they had seen them used before. The books on tape were set up and they could run by themselves. They stated activities were important as no one would want to just sit and stare at the wall all day and activities broke up the day and kept the residents socially engaged. During an interview on 11/16/2023 at 11:47 AM, RN #10 stated the calendar posted was for facility wide events. Recreation Leader #11 came up to the unit once or twice a week for unit specific events. They would show up to the unit with an activity, like horseshoes, balloon toss, or bowling. The recreation department had enough activities, however, the unit could add a few more activities. It would be nice to see the residents more involved. Activities were adapted to the resident abilities by residents helping each other. Resident #53 used their television as their preferred activity. The television was large and loud. During an interview on 11/16/2023 at 2:38 PM, licensed practical nurse (LPN) #9 stated that when Resident #53 was moved from their room to the alternate room they were given a smaller television without closed captioning. When the resident was moved back to their original room the TV remote did not work on the television. LPN #9 did not know when the television was fixed. The maintenance department was responsible for fixing televisions and a work order should be put in for assistance with the television. They stated Resident #53 was not provided other activities while their television was broken. During an interview on 11/16/2023 at 4:25 PM, recreation leader #11 stated that the director of recreation organized the facility events. Recreation leader #11 was responsible for units C and the second floor. Monday morning events were done briefly and done every other Monday between units C and the second floor. If a resident could not attend bingo, they would have no other activity for that day. CNAs on the unit sometimes did a mini movie with the lights down low during bingo for those that stayed on the unit. Recreation Leader #11 stated they were unaware of what the period was of Resident #53's television not working. Activities were important as the resident did not cook, clean, or work. Activities provided meaning for many residents. Some residents needed more support socially, and the recreation department tried to meet the needs for activity diversity and group size. Recreation Leader #11 stated there could always be more activities, and more could be provided if they had additional time to spend on one unit or another. During an interview on 11/17/23 at 11:50 AM, recreation leader #11 stated the facility had books on tape available, on CD and cassette in the gathering room. The residents tended to use them during independent time, but they had to be able to set up the devices themselves. 2)Resident #190 was admitted to the facility with diagnoses including spinal stenosis (narrowing of the spinal canal), epilepsy (seizure disorder), and hemiplegia affecting left dominant side (left side paralysis). The 8/15/2023 Minimum Data Set (MDS) assessment dated documented the resident was cognitively intact and required extensive assistance of two for most activities of daily living (ADLs). The 5/22/2023 MDS assessment documented it was very important to the resident to have books, newspapers, and magazines to read, listen to music they liked, be around animals such as pets, and to participate in religious services; it was somewhat important to do their favorite activities, to do things with groups of people, and to go outside to get fresh air when the weather was good. The comprehensive care plan (CCP) revised 6/24/2022 documented the resident was independently capable of pursuing own leisure activities. Interventions included independent leisure interests such as, TV (sports, news, history channel), music (country), outdoor activities, mass, dice, cards, current events, strolls, and socializing. Staff should periodically invite the resident to group activities they may enjoy, provide calendar of events, and provide conversation visits to maintain contact and rapport. The CCP was revised on 9/20/2022 and documented the resident was alert and able to make decisions regarding their preferences of care. Interventions included encouraging interactions socially with staff, peers, and visitors, offering and inviting the resident to preferred activities of interest, and providing weekly/monthly recreation calendars. The 6/24/2022 recreation leader #11 assessment documented Resident #190 required a wheelchair for mobility and was alert and oriented. It was very important they had their favorite activities to participate in. The activity preferences listed exercise/sports with additional clarifying comments of watching baseball, football, and college basketball. Resident #190 was a member of the American Legion and enjoyed playing cards. The 11/8/2023 recreation leader #11 activity participation note documented the resident was alert and oriented, they stayed in bed most of the day, they usually watched TV while in bed and followed major sports. They got up for Catholic mass on Tuesday mornings. When the resident was out of bed they participated in musical entertainment and unit activities, however, that did not happen often. The resident rarely read or worked on word puzzles. They participated in room-to-room activities, such as physical games and games of chance. Room activities, mass, and large group activities would be offered when they were out of bed. Transportation would be provided to all groups. The undated resident activity log for November documented there were 38 activity categories for residents. The activity log categories included games, movie, nail care, sensory stimulation, social, strolls, and religion. The November 2023 activity log documented Resident #190 was offered 1 entertainment/party on 11/3/2023, 1 communication visit on 11/6/2023, 1 recognition event on 11/11/20231, mass service on 11/14/2023, and 1 pet visit on 11/14/2023. During an observation and interview on 11/14/2023 at 9:18 AM, Resident #190 stated they enjoyed activities when they were available, but there were not many activities on the unit. The resident stated they mostly looked forward to Tuesday morning mass. During an interview on 11/15/2023 at 11:07 AM, certified nurse aide (CNA) #8 stated there was a monthly activities calendar and the activities were the same for the whole facility and were held downstairs. They did not know if the activities were adapted to the needs of the resident as they had never seen an activity occur. They had seen the other unit CNAs facilitate drawing and coloring one time in the last month. They stated Resident #190 preferred to stay in their room, and they were unsure if activities could be brought to their room. During an interview on 11/16/2023 at 11:15 AM, Resident #190 stated that the facility did not come to ask them about activities unless it was to go to mass on Tuesdays. At 2:47 PM, Resident #190 stated that if the facility offered sports related activities they would attend. They wanted to have a football or baseball game activity, or sports related trivia. They stated they greatly enjoyed historical related activities and a Super Bowl or World Series activity would be fun. During an interview on 11/16/2023 at 11:47 AM, RN #10 stated the calendar posted was for facility wide events. Recreation Leader #11 came up to the unit once or twice a week for unit specific events. They would show up to the unit with an activity, like horseshoes, balloon toss, or bowling. The recreation department had enough activities, however, the unit could add a few more activities. It would be nice to see the residents more involved. Activities were adapted to the resident abilities by residents helping each other. Resident #190 went to mass and was very interested in sports. They had the full listing of sporting events. There was a group of men that would sometimes get together to watch the local university sporting events, but they requested the television be changed for them, and it was not a pre-planned activity. During an interview on 11/16/23 at 1:03 PM, the Director of Recreation stated they created a shell of activities that were all house activities, meaning the entire building was included in to the one event. Those events were held in the chapel garden. Recreation leaders were assigned to specific units. They created additional small group activities that were added to the shell for their particular units. Once completed those were the documents hung up on the units and in resident rooms. The 2nd floor calendar indicated the only event listed on 11/15/2023 was bingo. If a resident did not prefer bingo, they would not have any activity for the day. This was scheduled every Wednesday. If a resident preferred not to attend church service, there were no other activities for them until 2:30 pm, which was an exercise class. They stated If a resident was blind and deaf, they could match the resident with a volunteer to assist with an activity. The recreation department had sensory activities, could do more room-to-room activities, or independent activities with assistance to help with a blind and deaf resident. If a resident had interest in sporting events, they had exercise activities and Bocce ball available. During an interview on 11/17/2023 at 12:40 PM, the director of nursing (DON) stated that activities were important for the residents, especially for cognition and happiness. The lack of activities could negatively affect the residents' quality of life. If a resident needed closed captioning on their tv, which was a preferred activity, it was expected the closed caption to be fixed or available right away, or an alternative activity of choice provided. Activities should be available for all interests and level of cognition. 10 NYCRR 415.5(f)(1)

Based on observation, record review and interview during the recertification and abbreviated surveys (NY00317835, NY00312624, NY00321818, NY00312845, NY00321300, NY00321978, NY00326461, NY00326492, and NY00326914) conducted 11/13/2023-11/20/2023, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 resident (Resident #146) reviewed. Specifically, Resident #146 had an unstageable (full-thickness pressure injuries in which the base is obscured by dead tissue) right heel pressure wound, and an unstageable right buttock wound and there was no documented evidence treatments were completed as ordered. Findings include: The facility policy Accountability of Medication and Treatment Administration revised 11/25/2016 documented the treatment nurse would document the administration of the treatment in the resident record immediately following the treatment. If the treatment nurse was unable to provide the treatment the charge nurse should be notified in a timely manner that the treatment could not be completed and notify the next shift the treatment could not be completed. The charge nurse should notify the Nurse Manager or nursing Supervisor the treatment was not completed. Resident #146 was admitted to the facility with diagnoses including an unstageable pressure ulcer of the right buttock and a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer of the right heel. The 10/4/2023 Minimum Data Set (MDS) Assessment documented the resident had intact cognition, did not reject care, was frequently incontinent of bowel, was at risk for developing pressure ulcers, had 1 stage 4 pressure ulcer and 1 unstageable pressure ulcer on admission, received pressure ulcer care, and received applications of ointments/ medications to areas other than their feet. The 9/28/2023, Weekly Wound/ Impaired Skin Tracking form completed by nurse practitioner (NP) #14 documented the resident was admitted with an unstageable right heel pressure wound that was 5 centimeters (cm) x 5.5 cm. The treatment plan included to cleanse with wound cleanser, apply wound gel every other day and as needed. Additionally, the resident was admitted with an unstageable sacrum (lower back) pressure wound that was 6 cm x 7.5 cm. The resident was being treated for osteomyelitis (bone infection) to the right heel. The treatment plan included to cleanse with wound cleanser, apply wound gel every other day and as needed, assist with toileting and incontinence care, assist with repositioning and they recommended an air mattress for their bed. The 10/4/2023, comprehensive care plan (CCP) documented the resident had an actual impairment to their skin. Interventions included avoid scratching; keep hands and body parts from excessive moisture; encourage good nutrition and hydration to promote healthier skin; monitor/document location, size and treatment of skin injury; report abnormalities, failure to heal, any signs or symptoms of infection to medical; a low loss air mattress for their bed; weekly treatment documentation to include measurement of each area of skin breakdown including width, length, depth, type of tissue and exudate; and any other notable changes or observations. The 10/14/2023 physician orders documented: - Cleanse the unstageable right heel pressure ulcer with wound cleanser, apply calcium alginate dressing (an absorbent dressing) cutting it to fit the wound, apply zinc (mineral that helps with healing), and cover with gauze. Lightly pack the undermining (erosion of tissue around the wound border) at 11-1 O'clock (location of area based on a clock) with calcium alginate daily on the day shift and as needed for wound care. - Cleanse the unstageable sacrum pressure ulcer with wound cleaner, apply calcium alginate dressing, cutting it to fit the wound, lightly packing to depth, apply Triad (a coating used to protect skin), cover with gauze, and use to use a brief to secure the dressing daily on the day shift and as needed for wound care. The 10/19/2023 Weekly Wound/ Impaired Skin Tracking completed by NP #14 documented the right heel pressure wound was a stage 4, had improved and measured 6 cm x 5 cm. Their treatment plan included to continue to cleanse with wound cleanser and apply calcium alginate dressing and follow up with the wound consult physician as recommended. The 10/2023 Treatment Administration Record (TAR) documented; - to the unstageable right heel, cleanse with wound cleanser, apply calcium alginate cutting to fit wound, apply zinc to peri wound, cover with gauze, and rolled gauze; to undermining from 11-1 O'clock lightly pack with calcium alginate every day shift. - to the unstageable sacrum, cleanse with wound cleanser. apply calcium alginate cutting to fit wound, lightly packing depth; apply Triad to peri wound, cover with ABD pad (absorbent dressing), and use brief to secure the dressing. The was no documentation the treatments to the right heel or the sacrum were completed on 10/23/2023. Licensed practical nurse (LPN) #48 documented they had provided the resident their medications and signed for them on the medication administration record (MAR) on 10/23/2023. There were no nursing progress notes for 10/23/2023 documenting the reason the treatments were not done. The October 23, 2023, B unit Day Shift Unit Assignment sheet documented there was 1 registered nurse (RN) Unit Manager, 1 LPN, and 3 certified nurse aides (CNAs) on the day shift. On 10/23/2023, NP #14 documented they and the Unit Manger and called and spoke to the resident's family about the resident's wounds and why healing was delayed. They reviewed the treatment order and the family had concerns and social work and nursing were aware. The 10/2023 Treatment Administration Record (TAR) documented; - to the unstageable right heel, cleanse with wound cleanser, apply calcium alginate cutting to fit wound, apply zinc to peri wound, cover with gauze, and rolled gauze; to undermining from 11-1 O'clock lightly pack with calcium alginate every day shift. - to the unstageable sacrum, cleanse with wound cleanser. apply calcium alginate cutting to fit wound, lightly packing depth; apply Triad to peri wound, cover with ABD pad (absorbent dressing), and use brief to secure the dressing. The was no documentation the treatments to the right heel or the sacrum were completed on 10/24/2023. LPN #50 documented they had provided the resident their medications and signed for them on the medication administration record (MAR) on 10/24/2023. There were no nursing progress notes for 10/24/2023 documenting the reason the treatments were not done. The 10/24/2023, The B unit Day Shift Unit Assignment sheet documented there was 1 RN Unit Manager, 2 LPNs, and 4.5 CNAs. On 10/25/2023, NP #30 documented they spoke to the resident's family member as they felt the resident's sacrum wound had gotten worse. NP #14 spoke to the family about the wound upon admission and how it was currently doing. The resident continued to be followed by the wound care physician twice monthly. The family member discussed the resident's incontinence of stool and hygiene of the wound. NP #14 communicated the family members concerns to the wound care physician. The family member was explained that the resident's hospitalization , infection, and use of antibiotics all played a part in wound healing. The 10/2023 TAR did not document the resident's dressing changes to their right heel and sacrum were completed on 10/30/2023. LPN #48 documented they had provided the resident their medications and signed for them on the MAR on 10/30/2023. The 10/30/2023, Day Shift Unit Assignment Sheet documented there was 1 RN Unit Manager, 1 LPN, and 2.5 CNAs. During an interview on 11/13/2023 at 1:02 PM, Resident #146 stated their wounds were improving, but their treatments were not always done. They stated it was hard to keep the area on their sacrum clean because they had loose stools at times and felt like the facility did not have enough staff to do everything they needed to do. During an interview on 11/16/2023 at 4:28 PM, RN Unit Manager #29 stated treatments were documented on the TAR when they were completed. If a nurse did not sign for the treatment, it meant they either failed to document the treatment was completed or they did not complete the treatment as ordered. If another nurse or physician completed the dressing the nurse should document who completed the treatment in the medical record. They stated typically the unit was scheduled with 2 nurses, usually 2 LPNs on the medication and treatment carts. Sometimes there would only be 1 nurse on the unit due to the census of the unit. If the census was 25 residents or less than they would have only 1 nurse on the treatment and medication carts. If a nurse was unable to complete treatments per the physician order, they should let the RN Unit Manager or RN Supervisor know so they could provide help or notify the physician the treatment was not done. Usually, the treatments also had an as needed order so they could be done anytime if they were not completed as scheduled. They stated they were not made aware of any treatments not being completed as ordered. During a telephone interview on 11/16/23 at 5:00 PM, LPN #48 stated if a resident had a wound treatment order it was located on the TAR and whoever completed the treatment should sign the TAR or document that it was completed by someone else. They stated if they signed that they provided the resident their medications then they were usually the nurse assigned to that resident. They also stated if they were working with Resident #146 that meant they were the only nurse passing medications and doing treatments on the unit. They stated they might not have documented the treatment was completed because there was not enough staff on the unit, and they should document a progress note if someone else completed the dressing change. During a follow up interview on 11/20/2023 at 11:40 AM, LPN #48 reviewed the resident's electronic medical record including the MAR and TAR. They stated they were the nurse assigned to Resident #146 on 10/23/2023 and 10/30/2023. They stated if they were the only nurse, it all came down to time and if they did not document the treatment was completed it was not done or they did not have time to sign for it. They stated it was important for treatments to be completed as ordered to promote wound healing. They stated they would ask for help when they needed to. During a follow up interview on 11/20/2023 at 11:55 AM, RN Unit Manager #29 stated nursing staff should document on the TAR when a treatment was completed. They had not been made aware the resident's treatments were not completed and they would want to be made aware. It was important for treatments to be completed to aid with wound healing. During an interview with Director of Nursing (DON) on 11/20/2023 at 12:41 PM, they stated it was expected that nursing staff complete the treatments per the physician's orders and document it was completed on the TAR. If for some reason a treatment could not be completed as ordered the RN in charge should be made aware and the physician should be notified. They stated if the treatment had not been signed as completed it meant the treatment was not done. They had not been notified treatments were not being completed due to possible lack of staffing on the B unit. It was important to complete the treatments as ordered to promote wound healing. 10 NYCRR 415.12

49448 Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00326492) conducted 11/13/2023- 11/20/2023, the facility did not ensure the implementation and development of person-centered comprehensive care plans (CCP) to meet residents' medical, nursing, and mental and psychosocial needs for 4 of 5 residents reviewed (Residents #91, #116, #141, and #216). Specifically, Residents #91's and #216's CCP did not include isolation precautions; Resident #116 did not receive ordered treatments or consume meals in the dining room as care planned; and Resident #141's low air loss mattress (used for pressure reduction) settings were not implemented as planned. Findings include: The facility policy Baseline Care Plan revised 12/23/2021, documented the care plan included physician orders, dietary orders, and infections. Direct care staff were educated about care plan interventions, services, and treatments to be administered by the facility and personnel acting on behalf of the facility. The facility policy Comprehensive Care Plans revised 10/17/2022, documented the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that were identified in a comprehensive assessment. The comprehensive care plan should be reviewed and revised based on changing goals, preferences, needs of the resident, in response to current interventions by the Interdisciplinary Team (IDT) after each assessment, and inclusive of the comprehensive and quarterly review assessments. The care plan should describe services that are furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. 1) Resident # 91 was admitted to the facility with diagnoses including obstructive and reflux uropathy (urine obstruction and backflow). The 9/7/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 1 for bed mobility, extensive assistance of 2 for transfers and toileting, and had an indwelling catheter (a tube used to drain urine into a collection bag), and did not have any multidrug-resistant organisms (MDRO). The CCP initiated 2/10/2023 documented the resident had occasional bladder incontinence. The CCP did not include the presence of MRSA (methicillin-resistant Staphylococcus aureus, a bacteria resistant to many antibiotics) in the resident's urine. There was no documented evidence the resident was planned for contact precautions. The undated resident care instructions (Kardex) did not include isolation precautions. The 7/20/2023 nurse practitioner (NP) #30 progress note documented the resident had MRSA in the urine. There were no documented physician orders for contact precautions from 7/20/2023-11/17/2023. During an observation interview on 11/13/2023 at 10:46 AM, Resident #91 had a contact precaution sign on the door frame of their room and a plastic cart containing personal protective equipment (PPE) outside the room. Certified nurse aide (CNA) # 27 stated the resident was on isolation for MRSA in their urine. The contact precaution sign on the door frame and a plastic cart with PPE remained outside the resident's from 11/13/2023-11/17/2023. During an interview 11/17/23 at 11:36 AM registered nurse (RN) Unit Manager #29 stated they were responsible for creating care plans. They stated that if a resident was on transmission based precautions it should be on the care plan. Precautions should be triggered to show on the Kardex (care instructions), and CNAs were expected to review the Kardex at the beginning of each shift. If precautions were not listed on the Kardex the CNAs would not know the resident was on precautions. They stated it was important for staff to know about transmission based precautions to prevent the spread of infection. They stated Resident #91 was on precautions and they did not put it on their care plan. 2) Resident # 116 was admitted to the facility with diagnoses diabetes mellitus, peripheral vascular disease (PVD, poor circulation), and right below the knee amputation (BKA). The 8/14/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 1 for bed mobility, transfers, dressing, eating, and toileting, and received application of non-surgical dressings and application of ointments/medications. The comprehensive care plan (CCP) initiated 10/29/2020 and revised 11/7/2023 documented the resident was to have meals in the dining room for close observation and encouragement. Resident #116's care instructions (Kardex) as of 10/1/2023 documented the resident would have meals in the dining room for close observation and encouragement. The 11/2023 treatment administration record (TAR) documented apply ACE wrap to left lower extremity (LLE) to above knee every morning for preventative skin care. Apply tubigrip (elastic covering) to LLE in the morning (9:00 AM) related to edema and remove per schedule (8:59 PM). There were no corresponding physician orders for ACE wraps or tubigrips. There was no documented evidence the application of ACE wraps or tubigrips was included in the resident's CCP. Resident #116 was observed: - on 11/14/2023 at 9:49 AM, in the hallway, wearing a hospital gown with their left leg exposed without an ACE wrap or tubigrip. - on 11/14/2023 at 10:49 AM wearing a hospital gown in their room with their left leg exposed without an ACE wrap or tubigrip. - on 11/14/2023 at 12:24 PM, sitting in a wheelchair in their room in front of a bedside table that had their lunch tray. - on 11/15/2023 at 9:15 AM, sitting in bed wearing a hospital gown with their left leg exposed without an ACE wrap or tubigrip. Their breakfast tray was on the bedside table. - on 11/15/2023 at 1:00 PM in their room sitting in a wheelchair with their lunch tray on their bedside table. - on 11/16/2023 at 8:34 AM, sitting in their wheelchair. Their left foot had a non-skid sock without an ACE wrap or tubigrip. At 9:04 AM eating breakfast in their room. The resident stated they always ate meals in their room. Their left leg did not have an ACE wrap or tubigrip in place. - on 11/16/2023 at 11:33 AM sitting in their wheelchair without an ACE wrap or tubigrip on. - on 11/16/2023 at 12:50 PM sitting in a wheelchair in their room eating lunch. Their left leg did not have an ACE wrap or tubigrip. - on 11/16/2023 at 2:18 PM and 3:06 PM sitting in their wheelchair without an ACE wrap or tubigrip on their left leg. The 11/2023 medication administration record (MAR) documented OOB (out of bed) to dining room for all meals, three times a day for monitoring/supervision. The MAR documented the task was completed: - on 11/14/2023 at 1:00 PM by LPN #48 - on 11/15/2023 at 8:00 AM and 1:00 PM by LPN #56 - on 11/16/2023 at 8:00 AM by LPN Staff Educator #28 and at 1:00 PM by LPN #21. The 11/2023 TAR documented ACE wraps and tubigrips were applied to the resident's LLE at 9:00 AM: - on 11/14/2023 at 9:00 AM by LPN #48. - on 11/15/2023 at 9:00 AM by LPN #56. - on 11/16/2023 at 9:00 AM by LPN Staff Educator #28. During an interview on 11/16/2023 at 2:24 PM, certified nurse aide (CNA) # 25 stated supervision with meals meant a resident was watched while they ate to help them or for choking precautions and that information would be on their Kardex. They stated they reviewed the Kardex at the beginning of the shift but did not see that the Resident # 116 was supposed to eat in the dining room. They stated if a resident was supposed to have meals in the dining room, they should not be eating in their room. During an interview on 11/16/2023 at 2:30 PM, LPN Staff Educator #28 stated if the resident was care planned for supervision while eating, they should eat in the dining area. CNAs were expected to check the Kardex every shift and follow it. They stated they did not know what a tubigrip was but it, as well as an ACE wrap, would be documented on the TAR. They stated if they signed it off on the TAR it meant the ACE wrap and tubigrip were in place. They stated they completed and signed off this task at approximately 1:45 PM that day. During an interview on 11/17/23 at 11:21 AM, RN # 29 stated that Resident # 116 was supposed to be supervised with meals and they expected the resident to eat in the dining room. They stated they had not seen the resident eat in the dining room for any meals from 11/13/2023 to 11/17/2023. They expected staff to know what a tubigrip was and if it was signed off on the TAR as completed, the tubigrips should be in place. They expected staff to follow medical orders and sign orders for treatments at the time they were completed. 3)Resident #141 was admitted to the facility with diagnoses including peripheral vascular disease (PVD, poor circulation), dementia, and muscle weakness. The 10/20/2023 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, was dependent for rolling from back to sides, was not transferred from bed to chair due to medical condition, was at risk for the development of pressure injury, did not have pressure injury, and had a pressure reducing device for the bed. The care instructions (Kardex) initiated 12/11/2021 documented monitor bed, pressure relieving surface low air loss mattress set at 120-130 pounds every day. An 8/29/2023 nurse practitioner (NP) #32 progress note documented the resident was resistant to turning and positioning and insisted on lying flat in their bed. Nursing reported the resident's back had a red, inflamed rash. The resident's back from shoulder blades to lumbar area above the hips was deep red in color. The plan included the resident was placed on a turning and positioning schedule and they would order a low loss air mattress. An 8/29/2023 NP #32 medical order documented low air loss mattress (used to distribute body weight over a broad surface to prevent skin breakdown), set at [120-130] pounds every shift for pressure relief, check setting. The CCP initiated 9/24/2021 and revised 8/8/2023 documented the resident had potential impairment to skin integrity. Interventions did not include a low air loss mattress. The resident had an order for no weights. The resident was observed lying in bed with their alternating air mattress set at a static normal pressure of 200 pounds: - on 11/14/2023 at 10:47 AM; - on 11/15/2023 at 8:35 AM; - on 11/16/2023 at 9:34 AM and 11:21 AM; and - on 11/17/2023 at 9:33 AM. The 11/2023 treatment administration record (TAR) documented low air loss mattress, set at [120-130] pounds every shift for pressure relief, check setting on days, evenings, and nights. The TAR documented the mattress was checked: - on 11/14/2023 days and evenings by licensed practical nurse (LPN) #57 and nights by LPN #58 - on 11/15/2023 days and evenings by LPN #21 and nights by LPN #59 - on 11/16/2023 days by an unidentified nurse, evenings by LPN #59, and nights by LPN #58. - on 11/17/2023 days by LPN #21. During an interview on 11/16/23 10:46 AM certified nurse aide (CNA) #20 stated residents at risk for pressure could get skin breakdown and an intervention to prevent skin breakdown was an alternating air mattress. They stated CNAs did not check the mattress settings, they just checked to see if the mattress was turned on. They stated if the mattress was not on, they would report it to the LPN because if the mattress was not set correctly the resident could get pressure sores. During an interview on 11/17/2023 at 9:37 AM LPN #21 stated nurses checked the bed every shift and documented it on the TAR. They stated they checked the order this morning and thought the order was for the pressure to be set at 160-165. They stated they were sure the mattress was at the correct settings. If the mattress was set too low, there would not be enough air and could cause skin breakdown. If the setting was too high, it would be too firm and could cause skin breakdown. LPN #21 reviewed the TAR and stated the order was for 120-130 and looked at the bed setting and stated it was set at 200 which was too high and not the ordered setting. During an interview on 11/17/23 at 2:46 PM LPN #24 stated the purpose of an air mattress was to prevent skin breakdown. Settings were ordered according to the residents' weight and if the setting was set below the ordered setting it would be too soft and the resident's body could hit the metal of the bed causing skin breakdown. They stated If the setting was set higher than ordered it could be too hard causing more pressure and could lead to skin breakdown. LPN #24 stated staff knew the settings because they were documented in the care plan, and both CNAs and LPNs checked the air mattresses. During an interview on 11/20/2023 at 11:01 AM NP #32 stated they ordered low air loss mattresses to prevent skin breakdown for residents that were immobile or spent time in bed. They determined the settings by the weight of the resident. If the setting was too low, it would not have enough inflation and would not benefit the resident. If the setting was set too high, it would be too much pressure and not provide pressure relief. They stated they would not expect the setting to be at 200 if it was ordered to be 120-130. During an interview on 11/20/23 at 2:15 PM the DON stated the purpose of a low air mattress was to alternate pressure for wound healing and wound prevention. If it was set too high or too low, it would not relieve the pressure and the resident could develop pressure ulcers. NY10CRR 415.11(c)(1)

Based on observation, interview and record review during the abbreviated (NY 301) survey, the facility did not ensure the resident's environment remained as free of accident hazards as possible for 1 of 4 residents (Resident #1) reviewed for accidents. Specifically, staff utilized an incorrect, non-facility issued mechanical lift sling and positioned Resident #1 improperly during a transfer. The resident fell from the mechanical lift onto the floor and sustained a laceration to the head requiring staples. This resulted in actual harm to Resident #1 that was not immediate jeopardy. Findings include: The 6/9/17 facility's Use of Mechanical Lift Device Policy documents safety measures will be taken to ensure safe transfers for the residents including correct use of sling (a support that wraps around the body and secured to the lifting device with straps or chains) size, positioning of the resident on the sling prior to transferring and requiring at least two staff members to use the mechanical lifts. The procedure documents nursing staff verifies the resident requires transfer with a mechanical lift and that the appropriate sling (and sling size) is being utilized as directed per the Resident Plan of Care (RP[NAME], care instructions). Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 9/2/19 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and she was dependent for transfers. The 8/29/19 comprehensive care plan (CCP) documented the resident had an ADL (activity of daily living) self-care performance deficit and was at high risk of falling. Interventions included 2 staff for transferring using a Hoyer (mechanical) lift. The 9/11/19 RP[NAME] documented the resident was totally dependent with assistance of 2 staff for transfers using a Hoyer lift. The RP[NAME] did not document the type or size of the Hoyer sling the resident required. The 9/19/19 at 12:32 PM, nursing progress note documented during a transfer with a Hoyer lift, the resident slid off the Hoyer sling, fell to the floor on her buttocks and hit the right side of her head on the Hoyer lift legs. Two staff and the resident's family member were present. The resident had a laceration to her right scalp and was transferred to the hospital for evaluation. The 9/19/19 Incident Report, completed by registered nurse (RN) #1 documented during a transfer with a Hoyer lift, the resident slid from the Hoyer sling while being moved from her bed to the wheelchair, and fell to the floor. Staff statements documented: - On 9/19/19, certified nurse aide (CNA) #2 was Hoyer lifting the resident out of bed. When she turned the Hoyer towards the wheelchair, the resident slipped out and hit her head on the base of the Hoyer. CNA #3 assisted CNA #2 with the transfer and the resident's family member was present during the incident. The investigative summary completed by registered nurse (RN) #1 documented the Hoyer sling was found to be from the hospital and not a sling issued by the facility. The sling fabric was shiny and slippery and did not fasten around the legs like other Hoyer slings. The facility was searched and all non-approved slings (from the hospital) were thrown away. All slings issued by the facility were labeled with the facility name and staff were educated to only use facility labeled slings. The investigation concluded the resident sustained [REDACTED]. The 9/19/2019 nurse practitioner (NP)'s progress note at 4:05 PM, documented she was paged to urgently assess the resident who slid out of the Hoyer lift sling onto the floor. The resident landed on her buttocks on the floor and hit her head on the frame of the Hoyer lift. When the NP arrived, the resident was on the floor and a nurse was putting pressure behind the resident's head with an ice pack. An ambulance was called, and the resident was sent to the emergency room . The 9/19/2019 at 9:55 PM, RN Supervisor (RNS) #14's progress note documented the resident returned from the hospital with 4 staples in her head. On 10/3/19 at 12:10 PM, the resident's family member stated in an interview, he witnessed CNAs #2 and 3 transfer the resident. He stated when the CNAs lifted the resident into the air, the resident slid to the floor. He stated the Hoyer lift sling the CNAs used was white in color and he did not recall seeing the sling crisscrossed between the resident's legs during the transfer. During the interview, the family member found another incorrect Hoyer sling from the hospital stored in one of the resident's drawers and stated the facility staff told him they threw all those away. On 10/3/19 at 2:15 PM, CNA #2 stated in an interview she was agency staff and floated to different units throughout the facility. She stated there were different types of Hoyer lifts on the unit, some were old, and some were new. The Hoyer lift slings were usually kept in resident rooms and that was how she knew which sling to use for a resident. She stated she had never cared for Resident #1 until 9/19/19 and when she transferred the resident that day, she used a white Hoyer lift sling because it was in the resident's room draped on a chair. She was not familiar with the sling and had not seen it before. The sling had a similar shape to the ones that could not be crisscrossed between the legs. She took the sling from the chair, placed it under the resident and did not crisscross the sling between the resident's legs. CNA #3 assisted CNA #2 with the transfer, they turned the resident toward the wheelchair and the resident slipped out of the Hoyer sling. The resident landed on her buttocks first and then hit her head. She stated when she placed the unfamiliar sling under the resident, she was not concerned because there were so many different Hoyer slings in the building. She stated the only way to know which sling to use for a resident was the sling would be kept in the resident's room. On 10/3/19 at 3:45 PM, CNA #3 stated in a telephone interview Hoyer slings always crisscrossed between a resident's legs and only the ones from the hospital did not. He stated the resident's sling was already hooked to the Hoyer when he arrived to assist CNA #2 with the transfer. He noticed the sling was not crisscrossed between the resident's legs and he never said anything to CNA #2 about it. On 10/3/19 at 3 PM, RN #1 stated in an interview, she completed the investigation and reviewed the incident to ensure the correct number of staff were present during the transfer and if they transferred correctly. She stated when a resident utilized a Hoyer per their care plan, it included using the appropriate sling and applying it correctly. Crisscrossing the sling between the resident's legs prevented a resident from sliding out. She stated she found during the investigation, the resident had the wrong sling, staff did not crisscross the sling between the resident's legs and that was a care plan violation. On 10/16/19 at 8:45 AM, NP #7 stated in an interview, she was at the facility the day the resident fell from the Hoyer and she assessed the resident after the fall. She stated at that time, the resident only complained of head pain. The resident went to the hospital and received staples to a [MEDICAL CONDITION]. She stated she became aware a day later that staff used the incorrect Hoyer sling and later found out staff did not crisscross the sling during the transfer. She stated not crisscrossing the sling and using the wrong Hoyer sling directly contributed to the resident fall. On 10/16/19 at 10:45 AM, the DON stated in an interview after she received CNA #2's statement, she questioned her about the Hoyer sling and whether she fastened it around the resident's legs properly. She determined the sling that was used with the resident was a non-facility issued sling and was obtained from the hospital. She stated the facility had slings that crisscrossed between the legs and slings that did not crisscross but cradled a resident. Physical therapy determined which type of sling a resident required. She stated she was not sure if the type of sling was documented on the RP[NAME] and was not sure how staff knew which sling to use. On 10/25/19 at 1:00 PM, physical therapist (PT) #19 stated in an interview, staff were trained when hired in using Hoyer lift pads so they should all be aware of how to use them. She stated the facility did not have any Hoyer lift pads that cradled residents. The lift pads available in the facility all crisscrossed between the resident's legs. 10NYCRR 415.12(h)(1)

Based on observation, record review, and interview conducted during the recertification survey, the facility failed to ensure that the residents' environment remained as free of accident hazards as possible; failed to have a system in place to identify the potential for resident entrapment by side rails; failed to assess resident safety in their side rail use regarding the 7 entrapment zones identified by the Food and Drug Administration (FDA) bed component safety guidelines; failed to develop criteria for assessing the safe use of the various side rail types present in the facility; failed to develop and implement policies and procedures to monitor residents' beds, mattresses, and side rails to reduce the risk of entrapment; and failed to educate staff on the entrapment risks associated with side rail use. Specifically, the facility did not conduct reviews of the 105 beds with side rails for appropriate use for the resident or entrapment risk. For 8 sampled residents' beds (Residents #4, 7, 8, 10, 11, 12, 16, and 33) and 40 of 66 observed beds, the beds contained unsafe side rail spacing from 7 inches to 16 inches. The measurements exceeded the FDA recommended space between rails of less than 4-3/4 inches for zones 1 and 2 and less than 2-3/8 inches for zones 3 and 4. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. The Immediate Jeopardy was removed on 10/14/2016, prior to the survey exit. Additionally, for 5 of 27 sampled residents (Residents #3, 6, 14, 23, and 24) and one additional resident (Resident #43), reviewed for accidents, the facility did not consistently provide supervision and assistance devices to prevent accidents. Specifically, Resident #6 had an escalation in behaviors, and timely interventions and supervision were not implemented. Residents #3, 14, 23, and 24 had histories of falls and were care planned to have fall mats, anti-skid strips, or a combination of the two, and were observed during survey without the interventions in place. Resident #43 was observed with an unsecured oxygen tank in her room. Findings include: Side rails: The New York State Department of Health Nursing Home Dear Administrator Letter (NYSDOH NH DAL) 15-05 entitled Entrapment Risk with Bed Systems and Components dated 6/19/15 documented the facility was to re-examine the nursing home's systems to ensure that adequate safeguards are in place for all aspects of bed safety encompassing the function of the beds' use. In addition, the DAL also recommended the facility review the FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment and use it as a resource to ensure bed systems and assistive bed components were safe. The Guidance for Industry and FDA Staff (the industry standard) for The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, with an issue date of March 10, 2006 and presented by the Center for Devices and Radiological Health, documented the following dimensions: - Zone 1, the area within the rail, should not exceed 4-3/4 inches; - Zone 2, the area between the rail and the mattress, should not exceed 4-3/4 inches; - Zone 3, the area between the rail and the mattress/platform, should not exceed 2-3/8 inches; and - Zone 4, the area between the rail and the mattress/platform, should not exceed 2-3/8 inches. 1) Resident #8 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 4/22/2016 documented the resident was at risk for falls and to modify the resident's environment to reduce the risks of fall-related injuries. The CCP documented the resident required 1-2 assistance as needed with bed mobility and moderate assistance with transferring. When the resident was unable, staff were to turn and reposition her every 2 hours. The CCP documented the resident had a 3/4 side rail to be up on the right side. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required extensive assistance of 1 for bed mobility and transfers. The resident's record had no evidence that the use of the 3/4 side rail had been assessed to determine the resident's ability to use the side rail and to discuss the safety risks with the resident. The certified nurse aide (CNA) care instructions dated 10/7/2016 documented the resident required minimum to moderate assistance with transfers and mobility, and the resident had a 3/4 side rail up on the right side of the bed. The physician order [REDACTED]. The resident was observed in her room in bed with one 3/4 side rail up on the right side on 10/11/2016 at 9:48 AM and 10:20 AM; and 10/12/2016 at 8:46 AM, 9:30 AM, and 10:10 AM. The resident's empty bed was observed on 10/11/2016 at 1:20 PM; and on 10/12/2016 at 12:19 PM, 1:27 PM, 2:07 PM, 3:01 PM, and 3:40 PM, with one 3/4 rail up on the right side. During an interview with the resident on 10/11/2016 at 2:20 PM, she stated she did not get up without staff assistance. She stated she did not know why she had the side rail, and the side rail was up at all times and was not able to go in the down position. During the interview the resident's 3/4 side rail was up on the right side with a gap between the mattress and the full length of the side rail, and the resident was seated in her wheelchair next to the bed. The semi-private/private bed breakdown sheet provided by the facility on 10/12/2016 identified Resident #8's room contained a bed with a manufactured side rail type that did not meet FDA requirements. The breakdown sheet documented the facility contained a total of 39 beds with the same type of side rails present in the facility. In an interview with the Director of Support Services on 10/12/2016 at 12:04 PM, he stated the bed breakdown sheet inventory was last conducted in 2015 for HUD (Housing and Urban Development). During an interview with CNA #47 on 10/12/2016 at 12:31 PM, she stated if a resident had a side rail in place, it would be in the up position and documented on the CNA care instructions. She stated if a side rail was not to be used, it would be tied down to the side of the bed and inaccessible. She stated she was not aware of any mattresses that slid to the left or right causing gaps, and she had not had to report any side rail concerns to nursing or maintenance. During an interview with registered nurse (RN) Manager #45 on 10/12/2016 at 12:37 PM, she stated the admitting RN was responsible for assessing a resident for a side rail. She stated they would then contact the physician or nurse practitioner for an order for [REDACTED]. She stated if a side rail was used for mobility, it was not assessed as a potential restraint or safety risk. She stated she did not know how it was decided what type and length of side rail would be put into place. She stated when an RN decided a side rail would be implemented, they notified maintenance and maintenance installed the side rail. She stated she had been at the facility a couple weeks and she had not been educated on the facility's policy for side rail use and assessment. She stated the residents' CCPs were supposed to be updated by the RN Managers or Assistant Managers. On 10/12/2016 between 10:10 AM and 10:45 AM, the following was observed for the side rail zone dimensions of the resident's bed: - Each Zone 1 gap in the side rail was 7-3/4 inches wide by 16 inches high (above the 4-3/4 inch recommendation by the FDA for Zone 1); and - No mattress devices to limit mattress movement were observed on the bed. The mattress was able to to slide around, which created the potential for Zone 3 and Zone 7 entrapment. 2) Resident #7 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact (BIMS score 15 of 15). The MDS also documented that the resident was at risk for falls. On 10/11/2016 at 12:47 PM, Resident #7 was observed in bed with the right 3/4 length side rail in the up position. On 10/12/2016 between 10:10 AM and 10:45 AM, the following was observed for the resident's side rail zone dimensions: - Each Zone 4 gap in the side rail ends was 7 inches high (above the 2-3/8 inch recommendation by the FDA for Zone 4); - Zone 2 openings between the bed and the side rail were 7 inches; - No mattress devices to limit mattress movement were observed on the bed. The mattress was able to to slide around, which created the potential for Zone 3 and Zone 7 entrapment. 3) Additional Observations: On 10/11/2016 between 10:15 AM and 12:55 PM, and on 10/12/2016 between 10:10 AM and 2:00 PM, the following rooms were observed with Zone 1 side rail gaps measuring 7-3/4 inches wide by 16 inches high (above the 4-3/4 inch recommendation by the FDA for Zone 1): for Residents #4 and 16, and resident rooms 70, 92-2, 101, 104-1, 204-2, 206-1, 318-2, and 334-1. On 10/11/2016 between 10:15 AM and 12:55 PM, and on 10/12/2016 between 10:10 AM and 2:00 PM, the following rooms were observed with Zone 2 openings between the bed and the side rail that were 7 inches (above the 4-3/4 inch recommendation by the FDA for Zone 1), and Zone 4 openings on the side rails ends that were 7 inches high (above the 2-3/8 inch recommendation by the FDA for Zone 4): for Residents #10, 11, 12, and 33, and resident rooms 20, 26-2, 50, 58, 60, 71, 86-1, 86-2, 88-1, 88-2, 89-1, 91-1, 92-1, 94-1, 94-2, 95-1, 96-1, 97-1, 97-2, 98-1, 98-2, 99-1, 104-2, 105-1, 105-2, 106-1, 106-2, 204-1, 214-2, 220-2, 332-1, and 332-2. In an interview with the Vice President for Nursing Facility on 10/12/2016 at 2:10 PM, he stated the following: - He was aware of the Department of Health DAL regarding side rails; - He was aware of safety concerns with the resident's side rails and stated he had been doing review of side rails for years; - A survey of beds was done approximately 4 years ago and older beds were identified that needed to be changed out; - He was not aware of the areas for entrapment and stated he only recalled that the maintenance team made a high recommendation for older beds to be changed out as fast as they could; - He was unsure if all staff were educated about about side rails and the potential for entrapment; - He could not recall what was done in 2015 based on the DAL; - He was aware of the FDA Guidelines and a copy was observed on the desk at the start of the interview; - It was his understanding that 3 types of beds with problematic side rail spacing were present in the facility. Only one particular older model was addressed with a replacement plan, and he thought there were approximately 30 of those remaining in use in the facility. In an interview with the Director of Support Services on 10/12/2016 at 2:30 PM, he stated the following: - Maintenance installs side rails if nursing needs them; - Approximately 1 month ago, side rail orders for new admissions were shared with maintenance to instruct them of the resident's side rail needs. Examples provided were: 1 side rail, 2 side rails, no side rails; - He was aware of the FDA guidelines in approximately 2007 or 2008. He stated he had recently reviewed the guidelines because a surveyor was asking questions about them; - He did not receive DALs and could not recall if he received the DAL regarding side rail entrapment; - He conducted an inventory of beds types in the facility in 2015 and had not conducted an inventory of what beds have side rails and what types of side rails the beds have; - He was aware of the 7 zones of entrapment and stated the beds may have been assessed for entrapment risks years ago, possibly prior to the current Administrator. In an interview with the Director of Support Services on 10/12/2016 at 4:30 PM, he stated he was aware of the Hazardous Items policy, as his name was on it. He stated maintenance staff did not conduct a bed assessment to evaluate beds and side rails for the 7 zones of entrapment. He stated the facility bought 9 new beds in 2016. In an interview on 10/12/2016 at 8:35 PM with the Administrator, the Vice President for Nursing Facility, the Director of Nursing, and the Vice President for Quality Management, they stated they had identified that 105 beds (of 284 total beds) in the facility had side rails. They identified 3 categories for the 105 beds: side rail(s) with no order; side rail(s) with an order, but the resident did not need side rail(s); and side rail(s) with an order, and the resident needed them. The facility was in the process of assessing residents for side rail need, and planned to discontinue side rails for any resident who did not have an order and/or did not require them, and all mattresses would be stabilized against sliding. The Immediate Jeopardy was removed on 10/14/2016 based upon the following corrective actions taken by the facility to reduce the risk of side rail entrapment: - Development of a policy and procedure to access the safety of facility beds using the FDA guidelines and assessment of residents for safe side rail use when needed. - Development and implementation of entrapment reduction controls including the discontinuance of side rail use for beds that did not meet the FDA guidelines, disabling side rails with heavy duty plastic bands to prevent use, and the installation of hook and loop stabilizing tape to reduce the potential for mattress movement. - Training of all duty staff in safe side rail use, the 7 potential zones for entrapment, and the importance of notifying others in the event of unsafe side rail use or entrapment. Falls: 4) Resident #23 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment. He required extensive assistance with one staff for transfers, did not ambulate in his room, used a wheelchair, and had a history of [REDACTED]. A fall risk assessment dated [DATE] documented the resident was at high risk for falls. An interim care plan review form dated 8/11/2016 documented the resident had a fall from bed on 8/6/2016. An interim care plan review form dated 8/25/2016 documented the resident had a fall from bed on 8/19/2016, and a mat was on the floor. The undated nursing staff assignment sheets (care instructions) documented the resident was to have a chair alarm, bed alarm, grip strips on the floor next to his bed, a contour mattress, Dycem (non-skid mat) on his wheelchair cushion, low bed, and self-locking brakes on his wheelchair. A physician visit summary dated 10/5/2016 documented the resident had fallen from bed due to attempts to get out of bed independently. A fall risk assessment dated [DATE] documented the resident was at high risk for falls. The comprehensive care plan (CCP) for Risk for Fall, which was current on 10/13/2016, documented the resident was at high risk for falls. All of the fall prevention interventions listed on the undated nursing staff assignment sheets (described above) were listed in the CCP. An additional intervention on the CCP, started 8/19/2016, was a mat on the floor next to the bed. Nursing progress notes documented the following: - On 7/24/2016 at 10:53 AM, the resident was found on the floor near his bed. - On 8/16/2016 at 3:30 AM, the resident was found on his knees on the floor near his bed. - On 8/24/2016 at 4:50 AM, the resident was sitting on the floor next to his bed, leaning against the bed. - On 10/6/2016 at 12:13 PM, the resident was found on the floor in his room with his head resting on the bed table. The resident's room was observed on 10/13/2016 at 1:58 PM, and there were no grip strips on the floor, there was no mat on the floor, and a mat was not visible in the room. The resident was interviewed at the time and stated he sometimes fell when he tried get in or out of bed by himself, and he did not have a floor mat. During an interview with certified nurse aide (CNA) #24 on 10/14/2016 at 12:32 PM, she stated the resident fell often and did not have a mat or grip strips by his bed. During an interview with registered nurse (RN) Manager #18 on 10/14/2016 at 12:50 PM, she stated the resident was at risk for falls, and his CCP included interventions for grip strips and a mat on the floor by the bed. She stated items on the CCP should be on the care instructions, and grip strips were on the resident's care instructions. The RN Manager accompanied the surveyor to the resident's room, where she verified there were no grip strips on the floor and there was no mat in the room. Supervision: 5) Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired and he required limited assistance with all activities of daily living (ADLs). Nursing progress notes documented on: - 7/24/2016, the resident required reminders that he needed supervision when leaving the unit; - 9/4/2016, the resident was seen kissing and holding hands with an elderly resident from another unit (Resident #19). The residents were redirected. Resident #6's mother was notified of the incident, who requested the resident be redirected; - 9/8/2016, the resident was observed holding hands with Resident #19 and staff redirected him back to his unit; - 9/9/2016, the resident was monitored for leaving the unit and for interactions with peers. He was reminded to return to the unit between therapy and meals; - 9/11/2016, the resident was observed on the unit holding hands with Resident #5 and poking her in the belly. The resident was redirected; - 9/14/2016 at 4:04 PM, the resident was compliant with going off the unit and returning for medications and no concerning behavior was observed; - 9/14/2016 at 6:51 PM, the resident was observed at 3:55 PM grabbing another resident's arm after he asked the resident to give him her arm and she did not comply; - 9/15/2016, the resident was reminded to be aware of asking prior to touching peers and he had been compliant with that; - 9/16/2016, the resident was observed holding hands with Resident #19, and then he was observed placing her hand toward his lap before staff intervened. The supervisor was notified; - 9/18/2016, the resident was observed attempting to bring a female resident (Resident #19) into his room, and when staff intervened, the resident became combative; - 9/19/2016, the incident on 9/18/2016 was discussed and the plan included consulting the neuropsychologist for new interventions, and the resident was to stay on the unit except for meals; - 9/24/2016, the resident was redirected back to his unit as he was observed in the lobby holding hands with Resident #19; - 9/27/2016, the resident was re-educated not to leave the unit without 1:1 supervision. An incident report dated 9/27/2016 documented the resident was in the lounge and was observed placing his hand in Resident #5's shirt and grabbing her breast. Corrective action was that the resident was placed on 1:1 supervision. A physician order [REDACTED]. The comprehensive care plan (CCP) initiated 9/14/2016 documented the resident attempted a physical relationship with an incapacitated resident from another unit. Evaluations of the CCP documented: - 9/14/2016, the resident was observed holding hands and kissing another resident who likes to spend time in the lobby. Even though the residents were capable of moving away from each other, both were cognitively impaired and the relationship was not encouraged. A behavioral intervention form was developed to assist the other unit and lobby staff on how to redirect the resident; - 9/15/2016, the resident was observed holding the hand of Resident #19, and he may have touched the arm of another resident and she was capable of moving away from him. The resident self propeled his wheelchair throughout the facility and liked to visit with others in the lobby. Interventions included the resident although impaired, understands more than he lets on and he was reminded not to seek out Resident #19 and his level of supervision was intermittent; - 9/22/2016, the resident had very limited interaction with Resident #19 compared to last week. The resident over the weekend had her follow him to his room, and when staff intervened, he became combative. The plan was to continue to discourage him from interaction with Resident #19 except in highly supervised areas, and his level of supervision remained intermittent; - 9/30/2016, the resident had been interacting appropriately with Resident #19, and on 9/27/2016 he inappropriately touched another female resident on the unit, and as a result the resident had been placed on 1:1 supervision. During an interview with certified nurse aide (CNA) #42 on 10/14/2016 at 9:05 AM, she stated the initial plan for the resident was to monitor his behaviors with Resident #19, as he could only go downstairs with a staff member. Then he was allowed downstairs unsupervised, as the receptionist would call the unit if she observed anything inappropriate, and the residents would be separated. On 9/27/2016, the resident put his hand up the shirt of Resident #5, who was unable to defend herself, and then the resident was placed on 1:1 supervision to prevent further incidences. During an interview with licensed practical nurse (LPN) #43 on 10/14/2016 at 9:30 AM, she stated the resident was placed on 1:1 supervision after inappropriately touching Resident #5. The LPN was not aware of any previous plan. She recalled a time when the resident was found holding hands and kissing another resident downstairs, at which time they were separated. During an interview with the registered nurse (RN) Unit Manager #41 on 10/14/2016 at 9:45 AM, she stated accident and incident reports (A&I's) were done for falls or touching someone else, to determine root cause and to prevent recurrence. The RN manager stated the resident and another female resident (#19) started holding hands and kissing downstairs, and the female resident could not consent. She also said attempts to keep the 2 residents separated worked for the most part, except for multiple instances when they were seen holding hands, at which time staff intervened. The RN Manager stated the resident was a very affectionate guy, and did not believe the interaction between the 2 residents was sexual in nature. She stated the resident was allowed downstairs off the unit unsupervised, and was monitored by a secretary down there. If the resident was seen holding hands and/or kissing Resident #19, then staff would go get him. She stated the resident was placed on 1:1 supervision when he touched Resident #5 inappropriately. During an interview with the social worker #44 on 10/14/2016 at 10:15 AM, she stated the resident touched another female resident (Resident #5), and it was very unexpected. She stated the resident was placed on 1:1 supervision at that time and the neuropsychologist got involved. The social worker described Resident #5 as cognitively impaired, and staff watched her because they felt she was young and could not defend herself. The social worker stated this behavior was unexpected for the resident. The staff identified the resident required an increased level of supervision after the incident on 9/27/2016, when he inappropriately touched Resident #5. The social worker stated she was really concerned when the resident touched the resident inappropriately, and she was not aware of any prior incident with Resident #5. The social worker stated prior to that incident, the resident would seek out Resident #19, as she was easy to find because she was always downstairs in the lounge. There was a concern as neither resident could consent, so the plan included having the downstairs secretary intervene if the two residents were seen holding hands or kissing. During an interview with the neuropsychologist on 10/14/2016 at 11:50 AM, he stated the resident and Resident #19 routinely held hands. He stated there was nothing further than the hand holding, and there was no indication of any sexual behavior until the incident on 9/27/2016, where his lack of control triggered the 1:1 supervision. He said in general he did not want to restrict the resident and recommended to adjust both residents' activities. The neuropsychologist stated he was not aware the resident poked Resident #5 in the stomach and maybe it was playful. He further stated Resident #5 should not be touched, since she had no ability to say no and was already under supervision to avoid unsafe situations. The neuropsychologist stated he did not know if they could have done more, as the resident did not display any behaviors that would lead them to believe he would touch another resident inappropriately. 6) Resident #43 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired; was independent with locomotion in wheelchair on the unit; and required extensive assistance from staff with transferring. The comprehensive care plan (CCP) dated 9/21/2016 documented the resident had decreased independence with activities of daily living (ADLs) and impaired breathing. The CCP documented to provide oxygen as ordered. The physician orders [REDACTED]. A nursing progress note dated 10/10/2016 documented the resident was self transferring that shift and was reminded to use the call bell for assistance. The treatment administration record documented the resident's oxygen saturations were within normal range and oxygen was not administered from 10/1/2016 to 10/12/2016. On 10/12/2016 at 9:38 AM, a surveyor in the resident's room observed an unsecured oxygen tank on the floor at the foot of the bed. The tank had oxygen in it. When interviewed on 10/12/2016 at 9:38 AM, the Director of Support Services stated the nursing staff should have known to have the oxygen tank properly secured. When interviewed on 10/12/2016 at 9:38 AM, certified nurse aide (CNA) #47 stated she was not allowed to touch oxygen tanks; only nurses handled the oxygen tanks. When interviewed on 10/12/2016 at 9:38 AM, licensed practical nurse (LPN) #50 stated licensed nurses were responsible for moving and exchanging the residents' oxygen tanks. The facility's Safe Handling of Portable Oxygen policy dated 1/16/2008, provided to the surveyor on 10/14/2016 at 11:59 AM, documented that all portable oxygen cylinders are to be maintained with a support mechanism (portable carrier, chair bag or rail, or a multi-cylinder cart) at all times. The occurrence of any unsecured portable oxygen cylinders shall constitute a safety hazard and will require an incident report and full investigation. NYCRR 415.12(h)(1)

Based on observation, interview, and record review conducted during the recertification survey, it was determined for 105 of 284 beds, the facility failed to ensure Administrative staff administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the Administrative staff failed to have a system in place to identify the potential for resident entrapment by bed side rails; failed to assess resident safety in their side rail use regarding the 7 entrapment zones identified by the Food and Drug Administration (FDA) guidelines; failed to develop a criteria for assessing the safe use of the various side rail types present in the facility; failed to develop and implement policies and procedures to monitor residents' beds, mattresses, and side rails to reduce the risk of entrapment, and failed to educate staff on the entrapment risks associated with side rail use. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of 105 residents at the facility. Refer to F323. The Immediate Jeopardy was removed on 10/14/2016, prior to the survey exit. Findings include: The New York State Department of Health Nursing Home Dear Administrator Letter (NYSDOH NH DAL) 15-05 entitled Entrapment Risk with Bed Systems and Components dated 6/19/15 documented the facility was to re-examine the nursing home's systems to ensure that adequate safeguards are in place for all aspects of bed safety encompassing the function of the bed's use. In addition, the DAL also recommended the facility review the FDA's Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment and use it as a resource to ensure bed systems and assistive bed components were safe. The Guidance for Industry and FDA Staff (the industry standard) for The Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, with an issue date of March 10, 2006 and presented by the Center for Devices and Radiological Health, documented the following dimensions: - Zone 1, the area within the rail, should not exceed 4-3/4 inches; - Zone 2, the area between the rail and the mattress, should not exceed 4-3/4 inches; - Zone 3, the area between the rail and the mattress/platform, should not exceed 2-3/8 inches; and - Zone 4, the area between the rail and the mattress/platform, should not exceed 2-3/8 inches. In an interview with the Director of Support Services on 10/12/2016 at 12:04 PM, he stated the bed breakdown sheet inventory was conducted last in 2015 for HUD (Housing and Urban Development). In an interview with the Vice President for Nursing Facility on 10/12/2016 at 2:10 PM, he stated the following: - He was aware of the Department of Health DAL regarding side rails; - He was aware of safety concerns with the residents' side rails and stated he had done review of side rails for years; - A survey of beds was done approximately 4 years ago and older beds were identified that needed to be changed out; - He was not aware of the areas for entrapment and stated he only recalled the maintenance team made a high recommendation for older beds to be changed out as fast as they could; - He was unsure if all staff were educated about side rails and the potential for entrapment; - He did not recall what was done in 2015 based on the DAL; - He stated interim controls to put metal clasps that held the rails down were in place; - He was aware of the FDA Guidelines and a copy was observed on the desk at the start of the interview; - It was his understanding that 3 types of beds were present in the facility. Only one particular older model was addressed, and he thought there was approximately 30 remaining in use in the facility. In an interview with the Director of Nursing on 10/12/2016 at 2:25 PM, she stated she thought she had seen the DAL and did not know about the FDA guidelines or the zones of entrapment. She stated she thought maintenance did an assessment on beds and side rails a few years ago, and they were transitioning old beds out and eventually wanted to get rid of side rails. She was unaware of any policy for assessing beds or side rails for risk of entrapment. She stated she trusted the maintenance department or direct care staff to report any concerns of entrapment they identified to management. In an interview with the Director of Support Services on 10/12/2016 at 2:30 PM, he stated the following: - The maintenance department installs side rails when nursing needs them; - Approximately 1 month ago, side rail orders for new admissions were shared with maintenance to instruct them of the resident's side rail needs. Examples provided were: 1 side rail, 2 side rails, no side rails; - He was aware of the FDA guidelines in approximately 2007 or 2008. He stated he had recently reviewed the guidelines because a surveyor was asking questions about them; - He did not receive DALs and could not recall if he received the DAL letter regarding side rail entrapment; - He conducted an inventory of beds types in the facility in 2015 and had not conducted an inventory of what beds have side rails and what types of side rails the beds have; - He was aware of the 7 zones of entrapment and stated the beds may have been assessed for entrapment risks years ago, possibly prior to the current Administrator. On 10/12/2016 at 4:00 PM, the facility provided a policy entitled Hazardous Items, revised and reviewed on 8/31/2015 with an effective date of 9/25/2015. The policy was to maintain an environment free of accident hazards, and addressed side rails that failed to meet current spacing requirements and had the potential to cause entrapment. The procedure documented maintenance staff would ensure the existing and new beds, mattresses, and side rail combinations were evaluated to assess for the 7 zones of entrapment. In an interview with the Director of Support Services on 10/12/2016 at 4:30 PM, he stated he was aware of the Hazardous Items policy, as his name was on it. He stated maintenance staff did not conduct a bed assessment to evaluate beds and side rails for the 7 zones of entrapment. During an interview on 10/14/2016 at 2:00 PM, the Vice President for Nursing Facility stated he was responsible for the overall administration of the facility. He also said it was his responsibility to carry out the requirements of the DAL and to oversee that policies were implemented to reduce the risk of entrapment. The Immediate Jeopardy was removed on 10/14/16 based upon the following corrective actions taken by the facility to reduce the risk of entrapment: - Development of a policy and procedure to access the safety of facility beds using the FDA guidelines and assessment of residents for safe side rail use when needed. - Development and implementation of entrapment reduction controls including the discontinuance of side rail use for beds that did not meet the FDA guidelines, disabling side rails with heavy duty plastic bands to prevent use, and the installation of hook and loop stabilizing tape to reduce the potential for mattress movement. - Training of all duty staff in safe side rail usage, the 7 potential zones for entrapment, and the importance of notifying others in the event of unsafe side rail usage or entrapment. 10NYCRR 415.26(a)

Based on record review and interview conducted during the abbreviated survey (NY 333), it was determined the facility did not provide an environment free of accident hazards or adequate supervision to prevent accidents for 1 of 4 sampled residents (Resident #1). Specifically, one to one supervision was not provided for Resident #1 from 3 PM to 6 PM and while in the Merry Walker, as ordered and planned. As a result, the resident experienced a fall with injury (laceration on the back of the head, laceration on the chin and skin tear to the right elbow). This resulted in actual harm that is not immediate jeopardy. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 2/6/2013 documented the resident had dementia, balance issues, and was at risk for falls. The CCP, dated 3/11/2013, documented interventions to assist the resident with her restless and agitated behaviors. One intervention was to use the Merry Walker to allow the resident to get exercise. The CCP documented specific details to follow when the resident was ambulating in the Merry Walker. These interventions included: use under the supervision of trained staff, and release every 2 hours for 15 minutes (meals and personal care). If the resident is agitated or stands up, staff were to try "walking with her in the Merry Walker or use a gait belt when not in the Merry Walker." On 3/18/2013, the CCP documented the resident had increased restlessness and impulsiveness, and 1:1 supervision was implemented from 3:00 PM to 8:00 PM. The CCP was updated on 3/22/2013, 4/26/2013, 5/23/2013, 6/18/2013, 7/30/2013, 8/26/2013, and 9/7/2013, 9/ each time documenting the resident was to remain on 1:1 supervision between the hours of 3:00 PM and 8:00 PM. Physician orders [REDACTED]. The physician's orders [REDACTED]. The orders also specified this plan was to be reassessed at scheduled behavioral meetings. On 10/3/2013, the CCP was updated and documented that starting on 10/7/2013, the resident's 1:1 would be changed to 3:00 PM to 7:00 PM, as the resident was usually ready for bed prior to 8:00 PM. The physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, required limited assistance for ambulation, and needed extensive assistance for transfers/bed mobility. The resident had a history of [REDACTED]. Physician orders, dated 10/10/13. documented the resident was to have a "Merry Walker with 1:1 for ambulation"; to be released "every 2 hours minimum." The CCP, updated on 10/11/2013, documented the resident did not have any recent falls and "current interventions" were to continue. physician's orders [REDACTED]." physician's orders [REDACTED]." These orders also documented the resident's 1:1 supervision from 3:00 PM to 6:00 PM did not need to be provided when the resident's family was present. The CCP was not updated on 10/23/13 to reflect the 10/23/13 physician's orders [REDACTED]. The licensed practical nurse's (LPN) progress note on 10/26/2013 at 4:45 PM documented that at 3:00 PM, the resident was in a Merry Walker (walker/chair combination) walking in and out of other residents' rooms. The resident was found on the floor in another resident's room by a CNA and the fall was unwitnessed. The resident sustained [REDACTED]. The note documented the resident was sent to the emergency room for evaluation. Two physician's orders [REDACTED]. The registered nurse (RN) Supervisor's progress note, dated 10/26/2013 at 8:54 PM, documented she assessed the resident following the fall; the resident's "normal base line" was confusion; and the resident was not able to report any information. The laceration on the head was documented to be 2.5 inches in length. The resident was sent to the emergency room . The 10/26/2013 emergency department report documented the resident was diagnosed with [REDACTED]. The Fall Related Incident Report and Investigation Form dated 10/26/2013, documented: - the resident was found on the floor of another resident's room with the Merry Walker on top of her; - the resident was lying on her side, bleeding from the back of the head, the chin, the elbow, and the wrist; - the resident was found between 3:14 PM and 3:20 PM and should have had 1:1 supervision at that time; - the resident was without 1:1 supervision at the time of change of shift from 3:00 PM to 3:14 PM, resulting in the fall; - The CNA's attached statement dated 10/26/2013 documented she arrived to unit at 3:10 PM, reported to the nursing station, and told the nurse she was the resident's assigned 1:1. She documented the nurse told her to look for the resident in her room, the resident was not there so she looked in the dining room, and then heard another CNA yelling that the resident was on the floor. - the RN Supervisor's attached statement dated 10/26/2013 documented she was informed when she arrived to the unit to assess the resident that the 1:1 supervision was not provided when the resident fell as the person assigned to do 1:1 was late for work. The RN documented that if the person assigned to do 1:1 supervision was late or not available, the unit nurse should assign someone else to the 1:1. The RN Manager stated in an interview on 12/26/2013 at 1:30 PM, the charge nurse was responsible for the shift assignment to the oncoming shift, and whichever CNA arrived to the unit at 3:00 PM, should have been assigned to provide 1:1 supervision to the resident at 3:00 PM. On 12/26/2013 at 1:45 PM, the Director of Nursing (DON) told the surveyor that the CNAs providing 1:1 are assigned prior to the shift. The assigned CNA did not call the facility to let them know she was going to be late. The DON stated when the CNA was late, the licensed practical nurse (LPN) should have notified the Supervisor that the CNA was not there at the start of the shift to start the 1:1 supervision. During an interview on 1/7/2014 at 11:35 AM, the LPN stated she worked a double shift on 10/26/2013 from 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM. She stated the resident required 1:1 supervision beginning at 3:00 PM and for part of the evening shift. She stated at 3:00 PM, she was at the nurse's station preparing for the evening shift and at around 3:08 PM to 3:10 PM, she was told the resident was on the floor. She stated there was not a reason why the 1:1 supervision was not provided starting at 3:00 PM. She said her priority was preparing for the evening shift. The LPN stated she initially forgot to ensure someone was assigned to provide the 1:1 supervision at 3:00 PM. 10NYCRR 415.12(h)(2)

Based on observation, staff interview and record review conducted during the standard survey, it was determined for 3 of 13 residents (Residents #10, 13, and 26), reviewed for pressure ulcers the facility did not ensure residents who entered the facility without pressure ulcers did not develop pressure ulcers and did not ensure residents with pressure ulcers received the necessary treatment and services to promote healing and prevent new ones from developing. Specifically; - For Resident #26, the facility did not have a plan in place for pressure relief of the fingers prior to the development of a suspected deep tissue injury (DTI), and did not implement a plan of care for pressure relief after the suspected DTI was found; did not ensure the resident's heels were offloaded consistently; and did not ensure the plan of care for pressure relief was clear. - For Resident #13, the facility did not ensure padding was applied to the oxygen tubing consistently; did not educate staff on the plan for padded oxygen tubing timely; did not ensure the plan of care contained a current and accurate plan for pressure relief; did not ensure the resident's footwear was assessed, and did not ensure a full skin assessment was done during a bed bath. - For Resident #10, the facility did not ensure the Wound VAC (vacuum assisted closure, use of negative pressure to help promote wound healing) treatment was consistently applied to the resident's pressure ulcer as ordered by the physician. This resulted in actual harm for Resident 26 and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #10 and 13. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF June 10, 2011. Findings include: 1a) Resident #26 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The April 12, 2012 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required extensive assistance for all activities of daily living (ADLs). The MDS recorded the resident had 1 unstageable pressure ulcer; received skin treatments, had pressure reliving devices for the bed/chair; and had contractures of the arms and legs. The comprehensive care plan (CCP) dated April 12, 2012, documented the resident was to have a hand roll at "HS" (hour of sleep) The CCP did not address a plan for the resident's hand contractures during the day. The resident's CCP dated April 20, 2012 documented staff should pay special attention to offloading (taking pressure off) the resident's contracted joints. The April 27, 2012 Braden Scale (for predicting pressure ulcer risk) documented the resident was at high risk for pressure ulcers due to being chairfast, having very limited mobility, and a problem of friction/shearing. The July 13, 2012 Braden Scale documented the resident was at moderate risk for pressure ulcers which was a decrease in risk from the previous assessment. The assessment documented an improvement in the resident's sensory perception and skin moisture from the last assessment (April 27, 2012). The July 20, 2012 Plan of Care (care instructions) documented the resident was to have range of motion (ROM) to her hands and fingers in the morning and at night, a left hand roll at HS. The resident was observed visiting with her family member on July 20, 2012 at 1:30 PM. The resident was sitting in a chair her hands were contracted with a white fabric woven between her fingers. The resident's family member stated the resident did not have a device for her hands and he was concerned as he did not think the staff were opening her hands and exercising them as they should. The resident was observed on July 20, 2012 at 2:10 PM, with the RN Manager and the assigned certified nurse aide (CNA) #4. The resident had white fabric woven between her fingers and the RN stated the fabric was used to keep air between the fingers and helped prevent "yeast." The RN opened up the resident's hand and the right thumb was soft in appearance. The RN touched it and stated the right thumb was "very soft and boggy" and discolored. She RN stated she was not aware of this area. On July 20, 2012 at 2:45 PM, CNA #4 stated in an interview, the resident did not have a hand roll or device for her hands, they "fell out" of her hand in the past. CNA #4 said the resident did not like her hands exercised. The RN Manager stated in an interview on July 20, 2012 at 2:45 PM, the fabric between the resident's fingers was recommended by the physician who was opposed to using anything else for the resident. She stated the CNAs were responsible for ROM and she did not know if they documented when it was done. On July 20, 2012, the resident's CCP was updated and documented "wool strip to be woven through fingers bilateral hands." The July 20, 2012 Weekly Wound Assessment Progress Sheets documented the resident had new a suspected DTI from pressure, on the right thumb, that measured 2 (centimeters) cm x 1.5 cm. The RN Manager stated in an interview on July 23, 2012 at 10:30 AM, the plan for the resident's thumb was to add more lambs wool between her fingers to keep the pressure off. She stated other devices "didn't work" for the resident and they were "seeing some success" with lambs wool. On July 23, 2012 at 11:35 AM, the attending physician/Medical Director stated in an interview, he did not recall recommending the lambs wool for the resident. He said it would be used for hygiene which was an issue with contractures. He stated he did not know if the resident had a therapy evaluation and did not know what they would be able to add. The physician said he discussed a surgical procedure of releasing the resident's tendons with the resident's family member who was not interested. He said he was informed today of the suspected DTI on the resident's right thumb and he had not yet assessed it. On July 23, 2012 1:05 PM and 1:10 PM, the physical therapy assistant (PTA) and physical therapist (PT) stated in separate interviews, they were not aware of the use lambs wool between the resident's fingers and were not involved in that plan for the resident. On July 23, 2012 at 3:40, the Assistant Director of Nursing (ADON) stated she was a "wound consultant" for every unit because the facility had a "decentralized" system for skin. She said every RN Manager was responsible for their own unit. On July 23, 2012 at 5:31 PM, the ADON's progress note documented she assessed the resident to have a suspected DTI on the right thumb related to contractures and the interventions were "pressure relief and monitoring." The July 23, 2012 Plan of Care (care instructions) did not contain instructions for the use of the lambs wool in the resident's fingers and documented the resident had a left hand roll at HS. The Plan of Care and CCP contained no documentation that pressure relief was implemented for the resident's thumb. In summary the resident experienced actual harm, a new suspected DTI on the right thumb, that was related to pressure from her contractures, as the facility: - did not have a plan in place for pressure relief before she developed the suspected DTI on the right thumb; and - did not implement a plan of care for pressure relief of the right thumb after the DTI was identified. 1b) Resident #26's Weekly Wound Assessment Progress Sheet dated March 16, 2012 documented the resident was found with a newly developed suspected deep tissue injury (DTI), on the right heel, that was 3 cm (centimeters) x 3.5 cm and was caused by pressure. The sheet documented the area was monitored regularly from March 16 - April 10, 2012. On April 10, 2012 the DTI was 3 cm x 4.5 cm. A Weekly Wound Assessment Progress Sheet documented on April 17, 2012, the suspected DTI on the resident's right heel had "soft, black eschar" (dead tissue) and measured 3 cm x 4 cm. The CCP dated April 20, 2012 documented the resident was to have her heels off the bed (offloading) on a pillow, and instructed staff should pay special attention to offloading the resident's contracted joints. The CCP not address a plan for pressure relief for the resident's heels when in the chair. The April 23, 2012 nurse practitioner's (NP) progress note documented the pressure ulcer on the resident's heel was starting to drain, a treatment was ordered, and the heel was to be offload. A Weekly Wound Assessment Progress Sheet documented on April 24, 2012, the suspected DTI was "changed" to a Stage II pressure ulcer with 50% "soft, black eschar" and measured 4.2 cm x 5 cm. The April 24, 2012 physician's progress note documented to offload the resident's heel "as best we can." A Weekly Wound Assessment Progress Sheet documented the pressure ulcer on the resident's right heel: - on May 1, 2012 was "unstageable," had 100% "hard, black eschar," and was larger in size measuring 6.2 cm x 7.8 cm; and - was monitored throughout the month of May 2012 and was documented as an unstageable pressure ulcer with black eschar through June 12, 2012. On June 12, 2012, the CCP was updated and documented the resident's heels were to be offloaded using a HeelZup Up cushion in bed. The CCP did not address a plan for relieving pressure on the resident's heels when in the chair. A Weekly Wound Assessment Progress Sheet documented the pressure ulcer on the resident's right heel: - on June 19, 2012, was changed from an unstageable to a Stage II and measured 5 cm x 4 cm; and - remained a Stage II on June 26, 2012, July 3, 9, and 16, 2012 measuring 2.5 cm x 3 cm. During the initial tour on July 18, 2012 between 9:35 AM and 10 AM, the registered nurse (RN) Manager stated the resident had a facility acquired Stage II pressure ulcer on the heel that was an "open blister." The resident was observed visiting with her family member on July 20, 2012 at 1:30 PM. The resident was sitting in a chair with a pillow behind her calves, and her heels rested directly against the webbing of the chair. The resident's family member stated to the surveyor he had a concern staff did not know how to use the HeelZup Up cushion to elevate the resident's heels. The resident was observed on July 20, 2012 at 2:10 PM, with the RN Manager and the assigned certified nurse aide CNA #4: - The resident's right heel pressure ulcer was red with a white/yellow area in the center, with necrotic (dead) tissue. The RN stated "I can't stage this." - The resident had multiple blisters on her body and the RN stated they were from the [DIAGNOSES REDACTED]. - When the RN was done assessing the resident's hand CNA #4 positioned the resident in bed with the HeelZup Up cushion below her calves to off load her heels. On July 20, 2012 at 2:45 PM, the CNA stated in an interview, the resident used the HeelZup Up cushion in bed and in the chair. The CNA stated the HeelZup Up cushion was placed under the resident's calves. The RN stated in an interview on July 20, 2012 at 2:45 PM, she thought the HeelZup Up cushion was not used for the resident anymore and that a bed pillow was used in the bed and chair. At that time, the resident was observed lying in bed with a HeelZup Up cushion in use. The July 20, 2012 Weekly Wound Assessment Progress Sheets documented the pressure ulcer on the resident's right heel was unstageable and measured 3.5 cm x 3 cm x 0.5 cm, with "yellow slough (soft dead tissue)." The resident was observed on July 22, 2012 between 4:05 PM and 4:20 PM sitting in the chair with her heels resting directly on a bed pillow. There was red drainage on the pillow and on the resident's sock. The surveyor alerted the licensed practical nurse (LPN) at 4:20 PM who stated, to the surveyor, it was her first day working at the facility. The LPN said she received shift report around 3 PM and was told the resident had a dressing, she did not know if there was a dressing change ordered for her shift. She removed the resident's sock and the dressing was off the heel inside the sock. The RN Manager stated in an interview on July 23, 2012 at 10:30 AM, she was not notified of the surveyor's observation of the resident's heel the previous day. She stated she planned to call Staff Education for guidance in training the staff on how to properly off load heels. On July 23, 2012 at 11:35 AM, the attending physician/Medical Director stated in an interview, he saw the pressure ulcer on the resident's heel many times and had sent the resident to the wound clinic. He said the resident's heel pressure ulcer was a challenge as she had poor circulation in her right leg. The physician stated he thought the area had improved with treatment and offloading. The physician stated the resident's heel should be offloaded and to his knowledge, the HeelZup Up cushion was not used anymore as it caused pressure to the resident's legs and calves. On July 23, 2012 at 2:15 PM, the Vice President for Quality Improvement stated in an interview, the facility's quality assurance (QA) for pressure ulcers did not involve monitoring wether pressure relieving devices were implemented as planned or used appropriately. On July 23, 2012 at 3:40, the Assistant Director of Nursing (ADON) stated she was a "wound consultant" for every unit because the facility had a "decentralized" system for skin. She said every RN Manager was responsible for their own unit. She stated to her knowledge, the resident's right heel pressure ulcer had improved and she did not know what the current plan was for offloading of the heels. On July 23, 2012 at 5:31 PM, the ADON's progress note documented the area on the resident's right heel was unstageable and had a small area of yellow slough. In summary the resident's right heel pressure ulcer developed from Stage II to unstageable as the facility: - did not ensure the resident's heels were offloaded consistently and properly; and - did not ensure the plan of care related to offloading the heels was clear. 2) Resident #13 had [DIAGNOSES REDACTED]. The April 12, 2012 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, and required extensive assistance with all activities of daily living (ADLs) except eating. The MDS recorded the resident was non-ambulatory, used a wheelchair for mobility, was occasionally incontinent of bowel and was always incontinent of bladder. The resident did not have a pressure ulcer, was at risk for developing pressure ulcers and had a pressure relieving device for the bed/chair. The comprehensive care plan (CCP) dated April 12, 2012 documented the resident was at moderate risk for developing pressure ulcers. Planned interventions included: - A&D ointment (a protectant) to the buttocks every shift; - skin prep (a protectant) to the heels every night; - encouraging the resident to shift her weight when in her wheelchair; - a wheelchair cushion; and - incontinence care as needed. The April 18, 2012 Braden Scale (used to predict pressure ulcer risk) documented the resident was at moderate risk for developing pressure ulcers related to: - slightly limited sensory perception; - moist skin; - being chairfast; - very limited mobility; and - a potential problem of friction/shearing. The June 6, 2012 physician orders [REDACTED]. The nursing progress note dated June 25, 2012 documented the resident had an open area "on right ear" from the oxygen tubing and the tubing was replaced with cushioned tubing. The note documented the open area was treated with [MEDICATION NAME] and the registered nurse (RN) Manager was made aware. The Weekly Wound Assessment Progress Sheet documented on June 25, 2012, the resident was found with a Stage II pressure ulcer "R (right) ear" (partial thickness loss of skin layers) measuring 0.5 cm (centimeters) x 0.25 cm. The nursing progress note dated June 26, 2012 documented grey sponge tubing was ordered for the resident's oxygen tubing. The nutrition note dated June 27, 2012 documented the resident had a Stage II pressure ulcer "behind the right ear from the oxygen tubing. The nursing progress note dated June 27, 2012 documented a new order from the nurse practitioner for [MEDICATION NAME] ointment to the right ear for 7 days and "please make sure resident has gray protective tubing on nasal cannula." There was no documented evidence the CCP was updated when the pressure ulcer developed and the CCP did not include the intervention of the grey prolective sponge to the resident's oxygen tubing. The Weekly Wound Assessment Progress Sheet documented the resident continued with a Stage II pressure ulcer to the right ear that measured 0.3 cm x 0.2 cm. The Treatment Administration Record (TAR) documented the last day the [MEDICATION NAME] was applied to the resident's right ear was July 3, 2012. The July 5, 2012 MDS documented the resident had modified independence with decision making and a Stage II pressure ulcer. The Weekly Wound Assessment Progress Sheet documented on July 9, 2012, the resident's Stage II pressure ulcer on the right ear measured 0.25 cm x 0.2 cm. The July 12, 2012 RN Manager's note documented she was called to the room on July 11, 2012 to assess an open area on the resident's right buttock. The RN noted the resident's "Skin is obviously disrupted by shearing." The RN documented she when she monitored the open area on July 12, 2012 she found the no sting barrier spray was not effective and "clear [MEDICATION NAME] ordered." The Weekly Wound Assessment Progress Sheet dated July 12, 2012 documented the resident was found with a Stage II pressure ulcer on the right buttock on July 11, 2012 that measured 1 cm x 0.5 cm. There was no documented evidence the CCP was updated when the pressure ulcer on the resident's right buttock was found. The Resident Plan of Care (care instructions) dated July 12, 2012 documented the resident was to wear oxygen continuously and did not document the use of the grey sponge padding on the oxygen tubing. The July 14, 2012 Braden Scale documented the resident remained at moderate risk for pressure ulcer development. The MDS documented improvements in the resident's mobility and skin moisture since the last assessment (April 18, 2012). The Weekly Wound Assessment Progress Sheet documented: - on July 16, 2012, the Stage II pressure ulcer on the right buttocks was "healed;" and - on July 16, 2012, the resident was found with a new pressure ulcer on left sacrum. The area had 50% "yellow slough" (soft, moist, dead tissue), was Stage II and measured 2.5 cm x 3 cm. There was no documented evidence the CCP was updated when the new pressure ulcer on the resident's left sacrum was discovered or when the area on the resident's right buttocks healed. On July 16, 2012 the physician ordered 5 sprays of no sting barrier spray and a [MEDICATION NAME] Oval (a dressing used to promote healing) to the resident's sacral pressure ulcer. On July 19, 2012 at 10:44 AM the surveyor, the RN Manager, the licensed practical nurse (LPN), a CNA and the resident's family member observed the resident: - the LPN removed the sacral pressure ulcer dressing and there was brown drainage on the dressing. The pressure ulcer was round and the top portion was bright red. The RN stated the last time she saw the pressure ulcer there was no depth and right now it had 40% slough; - the resident's socks and sandals were removed by the RN who stated the resident's left heel was "boggy." There was an open area on the top of the resident's left foot in the same place where there was an indentation in her foot from her sandal. The RN stated she was not aware of the open area, measured the area and stated it was 2 cm x 2 cm. The CNA stated she did not see the open area that morning when she gave the resident a bed bath as she did not remove the resident's socks and sandals. The RN stated she did not know if any other type of shoe had been tried for the resident. The resident's family member stated the resident had not been offered any specialized pressure relieving bootie or surgical shoe since her admission. The resident's family member stated because the resident's feet were deformed, she liked to wear a hard sole shoe to press against when her legs cramped up; and - behind the resident's right ear was a red area that was not open and the oxygen tubing was padded. The resident's family member stated the area behind the ear was worse last month and was originally found by the hairdresser. On July 19, 2012 11:20 AM, the RN stated in an interview she considered the area on the resident's sacrum a Stage II pressure ulcer with 40% slough. She stated the facility investigated the pressure ulcer behind the resident's right ear, that was found by the hairdresser, and "treated it right away." The Weekly Wound Assessment Progress Sheet documented: - on July 19, 2012 the pressure ulcer on the resident's left sacrum was 2.5 cm x 3.4 cm and had 40% slough with no drainage (this was inconsistent from the surveyor's observation of brown drainage); and - on July 19, 2012 the open area on the resident's left foot was a Stage II pressure ulcer measuring 2 cm x 1 cm. On July 20, 2012 at 2 PM, the RN Manager stated in an interview, she did not have documentation related to shoes or booties tried in the past. She said the resident needed a protective dressing for her foot and she was waiting for the NP to see the resident's foot. On July 23, 2012 at 10:20 AM, the resident was observed sitting in a chair wearing sandals on both feet. During an interview on July 23, 2012 at 10:30 AM, the RN was asked for the documentation of monitoring of the resident's right ear pressure ulcer after July 9, 2012. The RN gave the surveyor 2 copies of the Weekly Wound Assessment Progress Sheet for the right ear. On 1 photocopy there was no documentation after July 9, 2012 and on the second photocopy an assessment was documented as done on July 16, 2012 and the pressure ulcer measured 0.2 cm x 0.1 cm. The RN stated she could not explain the discrepancy. The RN said before the right ear pressure ulcer developed, the resident had grey sponge padding for her oxygen tubing, which was not consistently used. She said as a result, the resident developed the right ear pressure ulcer. The RN said there was no documentation that staff were re-educated, on the use of the grey sponge padding for oxygen tubing, after the resident developed the pressure ulcer on the right ear. She said she did not know why there was no treatment to the resident's right ear after July 3, 2012. She stated she was waiting for input from the physical therapist (PT) regarding the resident's sandals. On July 23, 2012 at 10:50 AM, the hairdresser stated in an interview, she saw the resident on June 25, 2012 and did not realize the oxygen tubing was stuck to the resident's skin. The Hairdresser said she pulled the tubing, and the resident's skin came off with the tubing, and she immediately alerted nursing. On July 23, 2012 at 1:10 PM the PT stated in an interview, he had not been asked to assess the resident's sandals. On July 23, 2012 at 1:30 PM, the attending physician stated in a telephone interview, he had not seen the resident's pressure ulcers and did not know if he was notified unless he checked his notes. He stated he would expect pressure relief and position changes to be done. July 23, 2012 at 3:40 PM, the ADON stated she was a "wound consultant" for every unit as the facility had a "decentralized" system for skin. The ADON said each RN Manager was responsible for their unit. She was not asked to assess the resident's skin but was involved with the investigation when the pressure ulcer behind the ear was found. She determined it was "avoidable" and the RN Manager was responsible for following up with unit staff. She stated she never saw the pressure ulcer on the resident's right ear which must have been "superficial" as ulcers behind the ear quickly go to Stage III or IV. On July 24, 2012 at 9:40 AM, the ADON provided documentation dated June 26, 2012 showing the RN Manager educated 6 staff members about the use of the grey sponge padded oxygen tubing. She stated this form was created on July 23, 2012. In summary, the resident experienced actual harm of an "avoidable" Stage II pressure ulcer behind the ear, a Stage II pressure ulcer on the top of the left foot, and a Stage II pressure ulcer ,with 40% slough, on the sacral area as the facility: - did not ensure the padded oxygen tubing was consistently implemented; - did not ensure staff were educated timely after the development of the area behind the ear; - did not ensure the Plan of Care and CCP contained a current and accurate plan for pressure ulcer prevention for the resident; - did not ensure the pressure ulcer on the sacrum was properly staged as it had 40% slough and was staged as a Stage II; - did not ensure the resident's footwear was assessed when she developed an open area under the strap of her sandal; and - did not ensure staff inspected the resident's skin during a bed bath when her shoes and socks were not removed. 3) Resident #10 had [DIAGNOSES REDACTED]. The nursing progress notes documented: - on March 27, 2012, the seal to the resident's Wound VAC interrupted and a prn (as needed) wet to dry dressing was applied to the pressure ulcer; - on March 28, 2012, the resident's Wound VAC was off from the previous shift; - on April 5, 2012, the resident's Wound VAC was off and the pressure ulcer was "packed" (placement of guaze in to the pressure ulcer wound bed); - on May 13, 2012, "due to inability to keep Wound VAC sealed" on the resident's sacral pressure ulcer, it was removed, the pressure ulcer was cleansed to remove fecal matter, "packed" with Kerlix (a type of guaze) and covered with a dressing. The June 8, 2012 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and a Stage IV pressure ulcer. The pressure ulcer measured 6.5 cm (centimeters) long x 6.5 cm wide and was 3.5 cm deep and had slough (soft, moist, dead tissue). The MDS recorded the resident received pressure ulcer care. The June 12, 2012, physician's orders [REDACTED]." The resident's July 2012 Treatment Administration Record (TAR) documented the Wound VAC was to be set at 125 mm/hg and was to be changed Monday, Wednesday, and Friday. The TAR documented if the Wound VAC malfunctioned it was to be removed and a wet to dry dressing was to be applied to the sacral pressure ulcer and changed every 12 hours. The resident was observed on July 20, 2012 at 10:45 AM. The Wound VAC was not on the resident's sacral pressure ulcer, a guaze dressing was on the pressure ulcer. The licensed practical nurse (LPN), was interviewed at that time and stated the Wound VAC was removed on July 19, 2012 on the 3 PM to 11 PM shift. She said she did not know why the Wound VAC was not on the resident's pressure ulcer. She stated she was going to use the same Wound VAC machine that had been used on July 19, 2012 and if there was a leak in the vacuum seal on a day other then Monday, Wednesday or Friday, a wet to dry dressing would be applied until the next scheduled day. The registered nurse (RN) Manager was interviewed on July 23, 2012 at 10:15 AM, and stated the Wound VAC dressing change was done on Monday, Wednesday, and Friday. If the vacuum seal leaked or was interrupted on a day that was not a scheduled change, the Wound VAC was not applied until the next scheduled day. The physician was interviewed on July 23, 2012 at 11:30 AM, and stated the Wound VAC dressing change should be done Monday, Wednesday and Friday, and if the vacuum seal was interrupted a referral should be made to the wound clinic. The RN Staff Educator, was interviewed on July 23, 2012 at 1:15 PM, and stated if the vacuum seal was interrupted staff should "trouble shoot" the machine for an air leak, and the Wound VAC should be reapplied immediately. She stated she was not aware that when the vacuum seal to the resident's Wound VAC was interrupted, the Wound VAC was not reapplied until the next scheduled day. During an interview with the Director of Nursing (DON) on July 24, 2012 at 9:30 AM, she stated if the vacuum seal to the resident's Wound VAC was interrupted, staff should try to reapply the seal, or change the Wound VAC dressing. The facility's policy Use of VAC dated April of 2007 documented if Wound VAC therapy was interrupted for more than 2 hours, a new dressing must be applied and therapy reinitiated. In summary the facility did not ensure the Wound VAC was consistently applied to the resident's sacral ulcer as ordered by the physician. 10 NYCRR 415.12 (c)(1),(2)

Based on record reviews, observations, staff interviews, and a review of facility policies and procedures conducted during the extended recertification survey, and abbreviated survey (Case # NY 1245) it was determined the facility's administrative staff failed to administer the facility in a manner that protected the health and safety of residents. Specifically, administrative staff failed to ensure there was a system in place that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents for 15 sampled residents (Residents #1, 2, 5, 8, 10, 11, 12, 14, 16, 17, 19, 22, 23, 28, and 29) and 26 residents outside of the sample (Residents #34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58 and 59) of 172 residents reviewed for resuscitative status identifiers, in a facility with a census of 265 residents,. Specifically, Administration failed to appropriately identify residents' resuscitative status and educate staff on how to identify residents' cardio-pulmonary resuscitation (CPR)/do not resuscitate (DNR) status. This resulted in Immediate Jeopardy and Substandard Quality of Care to resident health and safety. The immediate jeopardy situation was removed on [DATE] prior to the survey exit. Observations made during the initial day of survey ([DATE], from 10:40 AM to approximately 3 PM) revealed the following for 36 residents, Residents # 2, 5, 8, 11, 12, 14, 16, 17, 19, 23, 28, 29, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, and 57: - 26 residents were observed wearing 2 bracelets, both a red bracelet and a white bracelet, ( Residents #11, 12, 16, 19, 28, 29 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 54, 56, and 57). - Two residents had a wrist bracelet and a wheelchair bracelet that were different colors, one red and one white (Resident #51 and 58). - Three residents whose resuscitative status was DNR were not wearing a bracelet, and had a white bracelet (identifying full code) on their wheelchairs (Residents #2, 14, and 34). - Two residents had an incorrect bracelet on their wrist (Residents #5 and 55). - One resident had both a red and white bracelet on the wheelchair, (Resident #28). - Three residents were not wearing bracelets; Resident #19 (DNR status), Resident 5 (DNR status), and Resident #8 (Full Code status). - Two residents' chart binders had their resuscitative status incorrectly identified on the spine of their chart binders (Residents #2, and 22). - Resident #17 was not provided cardio-pulmonary resuscitation after [MEDICAL CONDITION] due to confusion over the resident's resuscitative status. F309 - Quality of Care - The facility failed to ensure Residents' resuscitative status CPR/DNR were appropriately identified. In an interview on [DATE] at 2 PM the Administrator stated she was aware of the incident with Resident #17, that she was present during the code and knew about the discrepancy regarding the code status identification. She stated the facility conducted an investigation into the matter. The Administrator stated her role in the immediate jeopardy situation was to monitor and assess along with the nursing staff, the Vice President of Quality Management, the Director of Nursing and the Medical Director. She said the facility solution to the confusion regarding Resident #17's code status was to try to find identification bracelets for the residents to wear that were different in some way other than just color. They had not implemented this change when the immediate jeopardy was identified. The Administrator stated the quality assurance committee had conducted an audit regarding the MOLST forms and the physician orders [REDACTED]. In summary, the facility's administrative staff failed to administer the facility in a manner that protected the health and safety of residents. ******************************************************* The Immediate Jeopardy situation was removed on [DATE] based on the following corrective actions taken by the facility: - Policies and Procedures were revised to specify identification of residents' resuscitative status including bracelets used on residents' wrists and wheelchair, the spine of the medical record and name plate outside of the residents' room. - All staff had been in-serviced on the new policies and procedures (staff on leave, would not be allowed to return to the residents' unit without receiving the required inservice training). - A full house audit was conducted on the MOLST (medical orders for life sustaining treatment) forms, physician orders, and comprehensive care plan process. - Based on the audit results, a new policy was developed for documentation of care plan reviews and "revamped" care plan form. - Facility administrative staff monitored all staff to ensure compliance with the new policies and procedures. 10 NYCRR 415.26

Based on observation, staff interview, record review, and a review of the policies and procedures conducted during the extended recertification survey, and abbreviated survey (Case # NY 1245) it was determined the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents for 15 sampled residents (Residents #1, 2, 5, 8, 10, 11, 12, 14, 16, 17, 19, 22, 23, 28, and 29) and 26 residents outside of the sample (Residents #34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58 and 59) of 172 residents reviewed for resuscitative status identifiers, in a facility with a census of 265 residents. Specifically, the QA committee failed to ensure that effective systems were in place to identify problems with the accuracy of the residents ' advance directive status. Additionally, the QA committee failed to identify staff confusion and lack of knowledge regarding the system for cardio-pulmonary resuscitation (CPR)/do not resuscitate (DNR) identification. This resulted in Immediate Jeopardy and Substandard Quality of Care to resident health and safety. The immediate jeopardy situation was removed on [DATE] prior to the survey exit. Findings include: Observations made during the initial day of the survey ([DATE], from 10:40 AM to approximately 3 PM) showed the following for 36 residents, Residents #2, 5, 8, 11, 12, 14, 16, 17, 19, 23, 28, 29, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, and 57. - 26 residents were observed wearing 2 bracelets, both a red bracelet and a white bracelet, ( Residents #11, 12, 16, 19, 28, 29 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 54, 56, and 57). - Two residents had a wrist bracelet and a wheelchair bracelet that were different colors, one red and one white (Resident #51 and 58). - Three residents whose resuscitative status was DNR were not wearing a bracelet, and had a white bracelet (identifying full code) on their wheelchair (Residents #2, 14, and 34). - Two residents had an incorrect bracelet on their wrist (Residents #5 and 55). - One resident had both a red and white bracelet on their wheelchair, (Resident #28). - Three residents were not wearing bracelets; Resident #19 (DNR status), Resident #5 (DNR status), and Resident #8 (Full Code status). - Two residents' charts had their resuscitative status incorrectly identified on the spine of their charts (binder) (Residents #2, and 22). - Resident #17 was not provided cardio-pulmonary resuscitation after [MEDICAL CONDITION] due to confusion over the resident's resuscitative status. F309 - Quality of care - The facility's QA program failed to ensure residents' resuscitative status CPR/DNR were appropriately identified. During an interview with the Vice President for Quality Management (QA Coordinator) on [DATE] between 12:45 PM and 1:45 PM, with the Medical Director present, she stated: - Social Services did audits related to compliance with residents' advance directive status; - quality assurance focused in the past on compliance with documentation and presence of red bracelets on residents whose advance directives included a DNR order; - audit documents did not focus on the presence of a clear bracelet to identity full code status. She stated the QA Committee did not consider a clear bracelet to be an indicator of full code status. In summary, the facility quality assessment and assurance committee did not effectively identify quality deficiencies with the facility's implementation of advance directives, resulting in immediate jeopardy to residents' health and safety. ******************************************************* The Immediate Jeopardy situation was removed on [DATE] based on the following corrective actions taken by the facility: - Policies and Procedures were revised to specify identification of residents' resuscitative status including bracelets, used on residents wrists and wheelchair, the spine of the medical record and name plate outside of the residents' room. - All staff had been in-serviced on the new policies and procedures (staff on leave, would not be allowed to return to the residents' unit without receiving the required inservice training). - A full house audit was conducted on the MOLST (medical orders for life sustaining treatment) forms, physician orders, and comprehensive care plan process. - Based on the audit results new policy was developed for documentation of care plan reviews and "revamped" care plan form. - Facility administrative staff monitored all staff to ensure compliance with the new policies and procedures. 10 NYCRR 415.27 (a-c)

Based on observation, staff and resident interview, and record review conducted during the extended recertification and abbreviated survey (Case # NY 1245), it was determined for 15 sampled residents (Residents #1, 2, 5, 8, 10, 11, 12, 14, 16, 17, 19, 22, 23, 28, and 29) and 26 residents outside of the sample (34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, and 59) of 172 residents reviewed for resuscitative status identifiers, in a facility with a census of 265 residents, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the facility failed to have an effective system in place that accurately and consistently identified residents' Advance Directive status. The system to identify residents' resuscitative status included the use of color-coded resident wristbands and a sticker on the binding of the medical record. The inconsistencies involved residents' having no wristband, wearing the incorrect wristband, wearing different color wristbands, and having wristbands placed on residents' personal equipment. Also, the stickers used on the binding of the medical record and in the medical record were not consistently applied designating the residents' advance directive wishes. The facility failed to ensure staff were educated on how to identify residents' resuscitative status. In addition, Resident #17 was not provided cardio-pulmonary resuscitation after [MEDICAL CONDITION] due to confusion over the resident's resuscitative status. This resulted in no actual harm with the potential for more than minimal harm that is Immediate Jeopardy and Substandard Quality of Care to resident health and safety of Residents #2, 5, 8, 11, 12, 14, 16, 19, 23, 28, and 29 and 15 residents outside of the sample Residents #34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 56, and 57, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #1, 10, 17, 22, 48, 49, 50, 51, 52, 53, 54, 55, 58, and 59. The immediate jeopardy situation was removed on [DATE] prior to the survey exit. Findings include: Per the CMS 672 form dated [DATE], there were currently 265 residents in the facility. The facility policy titled Staff Identification of Patients/Residents with DNR Status updated [DATE] documented residents with a DNR order would be identified with red colored vinyl bracelets. Alternative bracelets for residents with DNR orders would be clear bracelets (with a white insert) and a red mark next to the resident's name. Upon receipt of a DNR order, the admission identification bracelet should be removed from the resident's wrist and replaced with a red colored vinyl bracelet. 1) Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MOLST (Medical Orders for Life Sustaining Treatment) dated [DATE] and last reviewed on [DATE], documented the resident wanted full cardiopulmonary resuscitation. The physician orders, signed by the physician on [DATE], documented the resident wanted full cardiopulmonary resuscitation (CPR). Nursing progress notes dated [DATE] (timed 07:24 AM, 10:50 AM, 02:28 PM & 08:40 PM) documented the resident complained of feeling chilled and ill. She was seen by the physician. A transport aide found the resident slumped over in her wheelchair. She was unresponsive, surrounded by a "pool" of blood without a blood pressure, pulse, or respirations. An AED (automated external defibrillator) was applied and showed no cardiac activity (heartbeat). The resident was pronounced dead by the physician at 5:10 PM. The facility's incident report, signed by the Administrator on [DATE], documented the resident bled out from her [MEDICAL TREATMENT] shunt and staff mistook her bloody bracelet as a red Do Not Resuscitate (DNR) bracelet. The incident report documented in the narrative summary and on the event record that resuscitation did not occur. The report also documented that one licensed practical nurse (LPN) called out that he thought the resident was a full code. This LPN was asked to obtain the resident's medical record. When he couldn't locate the record he assumed it was with the team with the resident. The record was off the unit being copied to go out to the hospital with the resident. The physician was interviewed on [DATE] at 10:45 AM. He stated when he responded to the code staff told him the resident had a DNR order. No resuscitation was provided. The resident showed no signs of life, and the AED was used to establish death had occurred. The Assistant Director of Nursing was interviewed on [DATE] at 11:30 AM. She stated she was present during the code and asked staff if 911 had been called, and if the resident was a DNR or desired CPR. Staff stated that the resident had a DNR order. She looked at the resident's bracelet and it was red which signified DNR. She stated that later she looked at the bracelet and realized the red color was from blood. She stated the bracelet was clear which represented full code status. A licensed practical nurse was interviewed on [DATE] at 3:30 PM. He stated he told the code team, including the physician, that he thought the resident wanted CPR The team asked him to get the resident's record. He stated the medical record was not on the unit, and he assumed someone else had brought it to the team. He stated he did not learn until later that the team did not have the chart. The chart was off the unit being copied. In summary, the facility did not correctly identify the resident's code status and did not comply with the resident's wish for cardiopulmonary resuscitation in the event of [MEDICAL CONDITION]. 2) Resident #11 had [DIAGNOSES REDACTED]. The MOLST (Medical Orders for Life Sustaining Treatment) form dated [DATE], documented the resident signed consent for DNR (Do Not Resuscitate ). Physician orders [REDACTED]. On [DATE], in an interview during the initial tour of the facility at 9:45 AM, registered nurse (RN) unit manager #1 stated residents wore name bracelets, which also identified their resuscitative status. The RN said a red bracelet meant DNR and a white bracelet meant full code. In an interview with RN unit manager #1 on [DATE] at 10:45 AM, she stated residents should be wearing a red bracelet or a white bracelet, and that one could not tell the code status if both bracelets were applied. On [DATE] at 11:10 AM, registered nurse (RN) unit manager #2 told the surveyor the resident should only be wearing one bracelet that designated his advance directive status. The resident was observed on [DATE] at 11:35 AM, wearing two bracelets on his wrist. One bracelet was clear with a white insert with his name, the other was red with his name. In an interview with the Unit 3 secretary on [DATE], at 11:55 AM, she stated she had worked at the facility for 3 years and she did not know both the red and white bracelets should not be applied to a resident, until today, when she read the policy. In summary the facility did not clearly and accurately identify the resident's resuscitative status when both a red and a white bracelet was applied to the resident's arm. 3) Resident #2 had [DIAGNOSES REDACTED]. The MOLST form, dated [DATE], documented a DNR order, and was signed by the resident's Health Care Proxy and the attending physician. On [DATE] at 9:15 AM, registered nurse (RN) unit manager #3 was interviewed during the initial unit tour by the surveyor. She stated an order for [REDACTED]. She stated that residents who were "full code" wore white bracelets. On [DATE] at 10:20 AM registered nurse (RN) unit manager #4 was interviewed during the initial unit tour by a surveyor. She stated an order for [REDACTED]. On [DATE] at 12:55 PM, Resident #2 was observed seated in a wheelchair in the unit dining room. There was no bracelet observed on the resident's extremities. There was a clear plastic bracelet with a white insert (indicating Full Code) that had the residents name printed on it, which was attached to the arm of the wheelchair. Registered nurse (RN) unit manager #4 was present and was asked what action would be taken if the resident was not breathing, she stated she would call Code Blue and bring the resident's chart to the bedside to verify the code status. On [DATE] at 1:00 PM, the resident's chart was observed to have a white name label with black lettering (indicating Full Code). In summary, the facility did not ensure staff communicated Resident #2's advance directive wishes for Do Not Resuscitate when: - a white bracelet was placed on the resident's wheelchair; - there was no red bracelet on the resident; and, - there was no red name label on the resident's medical record. 4) Resident #5 was admitted to the facility with [DIAGNOSES REDACTED]. The MOLST form dated [DATE] documented the resident's status was DNR (Do Not Resuscitate). The physician orders [REDACTED]. On [DATE] between 9:20 AM and 9:30 AM, registered nurse (RN) unit manager #5 was asked about code status and how staff would know who had a DNR order. The unit manager stated residents who had DNR orders wore a red bracelet, and there was red on the spine of the medical record (binder) On [DATE] at 10:30 AM, Resident #5 was observed in her room lying in bed. She had two bracelets on, a white name bracelet and a orange fall bracelet. She did not have a red bracelet (DNR). When RN unit manager # 3 was interviewed on [DATE] at 1:45 PM, she stated a red bracelet indicated DNR, and a clear white bracelet indicated Full Code. On [DATE] at 2:00 PM, Resident #5 was observed lying in bed. The resident was alert and showed the surveyor her wrists, which had a white bracelet with her name printed on it and an orange bracelet. Both RN #5 and B Unit Secretary were interviewed separately on [DATE] between 3:10 and 3:30 PM. Both stated a resident should only have only one bracelet applied (related to code status); either a red bracelet or a clear white bracelet, not both. On interview on [DATE] at 11:50 AM, the social worker stated advance directives were documented in social services notes. Staff reviewed advance directives quarterly, and documented in the social service assessments in the medical record. In summary, Resident #5's advance directive status was incorrectly identified on the wrist bracelet. 5) Resident #53 had [DIAGNOSES REDACTED]. The physician order [REDACTED]. The MOLST form dated [DATE], documented the surrogate's consent for DNR. When the resident was observed in her wheelchair on [DATE] at 11:40 AM, there was a red bracelet on the wheelchair and a white bracelet on her wrist (there was no red dot on the white bracelet). In an interview with RN unit manager #1 on [DATE] at 11:40 AM, she stated if a resident refused to wear a red bracelet, it would be applied on the wheelchair. She said she did not know why the bracelets were different in color. In summary the facility did not ensure the resident's resuscitative status was accurately identifiable, by placing a white bracelet (with no red dot) on the resident and a red bracelet on the wheelchair. 6) Resident #34 had [DIAGNOSES REDACTED]. During the initial tour on [DATE] from 9:15 AM, through 10 AM, the licensed practical nurse (LPN) assistant nurse manager of unit 2 and the the registered nurse (RN) Clinical Care Coordinator of the TBI ([MEDICAL CONDITION]) Unit told a surveyor a resident's code status was determined by the color bracelet they wore. A red colored bracelet designated a resident's advance directive status was Do Not Resuscitate (DNR), and a white-colored bracelet designated a resident's advance directive status was Full Code (cardiopulmonary resuscitation). The LPN assistant nurse manager said if a resident's status was DNR, the resident would have a DNR sticker affixed to the inside of their chart, and a resident's advance directive status would be listed on the MOLST (Medical Orders for Life-Sustaining Treatment) form. Physician orders, dated [DATE], documented the resident's advance directive status was Full Code (cardiopulmonary resuscitation). A physician progress notes [REDACTED]. The resident's plan of care (used by the certified nurse aides (CNAs) to provide care, dated [DATE], documented the resident was alert and oriented, and used a wheelchair. On [DATE], at 12:15 PM, a surveyor and RN unit manager #2 checked advance directive bracelets for all residents on the unit, and observed Resident #34 in his room, lying in bed. The resident was observed not to be wearing any bracelet identifying his advance directive status. The resident's wheelchair which was located next to his bed, was observed to have an attached white band with his name written on it. When interviewed on [DATE] at 1:45 PM, RN unit manager # 2 said she was told by the Director of Nursing (DON) the white bands attached to residents' wheelchairs were used only for the identification of residents. In summary, there was no bracelet on Resident #34 person to identity their full code status. When interviewed on [DATE] at 11:45 AM, the Admissions Coordinator said the facility used a narrow, plastic bracelet for residents which was either clear or red colored, depending on the resident's advance directive status. The Admissions Coordinator showed a surveyor both the clear and the red plastic bracelets. When a surveyor inquired about a wider style, white-colored bracelet that was not plastic, which was observed on some residents, the Admissions Coordinator thought the wider style, white colored bracelets were placed on residents when they were admitted to the hospital. When the Director of Nursing was interviewed on [DATE] at 11:50 AM with the Administrator present, she stated red bracelets worn by residents indicated the residents' code status was DNR. She stated some residents wore both a red bracelet and a clear name bracelet. She stated the facility did not currently have a bracelet to designate a resident's status as Full Code (resuscitation). When interviewed [DATE] at 3:15 PM, a certified nurse aide (CNA) said a red colored bracelet designated a DNR (do not resuscitate) status. The CNA said, "I believe white (bracelet) is CPR (cardiopulmonary resuscitation)." When asked by a surveyor what she would do if a resident was unresponsive, and was wearing two different colored (red and white) bracelets, the CNA said she would call "code blue" and call for the nurse. The CNA said if a resident was wearing two different colored bracelets, there "could be a mix-up." [DATE] at 3:17 PM, an agency CNA was asked to explain the purpose of the clear/white or red resident bracelets and stated, "I work here a lot, I believe one is DNR and the other is for nothing by mouth, but I can't remember which is which." 7) Resident #45 had [DIAGNOSES REDACTED]. The MOLST (medical orders for life sustaining treatment) form dated [DATE] documented the resident's Health Care Proxy consented to a DNR (Do Not Resuscitate) order. A physician progress notes [REDACTED]. The physician orders [REDACTED]. The Interim Team Meeting form dated [DATE] documented the resident's advance directive status was full code. In summary, the current Interim Team Meeting form incorrectly documented the resident's code status as full code. 8) Resident #28 had the [DIAGNOSES REDACTED]. Physician orders, dated [DATE], documented a DNR (Do Not Resuscitate) per MOLST (Medical Orders for Life Sustaining Treatment). On [DATE] at 11:30 AM, the resident was observed with two bracelets on her wheelchair, one red bracelet and one white bracelet. The resident did not have a bracelet on her wrist or ankle. In summary, the facility did not ensure Resident #28's Do Not Resuscitate status was correctly identified when: - there was no red bracelet applied on the resident's wrist; and, - both a red bracelet and a white bracelet were applied on the resident's wheelchair. 9) Resident #8 had [DIAGNOSES REDACTED]. The resident's MOLST (Medical Orders for Life-Sustaining Treatment) dated [DATE] documented the resident status was full code (full resuscitation). On [DATE] at 1:10 PM, a surveyor observed the resident was not wearing a bracelet to identify her code/ resuscitation status. In summary, the facility did not ensure Resident #8's full code resuscitation status was identified, as there was no white bracelet applied on the resident's wrist. 10) Resident #51 had the [DIAGNOSES REDACTED]. The resident's MOLST (Medical Orders for Life Sustaining Treatment) dated [DATE], documented an order for [REDACTED]. Physician orders, dated [DATE], documented an order for [REDACTED]. On [DATE] at 11:30 AM, a surveyor observed the resident had a red bracelet on her wrist and a white bracelet on her wheelchair. In summary, the facility did not ensure Resident #51's Do Not Resuscitate code status was correctly identified, when staff placed a red bracelet on her wrist and a white bracelet on her wheelchair. ******************************************************* The Immediate Jeopardy situation was removed on [DATE] based on the following corrective actions taken by the facility: - Policies and Procedures were revised to specify identification of residents' resuscitative status including bracelets used on residents' wrists and wheelchair, the spine of the medical record and name plate outside of the residents' room. - All staff had been in-serviced on the new policies and procedures (staff on leave, would not be allowed to return to the residents' unit without receiving the required inservice training). - A full house audit was conducted on the MOLST (medical orders for life sustaining treatment) forms, physician orders, and comprehensive care plan process. - Based on the audit results, a new policy was developed for documentation of care plan reviews and "revamped" care plan form. - Facility administrative staff monitored all staff to ensure compliance with the new policies and procedures. 10 NYCRR 415.12