Every finding on record at St. Joseph's Hospital - Skilled Nursing Facility

Based on observations, interviews, and record review, the facility did not provide maintenance services necessary to maintain a safe and comfortable environment for one (1) of one (1) automatic door reviewed (Main Entrance). Specifically, the exterior and interior accessibility (handicap) automatic door opening pads at the main entrance were not functional, requiring residents who used wheelchairs to rely on others for entry and exit from the building.The findings include:The facility policy Maintenance and Service of Medical Equipment and Service Contract Agreements last reviewed March 2024 included completion of a work order in the event of malfunctioning equipment.Resident #9 had diagnoses including polyneuropathy (damage to peripheral nerves) and osteoarthritis (degenerative joint disease). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and used a wheelchair for mobility, independently self-propelling up to 150 feet with two (2) turns. Review of the current Comprehensive Care Plan initiated 02/10/2026 documented the resident required staff supervision for wheelchair mobility.During an interview on 02/11/2026 at 11:30 AM, Resident #9 stated the front entrance handicap pads had not worked since last summer and the doors must be held open by family members to allow exit from the building. The resident stated the doors were heavy.Resident #12 had diagnoses including left leg above-the-knee amputation, right leg below-the-knee amputation, and gait (a person's manner of walking) and mobility abnormalities. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and independently self-propelled a wheelchair 150 feet with two (2) turns.During an interview on 02/11/2026 at 10:45 AM, Resident #12 stated the entrance accessibility switch did not work and when returning to the facility, the resident must call security, flag down a security vehicle, or attempt to get someone's attention inside the building for assistance to re-enter.Resident #3 had diagnoses including traumatic brain injury and epilepsy. The Minimum Data Set, dated [DATE] documented the resident had moderately impaired cognition.During an interview on 02/11/2026 at 10:30 AM, Resident #3 stated the accessibility pads at the outside entrance had not worked in a while and the resident did not attempt to use them.During observations on 02/11/2026 at 8:15 AM and on 02/12/2026 at 8:30 AM, the surveyor pressed the exterior and interior accessibility automatic door opening pads. The automatic doors did not open on either date, and the doors had to be manually opened.During an interview on 02/11/2026 at 9:10 AM, the Administrator stated they were not aware the entrance accessibility pads were not functioning.During an interview on 02/11/2026 at 9:40 AM, the Director of Facilities stated they were not aware the entrance accessibility pads were not functioning. The Director of Facilities stated work orders are completed when equipment is reported as malfunctioning. Review of maintenance documentation did not include work orders related to the entrance accessibility pads. 10 NYCRR 415.29, 415.29(b), 415.29(j)(1)

Based on observations, interviews, and record review, the facility did not ensure allegations of neglect were thoroughly investigated and documented for one (1) of two (2) residents reviewed (Resident #9). Specifically, Resident #9 sustained an injury when [NAME] Elevator #5 closed on the resident's arm, and the facility did not complete an incident report, initiate an investigation, or conduct a root cause analysis following the incident.The findings include:The facility policy Accident Investigation and Analysis last reviewed December 2025 included all accidents and incidents would be investigated by the department director. Serious accidents, or any unusual frequency of accidents shall be investigated by the Safety Committee.The facility policy Equipment - Incident Investigation last reviewed October 2024 included preparing a report of findings when equipment has been involved in an injury to a patient. If it is suspected an incident was caused by equipment malfunction or caused entirely by improper use of equipment, an incident report form needed to be prepared and submitted. Resident #9 had diagnoses including polyneuropathy (damage to peripheral nerves) and osteoarthritis (degenerative joint disease). The Minimum Data Set (a resident assessment tool) dated 02/04/2026 documented the resident was cognitively intact and used a manual wheelchair for mobility.In a progress note dated 01/26/2026, Licensed Practical Nurse #1 documented Resident #9 bumped their left arm on the elevator doors during day shift.In progress notes dated 01/27/2026, Licensed Practical Nurse #2 documented Resident #9 reported left wrist and forearm pain following the elevator door closing on their arm. The left wrist and arm appeared bruised and slightly swollen.An orthopedic office visit note dated 01/27/2026 documented no acute bony abnormality on x-ray and conservative management was recommended.During an interview on 02/11/2026 at 9:40 AM, the Director of Facilities stated no work order was received related to [NAME] Elevator #5 closing on Resident #9's arm.During an interview on 02/11/2026 at 11:55 AM, Registered Nurse Manager #1 stated following the incident, the focus was on caring for the resident and notifying administration. Registered Nurse Manager #1 stated an incident report was not completed.During an interview on 02/12/2026 at 9:20 AM, the Director of Nursing stated an incident report and investigation report related to Resident #9's elevator injury could not be located and were not completed.Review of facility documentation did not include evidence an investigation was initiated, no root cause analysis was conducted, and no Safety Committee review occurred following the incident.10 NYCRR 415.4(b)(3)-(4)

Based on observations, interviews, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for two (2) of five (5) residents reviewed (Resident #9 and Resident #12). Specifically, Resident #9's arm was caught in [NAME] Elevator #5 when attempting to stop the elevator door from closing, and Resident #12 was observed using their arm to prevent the elevator door from closing on their wheelchair. The elevator remained operational and accessible to residents, and the facility did not investigate, test, repair, or remove the elevator from service following the incident involving Resident #9.The findings include:The facility policy Accident Investigation and Analysis last reviewed December 2025 included all accidents and incidents would be investigated by the department director. Serious accidents, or any unusual frequency of accidents shall be investigated by the Safety Committee.The facility policy Equipment - Incident Investigation last reviewed October 2024 included preparing a report of findings when equipment has been involved in an injury to a patient. If it is suspected an incident was caused by equipment malfunction or caused entirely by improper use of equipment, an incident report form needed to be prepared and submitted. 1. Resident #9 had diagnoses including polyneuropathy (damage to peripheral nerves) and osteoarthritis (degenerative joint disease). The Minimum Data Set (a resident assessment tool) dated 02/04/2026 documented the resident was cognitively intact and used a manual wheelchair for mobility, independently self-propelling up to 150 feet with two (2) turns.Review of the current Comprehensive Care Plan initiated 02/10/2026 documented Resident #9 could self-propel in a wheelchair with staff supervision.In progress notes dated 01/26/2026, Licensed Practical Nurse #1 documented Resident #9 bumped their left arm on the elevator doors during day shift. In progress notes dated 01/27/2026, Licensed Practical Nurse #2 documented Resident #9 reported left wrist and forearm pain following the elevator door closing on their arm. The left wrist and arm appeared bruised and slightly swollen. The left arm was wrapped for comfort and pain medication was administered. An orthopedic office visit dated 01/27/2026 documented x-rays of the left wrist showed no acute bony abnormality (no fracture). Conservative management was recommended, including use of an Ace bandage or splint for comfort and a short course of narcotic pain medication.During an interview on 02/11/2026 at 11:30 AM, Resident #9 stated the elevator door did not stop when their arm was placed against it to prevent it from closing. Resident #9 stated a staff member pulled the door open so their arm could be removed.During an interview on 02/11/2026 at 12:05 PM, Sitter #1 stated the elevator door closed fully on Resident #9's wrist and did not re-open when the arm was placed across the doorway. Sitter #1 stated the door had closed on them previously and had been doing so since beginning employment five (5) years ago.During an interview on 02/12/2026 at 9:20 AM, the Director of Nursing stated an incident report related to Resident #9's elevator injury could not be located and was not completed.2. Resident #12 had diagnoses including left leg above the knee amputation, right leg below the knee amputation, and mobility abnormalities. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and independently self-propelled a manual wheelchair up to 150 feet with two (2) turns.Review of the current Comprehensive Care Plan initiated 06/10/2025 documented Resident #12 navigated the facility independently in a wheelchair.During an observation on 02/12/2026 at 12:05 AM, Resident #12 self-propelled their wheelchair into [NAME] Elevator #5. The elevator door closed while the wheelchair was partially inside the elevator and made contact with the wheelchair. Resident #12 used their arm to stop the elevator door from closing and repositioned the wheelchair.During an interview on 02/11/2026 at 10:35 AM, Certified Nursing Assistant #1 stated staff avoid placing arms in the doorway because the [NAME] Elevator doors will close quickly and slam shut.During an interview on 02/11/2026 at 10:45 AM, Resident #12 stated the elevator doors close too fast and sometimes must be stopped manually with hands to prevent them from closing.During an interview on 02/11/2026 at 9:10 AM, the Administrator stated they were aware [NAME] Elevator #5 closed quicker than the other elevator and stated Resident #9 put their arm out to stop the door and Resident #9's arm got pinched.During an interview on 02/11/2026 at 9:40 AM, the Director of Facilities stated elevator doors are inspected yearly and not checked routinely. The Director of Facilities stated work orders are completed when problems are reported. Review of maintenance documentation did not include a work order for [NAME] Elevator #5 related to door malfunction.Review of elevator inspection reports dated 02/19/2024, 08/13/2024, 12/23/2024, and 09/25/2025 identified violations for [NAME] Elevator #5. A letter from the facility's contracted elevator repair company dated 02/13/2026 referenced violations items on an inspection report from 09/25/2025 and documented some violations identified for [NAME] Elevator #5 had been completed, while others were in process of being addressed. The facility did not provide documented evidence the door sensor or closing mechanism for [NAME] Elevator #5 were tested or repaired following the incident involving Resident #9. 10 NYCRR 415.29, 415.29(b), 415.29(j)(1)

Based on interviews and record review conducted during the Recertification Survey from 7/22/24-7/26/24, for 7 (Residents #27, #35, #36, #38, #58, #66, #76) of 14 residents reviewed, the facility did not ensure the baseline care plan (developed within 48 hours of admission and included minimum healthcare information necessary to properly care for the immediate needs of the residents, that they were able to understand) was completed within 48 hours of a resident's admission and that a summary of the baseline care plan was provided to the resident and/or their representative. Specifically, for Resident #36, #38, #58, #76, the facility could not provide documented evidence that a baseline care plan was completed within 48 hours of the resident's admission. For Residents #27, #66, and #73, the facility could not provide evidence that a summary of the baseline care plan was provided to the resident and/or their representative. The findings include, but was not limited to, the following: Review of the facility policy Baseline (48-Hour) Care Plan, dated July 2024, revealed that the baseline care plan would be developed within 48 hours of a resident's admission and include an initial set of instructions needed to provide effective and person-centered care for the resident. Additionally, the policy documented the baseline care plan would be shared with the resident and/or the residents representative. 1. Resident #28 was admitted to the facility with diagnoses that included breast cancer, history of transient ischemic attack (mini stroke), and anxiety. The Minimum Data Set Resident assessment dated [DATE], documented the resident was cognitively intact. Review of the electronic health record for Resident #28 did not include documented evidence that a baseline care plan had been completed. The facility was unable to provide any documented evidence that the resident's baseline care plan had been completed and that a summary had been provided to the resident. 2. Resident #36 was recently admitted to the facility with diagnoses including a fracture of the upper right arm, congestive heart failure, and gout. The Minimum Data Set Resident assessment dated [DATE], revealed the resident was severely cognitively impaired. Review of the electronic health record for Resident #36 did not include any documented evidence that a baseline care plan had been completed following admission to the facility. The facility was unable to provide any documented evidence that a baseline care plan had been completed for Resident #36 and a summary provided to the resident's representative. 3. Resident #27 was admitted to the facility with diagnosis including a fracture of the upper arm, dementia, and type 2 diabetes mellitus. The Minimum Data Set Resident assessment dated [DATE], revealed the resident had moderately impaired cognition. Resident #27's baseline care plan, signed by Registered Nurse Clinical Coordinator #1 on 5/7/24, did not include that a summary of the baseline care plan had been reviewed with the resident and/or their representative. During an interview on 7/25/24 at 1:35 PM, Registered Nurse Clinical Coordinator #1 stated nurse managers or the nurse admitting the resident are responsible for baseline care plans and providing a copy to the resident and/or their representative. Registered Nurse Clinical Coordinator #1 stated that they were completing the baseline care plans on an electronic health system and in that health system there is not anything that reminds the nurses to complete a baseline care plan. In an interview on 7/25/24 at 4:06 PM, the Director of Nursing stated that within 48 hours of admission the resident should have a baseline care plan started with their immediate needs and that it should be reviewed with the resident and/or the resident representative. The Director of Nursing stated the electronic health system did not make it obvious that a baseline care plan needed to be completed and that they have some newer staff that may not have gotten the training or the understanding to complete the baseline care plans. 10 NYCRR 415.11 47642

Based on observations and interview conducted during the Recertification Survey from 7/22/24-7/26/24, the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: Observations on 7/23/24 at 10:40 AM included a carbon monoxide detector located on the wall in the Energy Center that housed the 500-Kilowatt (kW) generator. During an interview on 7/24/24 at 2:35 PM, the Facilities Manager asked the surveyor how often the facility is supposed to test the carbon monoxide detectors. When the surveyor responded that they need to be inspected/tested monthly, the Facilities Manager stated that they are probably not doing that monthly. There was no additional documentation provided by the facility of the locations of all carbon monoxide detectors within the facility, nor was their documentation of monthly inspections and testing of carbon monoxide detectors. Observations on 7/25/24 at 12:25 PM included a natural gas range in the main kitchen and a carbon monoxide detector on the wall outside the staff dining area in the middle of the kitchen. The 2015 edition of the International Fire Code (IFC), requires carbon monoxide detection to be provided in an approved location between the fuel burning appliance and the dwelling unit, sleeping unit, or classroom; or on the ceiling of the room containing the fuel-burning appliance. Additionally, carbon monoxide alarms shall be maintained in accordance with NFPA 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer ' s published instructions at least monthly. 10 NYCRR: 415.29(a)(2), 711.2(a)(1); 42 CFR: 483.70(b), 2015 IFC: Section 915, 915.1, 915.1.4, Section 1103.9, 2012 NFPA 720: 8.7.1

Based on observations, interviews, and record review conducted during a Recertification Survey from 7/22/24-7/26/24, the facility did not ensure the nurse staffing information was posted with the required information and in a prominent place readily accessible to all residents and visitors. Specifically, the nurse staffing information did not consistently include the accurate number and total hours worked by licensed (Registered Nurses and Licensed Practical Nurses) and unlicensed (Certified Nurse Aides) nursing staff who were directly responsible for resident care. Additionally, the staffing information was only posted on one residential unit preventing access of the information to the residents and visitors on the second unit (a secured unit that was locked and required staff to provide elevator access to all residents or visitors). This is evidenced by the following: During observations on 7/24/24 at 12:16 PM and 4:04 PM and 7/25/24 at 1:46 PM, the facility's nurse staffing information posted did not include the actual and total hours worked for both licensed and unlicensed nursing staff. Additionally, the nurse staffing postings were located on the third-floor residential care unit, which was not accessible to residents or visitors on the fifth floor without staff assistance (badge access). Review of the daily nursing information from 6/1/24 to 7/24/24 revealed multiple days that did not include the accurate number of Registered Nurses (Registered Nurse Supervisors not included) when reviewed with the staffing schedules. During an interview on 7/24/24 at 12:30 PM, the Director of Nursing stated that the facility had 24-hour Registered Nurse Supervisor coverage in the facility at all times (7 days a week). During an interview on 7/25/24 at 8:30 AM, Scheduler #1 said they schedule staff and complete the daily nursing staffing postings. Scheduler #1 said they go over nursing staff with the Director of Nursing each morning, complete the nursing staff form for the day shift, and post it. Scheduler #1 said they would fill out the second part (evening shift staffing) around 3:15 PM, and they would complete the night shift staff the next morning (after the shift) when the posting is removed and the new day's information posted. Scheduler #1 said the purpose of the daily nursing staffing posting is to show they have adequate nursing staffing. Scheduler #1 said the daily nursing staffing is posted on the third floor (across from a nurses' station) and included the number of registered nurses, licensed practical nurses, and certified nurse aides (registered nurse supervisors not included). Scheduler #1 said they were not aware that the total number of hours worked by each discipline was required to be on the postings. Scheduler #1 said the daily nurse staffing was posted in one location in the facility (on the third-floor resident unit). If a resident (or visitor) on the fifth-floor resident unit wanted to observe it, they could ask staff who could provide a copy of the information, but that residents or visitors would not know the information was posted on the third floor if they had never been there. During an interview on 7/26/24 at 12:20 PM with the Administrator and the Director of Nursing, the Director of Nursing stated that both the number of each nursing discipline and the total hours worked by each were required to be on the daily nurse staffing posting. The Director of Nursing said they were not aware that the total hours worked was also required and were not sure why the information was only posted on one unit. 10 NYCRR 415.13

Based on observations, interviews, and record review conducted during a Recertification Survey and a complaint investigation (NY 223), from 3/39/22 to 4/1/22, the facility failed to ensure that one (Resident #7) of five residents reviewed was free of significant medication errors. Specifically, Resident #7 was not provided [MEDICATION(S)] (an anti-[CONDITION(S)] medication) as ordered and subsequently experienced [CONDITION(S)]-like activity requiring hospitalization . This resulted in actual harm to Resident #7 that was not immediate jeopardy. Findings include: Resident #7 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], documented the resident's cognition as severely impaired and that the resident required extensive assistance for activities of daily living. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record (MAR) for 6/28/21- 7/2/21 documented that 7 out of 10 opportunities for the [MEDICATION(S)] were documented as not being administered with the first missed dose on 6/28/21 6:00 a.m. In a nursing progress note dated 7/2/21 at 9:32 p.m., Registered Nurse (RN)/ Clinical Coordinator #1 documented that Resident #7 did not receive their [MEDICATION(S)] medication as ordered due to the medication being unavailable. RN/Clinical Coordinator #1 wrote they were notified by staff to come to Resident #7's room where the resident was having [CONDITION(S)]-like activity. Vital signs revealed an elevated blood pressure of 181/85, and the resident was transferred to the hospital. A review of the resident's lab work dated 7/2/21 documented [MEDICATION(S)] levels were < 2 with a normal reference range of 12 to 46. A review of the facility's Investigation Report documented that Resident #7's MAR had multiple missed doses of the [MEDICATION(S)] with nursing notes stating the medication was not available. In a statement given on 7/9/21, Licensed Practical Nurse (LPN) #1 stated they had discovered on 6/29/21 that the [MEDICATION(S)] medication for Resident #7 was circled as not administered for the morning dose and that the medication was not in the medication cart. LPN #1 then stated they were able to administer Resident #7 medication but was unable to provide details as to where they obtained the medication. The Investigation Report included a message from the pharmacy that Resident #7's [MEDICATION(S)] was ordered on 5/31/21 and then not until 7/2/21 at 9:37 p.m. Review of Resident #7's medical record and the Investigation Report documented there was no documented evidence that the physician was notified of any missed doses of [MEDICATION(S)]. There was no documented evidence the facility requested refills for Resident #7's [MEDICATION(S)] refill until after the resident was transferred to the hospital. During an interview on 3/31/22 at 7:54 a.m., LPN #2 stated they were aware of the issue at the time and that the [MEDICATION(S)] medication for Resident #7 had been running low and that two attempts had been made to the facility's contracted pharmacy requesting a refill of the medication. LPN#2 stated they were then off for two days and when they returned to work, Resident #7 still had not received the medication. LPN #2 stated they did not notify the provider as they would only notify the provider if the resident had missed a dose because there are other ways to get a medication and thought this may have occurred. During an interview on 3/31/22 at 8:36 a.m., the Pharmacist stated that Resident #7 had an order to refill the [MEDICATION(S)] but did not receive an order from the facility until 7/2/21 at 9:37 p.m. (at the time of discharge to the hospital). During an interview on 3/31/22 at 9:46 a.m., the RN/Clinical Coordinator #1 stated they were working the evening shift the night the resident was transferred to the hospital and when they attempted to pull Resident #7's 6:00 p.m. medications, they could not locate the [MEDICATION(S)]. The RN/Clinical Coordinator #1 stated they could see on the MAR that the resident had missed some doses of the [MEDICATION(S)] medication previously but could not recall how many. The RN/Clinical Coordinator #1 stated that they were called into the resident's room and discovered that Resident #7 was having [CONDITION(S)]-like activity and was sent to the hospital. During an interview on 3/31/22 at 12:50 p.m., the Director of Nursing (DON) stated they were first notified of the medication administration issues on 7/2/21 after Resident #7 was transferred to the hospital. The DON stated the nurses document their initials on the MAR to represent the medication as administered or the nurses will place their initials and a circle to represent the medication were not administered. The DON stated they had provided education to their staff about leaving holes on the MAR and that if a nurse forgets to document they have 48 hours to update the MAR. The DON stated that during their investigation they received mixed statements from nursing regarding the missed doses and was unable to come to a conclusion about the number of missed doses and the reason for them. The DON stated they were told by one nurse that a bottle of [MEDICATION(S)] had been requested by the pharmacy and delivered but the that the nurse had thrown out the copy of the fax information and no proof was found of the request. The DON stated they were also told by nursing that another resident on the unit was receiving the same medication as Resident #7 and that the medication was borrowed and provided to Resident #7. During an interview on 3/31/22 at 2:04 p.m., the Physician stated they would want to be notified if a single dose of a medication was missed. The physician stated if an individual does not receive their anti-[CONDITION(S)] medication, they can have a [CONDITION(S)]. 10NYCRR 415.12(m)(2)

Based on observations, interviews and record reviews, conducted during the Recertification Survey, completed on [DATE], it was determined that for one of one main kitchen, the facility failed to store, prepare, distribute and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were multiple undated and unlabeled food items and non-food contact surfaces within the kitchen were not maintained in clean and sanitary condition. This is evidenced by the following: The facility policy, 'Food Storage', reviewed/revised [DATE], included that all products are to be labeled and dated with the receiving date. The policy included that old supplies should be moved to the front of the shelf to ensure rotation of products and new supplies should be placed to the rear of the shelf. The policy included that storerooms, refrigeration units and freezers should be mopped and swept as scheduled and as needed. The facility policy, 'Cleaning and Sanitizing of Work Surfaces', reviewed/revised [DATE], included that a cleaning schedule is completed and posted to ensure routine cleaning is completed weekly. Larger pieces of equipment and areas are scheduled on a biweekly and monthly basis. The policy included that when cleaning fixed equipment, non-removable parts are cleaned with detergent and hot water, rinsed, air-dried and sprayed with a sanitizing solution at the appropriate concentration. The equipment is reassembled, and any food contact surfaces that may have been contaminated during the process are re-sanitized. Observations during the initial brief tour of the main kitchen on [DATE] from 9:40 a.m. to approximately 10:40 a.m. revealed the following: a. Three bags of instant gravy mix, two bags of powdered mashed potato, three bags of potato pearls, and three 10-pound (lb.) bags of pasta were all open and undated, in the dry storage area. b. A case of eight-ounce (oz.) cans containing tube feed (liquid form of nourishment), expired [DATE], remained on the shelf in the dry storage area. c. A 32oz. container of liquid egg product, a container of horseradish and a container of vegetable base were open, partially used and undated in a walk-in cooler. d. A bag of fries, a bag of hash brown potatoes, a bag of cheese tortellini, a tray of cheese manicotti, a 5lb. bag of meat balls, a 10lb. bag of cod nuggets, a 10lb. bag of scallops and a large box of tilapia patties and a box of French loaf garlic slices were all open and undated, in a walk-in freezer. The was also an undated 32oz. jar of bruschetta without a lid and a broken rim, covered in plastic. e. A undated and unlabeled grocery bag of what was identified as decayed parsley, in the produce cooler. f. A 5lb. container of sour cream was open, partially used and undated in a walk-in cooler. g. Ten portioned cups of grapes were undated and three portioned cups of what was identified as pureed cottage cheese were undated and unlabeled, in a walk-in cooler. h. Sticky floors were identified in the nourishment cooler. i. A sheet tray each of prepared cups of what was identified as applesauce, grapes, butterscotch pudding and tossed salad were all uncovered, unlabeled and undated, in a stand-up refrigerated unit. j. An open, undated box of raspberries and a shelving unit that was covered in crumbling food debris, and large white and pink dried drips on it in the deep freezer. Observations during the follow-up tour of the main kitchen on [DATE] at 11:10 a.m. revealed the following: a. A food processor that was not air-dried after sanitizing and remained wet when ready to be stored. b. A bag of pizza crusts that were open and undated, in a walk-in freezer. The 10lb. bag of cod nuggets and box of tilapia remained open and undated from two days prior. c. Readily accessible and exposed piping behind and next to two steam jacketed kettles that were in the cook's area were covered in thick green, black and brown grime. The grime was easily scraped by the surveyor's fingernail. d. Walls in the cook's area were covered in dried-on tan drips. e. Hot-holding equipment and an oven in the cook's area were covered in dried-on tan drips and food debris. During an interview on [DATE] at 12:03 p.m., the Kitchen Aide stated they didn't know what the grime and debris on the pipes was. The Kitchen Aide said that the cook's area needed to be cleaned and that the big equipment was usually cleaned on the weekends. During an interview on [DATE] at 12:35 p.m., the Kitchen Support Manager stated that they did not know how to clean the cook's prep area equipment and pipes and thought that it was previously power sprayed. The Kitchen Support Manager said that it was in the job description for each shift what should have been done for cleaning. 10NYCRR: 415.14(h) 10NYCRR: ,d+[DATE].10, ,d+[DATE].21, ,d+[DATE].110, ,d+[DATE].116, ,d+[DATE].171 U.S. Food and Drug Administration's (FDA) Food Code Centers for Disease Control and Prevention's (CDC) food safety guidance

Based on interviews and record reviews conducted during the Recertification Survey, completed on 4/1/22, it was determined that for two (Resident #64 and #73) of three residents reviewed, the facility did not provide the appropriate appeal notice to the Medicare beneficiary in order to notify them of their appeal rights under the regulations. Specifically, the facility did not provide the Medicare A beneficiaries with a Notice of Medicare Non-Coverage (NOMNC) letter prior to discharge from the facility per the regulations. This is evidenced by: Resident #64 was admitted to the facility 3/2/22 under Medicare part A benefits and was discharged to the community on 3/18/22. There was no documented evidence that the resident or responsible party was provided with and properly completed the required appeal notice prior to discharge. Resident #73 was admitted to the facility 1/17/22 under Medicare part A benefits and was discharged to the community on 1/27/22. There was no documented evidence that the resident or responsible party was provided with and properly completed the required appeal notice prior to discharge. In an interview on 4/1/22 at 11:05 a.m., the Social Worker (SW) stated that signed NOMNC forms were not completed for Resident's #64 and #73 because they did not know they had to be completed. In an interview on 4/1/22 at 11:40 a.m., the Administrator stated the SW was responsible for completing NOMNC forms and was not aware SW did not issue the right forms. 10 NYCRR 415.3(g)(2)(i)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that that for one of one main kitchen, the facility did not prepare, distribute, and store food under sanitary conditions. The issues involved grilled ham and cheese sandwiches that were not hot held at the proper temperature for food service, improper freezer and dry storage, and the use of metal scouring pads. This is evidenced by the following: The facility's policy, HACCP and Food Handling Principles, dated (MONTH) 2010, included that hot foods are to be served at between 140 degrees Fahrenheit (*F) to 155*F. The facility's policy, Cleaning and Sanitizing of Work Surfaces, dated (MONTH) (YEAR), revealed that a nylon-scouring pad is used as an abrasive to remove food soil from surfaces. Steel wool and metal scouring pads are not permitted. The initial tour of the kitchen on 1/21/20 at 10:30 a.m. and a subsequent tour on 1/23/20 at 11:30 a.m. revealed the following: a. A steel wool, metal scouring pad was in use in the cook's area. The Food Service Director said the steel scouring pad was used to scrub the macaroni and cheese out of the soup kettles. He said that he was unaware that the metal scouring pads were not allowed. b. The facility's two freezers had boxes stored a few inches from the ceiling, and in Freezer #1 there were two boxes wedged below the fan. c. The dry storeroom had four boxes of coffee lids on the floor. The Food Service Director said the boxes should not have been on the floor. During an observation of the lunch tray line on 1/23/20 at 11:45 a.m., there were grilled ham and cheese sandwiches on the tray line that were stacked three layers high in a steam table pan. Using the facility[NAME]Aqua Tuff 351 digital thermometer, the Food Service Director inserted the thermometer into the top layer of sandwiches under the light (in the back of the pan) and it registered 110*F, and the front of the pan registered 88*F. The second layer of grilled ham and cheese sandwiches registered at 112*F. When interviewed at that time, the Food Service Director said the temperature should be at least 135*F, and then asked the cook to send the top two layers of grilled ham and cheese sandwiches to be reheated. When interviewed on 1/24/20 at 10:00 a.m. the Food Service Director said that he ideally wants the hot food at 160*F on the steam table. (10 NYCRR 415.14(h), 14-1.43, 1.40, 1.90)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (one Housekeeping employee and one Certified Nurse Assistant) of eight employees records reviewed, the facility did not properly implement policies and procedures to prevent abuse. Specifically, the facility did not conduct a Nurse Aide Registry Check prior to hiring employees. This is evidenced by the following: A review of the facility records on 1/23/20 from 2:05 p.m. to 2:55 p.m. revealed one Housekeeping employee began work at the facility on 9/16/19 with no proof of Nurse Aide Registry verification prior to their start date. Further record review of the employee's time detail report revealed the employee worked the following dates: 9/16/19, 9/17/19, 9/19/19, 9/20/19, 9/23/19, 9/24/19, 9/25/19, 9/27/19, 9/28/19, and 9/29/19. Additionally, a timestamp of 1.25 hours was also recorded in the time detail report on 10/4/19. During an interview on 1/23/19 at 2:25 p.m., the Human Resources Manager stated she was unable to locate the Nurse Aide Registry verification for the Housekeeping employee. She stated that the employee was removed from the work schedule on 10/3/19 due to a pending denial letter from the CHRC. She stated the Housekeeping employee was terminated on 12/9/19 due to a final denial letter from the CHRC. A review of the facility records on 1/23/20 from 2:05 p.m. to 2:55 p.m. revealed one Certified Nurse Assistant (CNA) began work at the facility on 1/14/20, and a Nurse Aide Registry verification was completed on 1/23/20. During an interview on 1/23/20 at 2:35 p.m., the Human Resources Manager stated she was certain the Nurse Aide Registry verification was performed prior to the CNA's start date, but she was unable to locate that record. She stated that the CNA was unable to use the normal time tracking system, and her work hours were recorded by her nursing supervisor. On 1/24/20 at approximately 2:00 p.m., a copy of the CNA's work schedule was provided for the surveyor to review. Review of the CNA's work schedule revealed she worked the following dates without a Nurse Aide Registry verification: 1/17/19 (7:00 a.m. Start), 1/20/19 (7:00 a.m. Start), 1/22/19 (7:00 a.m. Start), and 1/23/19 (7:00 a.m. Start). (10 NYCRR 415.4(b)(1)(ii)(b))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #55) of one resident reviewed for infections, the facility did not ensure proper infection control procedures were followed. Specifically, a staff member did not remove soiled gloves or wash their hands prior to touching surfaces in the room and handling a stack of clean briefs. This is evidenced by the following: Resident #55 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/19/19, revealed the resident was cognitively intact. The Active Care Plan, dated 1/13/20, revealed that the resident was positive for [MEDICAL CONDITION], was on contact precautions, and required the assistance of staff with personal hygiene after episodes of loose stools. A progress note, dated 1/13/20, revealed the resident was on an antibiotic ([MEDICATION NAME]) three times a day and was still having liquid mucous stools. During an observation of care on 1/24/20 at 8:25 a.m., the Registered Nurse (RN) Unit Coordinator was observed wearing the appropriate personal protective equipment prior to contact with the resident. The resident's incontinence brief had a moderate amount of loose stool present. The nurse cleansed the resident's perineal area. She stated that there were no clean briefs in the room. Without removing her soiled gloves, the nurse touched the privacy curtain to open it, and then touched the room door handle to access the hallway. While standing in the doorway, the nurse alerted staff who were in the hallway to bring her clean briefs. The nurse received a stack of briefs with the soiled gloves, placed them on the resident's nightstand, and again touched the privacy curtain to close it. She then resumed performing incontinence care. When interviewed on 1/24/20 at 8:50 a.m., the RN Unit Coordinator stated that she did not think to remove her gloves, but should have removed her gloves. She should have washed her hands prior to touching the privacy curtain and the door handle. During an interview on 1/24/20 at 11:48 a.m., the Infection Preventionist stated that staff should not be touching any surfaces with soiled gloves. She said if a resident has [MEDICAL CONDITION], surfaces that were touched with contaminated gloves should be cleaned. She said gloves should be removed, and hands should be washed with soap and water prior to leaving the room. When interviewed on1/24/20 at 1:18 p.m., the Director of Nursing stated that if a resident was on contact precautions, she would have expected the nurse to remove her gloves and wash her hands before touching any surfaces in the room. (10 NYCRR 415.19(a)(1-4))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of three residents reviewed for non-pressure related skin conditions, the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs. Specifically, Resident #17 had documented combative behaviors, was at a high risk for skin impairment, and did not have a care plan developed to address behaviors or skin impairment, and Resident #61 had a history of [REDACTED]. This is evidenced by the following: 1. Resident #17 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/11/19, revealed the resident had severely impaired cognition. Review of Injury of Unknown Origin Investigation Reports revealed that the resident was found to have sustained a skin tear to the right shin on 12/13/19. The resident was combative during cares and sustained skin tears on 12/15/19 and 1/20/20. The current Active Care Plan did not address the resident's risk for skin impairment or behaviors. When observed on 1/21/20 at 11:15 a.m., the resident was noted to have a skin tear to her right forearm and several areas of possible bruising that were purple and red in color. When interviewed on 1/24/20 at 10:08 a.m., Registered Nurse (RN) Unit Coordinator #1 stated that based on nursing judgment, Geri-sleeves and leg sleeves were placed on the resident after sustaining skin tears. She said the leg sleeves were placed on the resident for protection following an incident that resulted in skin tears but were not continued after the area healed. She said the resident's care plan should address the resident's behavior and any factors placing the resident at risk for skin tears including interventions, but it does not. 2. Resident #61 had [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/27/19, revealed the resident had moderately impaired cognition. Review of Injury of Unknown Origin Investigation Reports revealed that the resident was found to have a bruise to the right foot on 11/3/19, a bruise to the right elbow on 11/6/19, and bruises to the left lower leg and left hand on 1/23/20. The Active Care Plan, dated 1/7/20, and the Door Care Plan, dated 11/6/19, did not include resident specific needs or precautions related to the resident's history of bruising. During an observation on 1/21/20 at 2:00 p.m., the resident was observed to have localized swelling and bruising that was purple and blue in color noted to the left hand at the joint between the thumb and forefinger. On 1/23/20 at 10:16 a.m., the resident was observed to have localized swelling and bruising that was purple and blue in color to her left lateral ankle. Interviews conducted on 1/24/20 included the following: a. At 11:20 a.m., RN Unit Coordinator #2 stated the resident should have had a care plan in place for fragile skin. She said interventions were put into place including a new chair, padding to the chair, and removal of a bed assist rail. b. At 1:22 p.m., the Director of Nursing (DON) stated that interventions had been put into place as a result of past bruises. After review of the resident's Active Care Plan at that time, the DON stated that it did not address the resident's risk for bruising or skin tears and does not include interventions that were implemented after previous incidents of bruising. She said the resident's risk for bruising should be addressed in the Active Care Plan or Door Care Plan. c. At 1:25 p.m., the Administrator stated that every resident admitted to the facility should have a care plan that addresses skin integrity. She said if a resident was identified as having frequent bruising or skin tears, there should be a care plan in place including interventions. (10 NYCRR 415.11(c)(1))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of three residents reviewed for resident right's, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries to notify them of their appeal rights under the regulation. Specifically, Resident #44 did not receive a Skilled Nursing Facility Advanced Beneficiary Notice or a denial letter at the termination of Medicare Part A benefits. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] and was discontinued from Medicare Part A services on 12/6/19 and remained in the facility. There was no evidence that a Skilled Nursing Facility Advanced Beneficiary Notice or denial letter was given to the resident or legal representative informing them of their potential liability for payment. When interviewed on 1/23/20 at 11:30 a.m., the Licensed Practical Nurse responsible for billing said she was new to the position, and had just started learning about liability notices. At that time, the Administrator said that the person who did the job for [AGE] years had retired and they were in the process of learning her job. (10 NYCRR415.3(g)(2)(i))

Based on interviews and record review conducted during an Abbreviated Survey (#NY 332), completed on 6/14/19, it was determined that for three (Residents # 3,4, and 5) of three residents reviewed for quality of care related to bowel protocol, the facility did not ensure residents received treatment and care in accordance with professional standards of practice. The issue involved the lack of monitoring of bowel movement logs to determine the need for as needed bowel medications. This is evidenced by the following: A review of the facility's Bowel Care policy, dated (MONTH) (YEAR), revealed the nurse is to assess the need for bowel care, to administer Milk of Magnesia (MOM) (laxative) with either juice or warm water and schedule a [MEDICATION NAME] (laxative) suppository to be administered the following morning as needed. If no results, repeat the suppository or administer an enema as needed. The policy included to document treatments and results and add interventions to the care plan. 1.Resident #3 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the current Comprehensive Care Plan (CCP) did not include a history of constipation. Physician orders, dated 4/29/19, included MOM 30 cubic centimeters (cc's) every morning as needed for constipation, give [MEDICATION NAME] suppository this morning for no bowel movement (BM) since 4/25/19 and every morning as needed, and a Fleets enema this morning if no results and to repeat every morning as needed. On 4/30/19, the orders again included a Fleets enema now and to repeat if no results. The (MONTH) 2019 Medication Administration Record [REDACTED]. A Fleet enema was administered on 4/30/19 resulting with a large BM. An interdisciplinary team note, dated 4/30/19, revealed the resident was cognitively intact, was dependent for toileting and used a bedpan for his bowels. Review of the (MONTH) 2019 Bowel and Bladder Summary Record revealed there were no documented BM's from 5/1/19 through 5/6/19. physician progress notes [REDACTED]. Orders included to give a [MEDICATION NAME] suppository every morning and a fleet enema this morning and every morning if no BM. The (MONTH) 2019 MAR indicated [REDACTED]. Physician orders, dated 5/10/19, included [MEDICATION NAME] suppository every morning at 6 a.m. and on 5/15/19 the orders included to give a [MEDICATION NAME] suppository now (if last BM was 5/12/19 as recorded) and then a Fleets enema if no BM. Review of the (MONTH) 2019 MAR indicated [REDACTED]. There was no documentation that the physician was notified. On 5/27/19 the physician ordered that if no BM in two days please administer as ordered bowel medications. Review of the (MONTH) 2019 Bowel Summary revealed there were no BM's documented from 6/3/19 day shift until 6/14/19. Review of the (MONTH) 2019 MAR indicated [REDACTED]. No other as needed bowel medications were documented as administered. Interviews conducted on 6/14/19 included the following: a. At 12:06 p.m., the Registered Nurse Clinical Coordinator (RNCC) stated the Certified Nursing Assistants (CNA) documented the Residents BM's in the computer. She stated the nurses on each shift review the bowel summary and administer medications per orders if the resident has no BM in 72 hours. The RNCC stated if a resident refused medications it should be documented, and the physician notified. The RNCC stated she was responsible for the development of the CCP. She said she should have developed a care plan for a resident with a history of constipation. b. At 12:33 p.m., a day shift Licensed Practical Nurse (LPN) stated if a resident has no BM in 3 days prune juice is given, then MOM, and then a suppository and Fleets enema if they have physician orders. She stated the nurses are supposed to review the bowel summary every day. c. At 12:46 p.m., the primary CNA stated the resident moved his bowels every day on the commode. She stated the only time she would report BM's was if the resident did not move their bowels. She stated she did not always document BM's every day as she did not have time. d. At 3:03 p.m., the evening shift LPN stated she looks to see when a resident last moved their bowels. She said if it has been three days she checks for bowel medication orders and if there are no orders she would call the doctor. 2) Resident #4 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Physician orders, dated 5/15/19 and 5/27/19, included [MEDICATION NAME] suppository and a Fleets enema every morning as needed for constipation. The physician documented on 5/28/19 that the resident had moderately impaired cognition. Review of the Bowel Summary from 5/28/19 through 6/14/19 revealed no documented BM's for greater than three days on three different occasions. Review of the (MONTH) 2019 MAR indicated [REDACTED]. 3) Resident #5 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Physician orders, dated 4/13/19, included [MEDICATION NAME] (laxative) suppository, [MEDICATION NAME] tablets and MOM 30 cc at bedtime as needed for constipation. The orders did not clarify timing of the medications or reference the bowel protocol. Review of the Bowel Summary from 6/5/19 through 6/13/19 revealed just four BM's documented. A review of the (MONTH) 2019 MAR indicated [REDACTED]. When interviewed on 6/14/19 at 1:16 p.m. the Director of Nursing (DON) stated the CNA's document every day if a resident moved their bowels. She said the nurse should review the bowel summary for residents who have had no BM for 3 days and follow the physician's orders [REDACTED]. The DON stated if a resident is known to have constipation it should be addressed on the CCP. (10NYCRR 415.12)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 26 of 83 residents reviewed for advanced directives, the facility did not ensure that there was an organized, effective system to ensure that residents' wishes regarding Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) are initiated and implemented according to their wishes. The issue involved code status that was not accurately identified on the residents' charts (Residents #54, #65, and #16,), wristbands (Residents #9, #49, #74, #51, #73, #53, #61 #54, #56, #30, #43, #15, #31, #37, #40, #55, #66, #180, #181, and #182), and door plates (Residents #49, #30, #43, #56, #15, #31, #37, #40, #46, #55, #59, #66, #72, #180, #181, and #182), and did not match the residents' Medical Orders for Life Sustaining Treatment (MOLST) for code status. This is evidenced by, but not limited to, the following: Review of the current facility policy, Advanced Directives included residents wishing to be DNR status will have a MOLST in their chart documenting such, as well as a DNR sticker placed on their medical chart to alert staff of their status. 1. Resident #49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated [DATE], revealed that the resident had moderately impaired cognition. The current MOLST in the resident's medical record documented that the resident's wishes were for a DNR status. In an observation on [DATE] at 2:07 p.m., the resident's door near the name tag had a blue dot (indicating that the resident was a full code). When interviewed at that time, Registered Nurse (RN) #1 stated the blue dot means that the resident was a full code which was incorrect. 2. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident had severely impaired cognition. The current MOLST in the medical record documented that the resident's wishes were for a DNR status. In an observation on [DATE] at 3:10 p.m., the resident's wristband did not have purple doves on it or a blue dot. When interviewed on [DATE] at 2:10 p.m., RN #1 stated that the purple doves on the doors and wristband means the resident is a DNR, and either a blue dot or nothing on the wristband means the resident is a Full Code. When interviewed on [DATE] at 2:23 p.m., the Licensed Practical Nurse stated that a purple dove on the resident's wristband means the resident is a Full Code. 3. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed that the resident's skills for daily decision making were severely impaired. The current MOLST in the medical record revealed that the resident's wishes were for a DNR status. The binder of the resident's chart revealed DNR, and an advanced directive note on the front of the chart revealed CPR (Full Code). In an interview on [DATE] at 3:18 p.m., RN #2 stated that new admissions should arrive with a MOLST and if not, one would be initiated. She said residents who are a DNR code status have a red sticker on the chart's spine, a purple bracelet with white doves on it, and nothing on the resident's door near the name plate. RN #2 said if a resident was a Full Code, the door would have a blue dot on it and there would be nothing on the bracelet. In an interview on [DATE] at 2:51 p.m., the Administrator stated that the facility policy is that purple doves mean a resident is a DNR and a blue dot means the resident is a Full Code. She said the code status should be documented on the spine of the resident's chart, the resident's wristband and the resident's door. She stated that the sticker on the front of the chart is no longer used, just the binder. The Administrator said many of the nurses are using places that no longer should be used to document the resident's code status. She said that all of the resident's medical records need to be reviewed for code status and corrected. (10 NYCRR 415.3(e)(1)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 4 of 24 residents reviewed for care planning, the facility did not develop and implement a person-centered Comprehensive Care Plan (CCP), including measurable goals, interventions and timeframes to meet resident preferences and goals and to address the resident's medical, physical, mental and psychosocial needs. The issues involved the lack of a care plan for pressure ulcers and/or deep tissue injury (Residents #25 and #57), lack of a care plan for the use of anticoagulants (Resident #56), and lack of a care plan for residents on isolation precautions (Residents #25 and #43). This is evidenced by, but not limited to, the following: 1. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/15/18, revealed the resident had moderately impaired cognition, [DIAGNOSES REDACTED]. A medical provider progress note, dated 8/22/18, revealed the resident was seen for a sore on his left fourth toe, was diagnosed with [REDACTED]. Review of the physician's orders [REDACTED]. a. On 8/24/18, a wound culture was obtained and included treatment orders for the left fourth toe ulcer. b. On 8/27/18, culture results [MEDICAL CONDITION]. c. On 9/6/18, an arterial doppler of the left lower extremity was ordered due to vascular disease and a non-healing toe ulcer. Review of the current CCP, last reviewed 8/7/18, revealed the resident was at risk for pressure ulcer development related to fragile skin. The care plan did not include problems, outcomes, or interventions that addressed the vascular ulcer [MEDICAL CONDITION] infection. During an observation on 9/19/18 at 1:25 p.m., there was a precaution cart attached to the outside of the resident's room door which included gloves, disposable gowns, and masks. There was a sign that documented that the resident was on contact precautions with instructions that gown and gloves were to be worn at all times even when contact with the environment was not anticipated. On 9/20/18 at 2:41 p.m., the resident stated that he had an infection in his toe and that the staff were supposed to wear all the gear over there (pointing to the precaution cart) but they do not always do that. He said they wear gloves when they are caring for him and when the dressing to his toe is changed. On 9/24/18 at 3:10 p.m., Licensed Practical Nurse (LPN) #1 stated that the resident had [MEDICAL CONDITION] infection in his left fourth toe and was on contact precautions due to the infection. On 9/25/18 at 10:31 a.m., the Registered Nurse (RN) Leader stated that when a resident is found to have an infection and needs contact precautions, a cart and sign directing what precautions are necessary is placed outside of the resident's room. The RN Leader said that a resident who has a vascular ulcer and needs contact precaution for an infection should have a CCP in place. After review of the CCP at that time, the RN Leader said there was no care plan in place to address [MEDICAL CONDITION] and need for contact precautions or that the resident had a vascular ulcer. 2. Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 9/9/18, revealed the resident was cognitively intact and used an anticoagulant daily. The current physician orders, directed the daily use of [MEDICATION NAME], an anticoagulant to help prevent risk of blood clots. Review of the current Resident Mini Door Care Plan and the CCP, dated 9/13/18, does not include the use of an anticoagulant. In an observation on 9/20/18 at 10:04 a.m., LPN #2 entered the resident's room with her morning medications, including [MEDICATION NAME]. LPN #2 asked the resident where she had gotten her shot of [MEDICATION NAME] the previous day so she could administer it in a different location that day. Interviews conducted on 9/26/18 included the following: a. At 8:10 a.m., Certified Nursing Assistant (CNA) #1 said that the use of a blood thinner is not on the closet care card. She said the nurses share that kind of information in report. b. At 8:11 a.m., LPN #2 said she notifies the aides of anticoagulant use during report. She said that information is not written on the care cards. c. At 8:45 a.m., RN Leader #1 said the use of an anticoagulant should be on the CCP. d. At 9:33 a.m., CNA #2 said she finds the use of a blood thinner on the closet care card. CNA #2 said the resident was not on a blood thinner. 3. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/1/18, revealed the resident was cognitively intact, received an antibiotic daily, had a wound infection other than the foot, and had a Multidrug Resistant Organism infection. Physician orders, dated 9/24/18, did not include the use of any precautions. The current Resident Mini Door Care plan and the CCP do not include the use of contact precautions. During an observation and interview on 9/19/18 at 12:45 p.m., there was no sign identifying the type of precautions on the door to the resident's room. A Personal Protection Equipment storage unit was hung on the door. There was a visitor in the room touching the overbed table and bed linens. When interviewed at that time, LPN #3 said the resident [MEDICAL CONDITION] and was on isolation precautions. When interviewed on 9/20/18 at 9:25 a.m., LPN #2 said the resident was on contact precautions but only during cares. During an interview on 9/25/18, the RN Leader said that there should be a CCP if a resident is on contact precautions. (10 NYCRR 415.11(c)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #183) of one resident reviewed for feeding tubes, the facility did not have a mechanism in place to ensure that the administration of enteral nutrition and additional water ordered for flushes was consistent with and followed physician orders. This is evidenced by the following: A facility policy, Enteral Tube Feeding, Gastric, dated 11/17/17, included to make sure the enteral formula container is labeled with the patient's identifiers: formula name and strength if diluted, date and time of formula preparation, date and time the formula was hung, administration route, rate of administration, administration duration, initials of who prepared, hung and checked the enteral formula against the order, expiration date and time. Also, label the enteral administration set with the date and time that it was first hung. Monitor the pump infusion rate frequently to ensure accurate delivery of the enteral formula. Document the date, volume of formula and volume of water, note the amount, type and time of feeding. Resident #183 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 9/12/18, revealed the resident was cognitively intact, had a feeding tube, and was on a mechanically altered diet. The nutrition note, dated 8/7/18, revealed that the resident was receiving a tube feeding of Two Cal High Nitrogen at 35 milliliters (mls) per hour per day (24 hours). A tube feeding at 840 mls per day will provide 1,680 calories. Physician orders, dated 8/24/18, included a continuous tube feeding of Two Cal at 35 cubic centimeters (cc) every hour and daily water flushes through the tube at 100 ccs every two hours. The (MONTH) (YEAR) Medication Administration Record (MAR) included that order. The nurses signed off the tube feeding as completed each shift. There are no tube feeding amounts documented on the MAR. The Nutrition Care Plan, dated 9/16/18, included interventions to provide the tube feeding and flushes per physician orders. In an observation on 9/19/18 at 12:37 p.m., the display on the feeding pump revealed it was set to deliver 35 mls per hour of tube feeding nutrient and that 2,813 mls had been delivered, flush 100 mls every two hours, and that 4,819 mls of water had been delivered. There was no label on the bag of tube feeding nutrient, and a label on the bag of water read 9/19 0100 (1:00 p.m.) 35 ml per hours. There was about 700 mls of tube feeding left in the bag. In an observation on 9/20/18 at 9:28 a.m., the resident was asleep in bed. The bag of tube feeding was dated 9/20, 0100 (1:00 a.m.) 11 to 7. There was no product name on the tube feeding, and there was no label on the bag of water. The pump was set to deliver 35 mls of tube feeding per hour and 3,494 mls had been administered. The water flush was set at 100 mls every two hours and 5,921 mls had been delivered. In an observation on 9/21/18 at 12:57 p.m., the bag of tube feeding nutrient was labeled 9/21, 2315 (11:15 p.m.), there was no product information on the bag. The pump display read that 798 mls of tube feeding and 1,302 mls of water had been administered. (rate for both tube feeding and water set per order). Observations and interviews conducted on 9/25/18 included the following: a. At 10:33 a.m., Licensed Practical Nurse (LPN) #1/Days said she had just cleared the feeding pump and it had read about 1,400 mls of tube feeding given. LPN #1 said the 11 to 7 shift starts the tube feeding and hangs a new bag of feeding. LPN #1 said the 11 to 7 shift does not keep track of the amounts given. She said no one really does that. LPN #1 said she had just cleared the pump so she could keep track of it on the day shift. At 10:37 a.m., the pump display read that 25 mls of tube feeding and 200 mls of water had been delivered. The tube feeding bag was dated 9/25/18 and read 2 cal, 0000 (midnight), rate 35 ml/hour. b. At 3:10 p.m., the Registered Dietitian (RD) said she does not know who is responsible for monitoring the daily intake of the resident's tube feeding and/or water. She said maybe nursing does that. The RD said the resident receives 35 mls of tube feeding per hour for 24 hours, 840 mls per day, and 1,200 mls of water flush. c. At 3:13 p.m., a Registered Nurse (RN) said she did not know who monitors the total volume of tube feeding or water delivered in a 24-hour period, and she would have to ask an LPN. The RN said she did not know if there was a process in place for monitoring amounts. d. At 3:18 p.m., LPN #1 told the RN and surveyor that no one monitors the tube feeding or flush intake. LPN #1 said that she does not think anyone has ever monitored intakes. e. At 4:35 p.m., LPN #2/Evenings said she starts a new tube feeding and hangs the bag on her shift. LPN #2 said that she does not record any amounts delivered and has not been told to do so. (10 NYCRR 415.12(g)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #56) of three residents reviewed for hydration, the facility did not ensure sufficient fluid intake to maintain proper hydration. The issues involved inconsistent monitoring of a physician ordered fluid restriction. This is evidenced by the following: Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician order, dated 8/28/18, directed a 1,000 cubic centimeter (cc) daily fluid restriction. The Minimum Data Set Assessment, dated 9/9/18, revealed the resident was cognitively intact, on a therapeutic diet, and used a diuretic daily. The Nutrition Care Plan, dated 9/13/18, included interventions to provide the resident with diet as ordered, monitor labs as available, monitor meal and fluid consumption records, and encourage to drink appropriate fluids of choice unless restricted by physician. The current Resident Mini Door Care Plan revealed that the resident was on a 1,000 cc fluid restriction. During an interview on 9/20/18 at 10:14 a.m., the resident and a family member said the resident was on a 1,000 cc fluid restriction due to kidney disease. The family member said she brings in a special cup every day to fill with fluid to help staff monitor intake. The resident said the dietitian is keeping track of her intake and has met with her and said it is okay to trade out things, like water for juice or if fluid not taken, to save that amount for later. Interviews conducted on 9/25/18 included the following: a. At 2:47 p.m., a Registered Dietitian (RD) said the resident was on a 1,000 cc fluid restriction. She said the aides document daily fluid intake on the meal and snack intake summary. The RD reviewed recent intake summaries and said the resident was taking closer to 1,185 ccs per day. She said she does not know where the nurses document fluids given with medications. The RD said she notifies the nurses of how much fluid is given with trays and how much is left for medication passes. The RD said the resident was consuming more fluids than prescribed. b. At 3:06 p.m., the RD said she does not monitor the daily fluid intake and does not know who is responsible to do that. c. At 3:09 p.m., a Registered Nurse (RN) said she did not know how 24-hour fluid intakes are monitored. d. At 3:12 p.m., a Licensed Practical Nurse (LPN) said she does not document the resident's daily fluid intake. She said the resident's family member brings in a cup everyday filled with water. The LPN said she uses that to give the resident her medications. The LPN said she uses 120 ccs fluid with each medication pass. She said that the resident has four medication passes per day. e. At 3:15 p.m., the resident's family member said the mug she brings in is about 12 to 16 ounces. The family member said she wonders how much the resident has been drinking because she never sees anyone write anything down. The resident said she has stopped drinking juice and would prefer water. f. At 3:20 p.m., the RD provided a slip of paper she had given to nursing which revealed dietary provides 720 ccs fluid daily and nursing 280 ccs daily. The RD said that information is kept in the Medication Administration Record (MAR). In an interview on 9/26/18 at 8:45 a.m., the RN said the resident was on a fluid restriction for [MEDICAL CONDITION] and should be monitored. Review of the (MONTH) (YEAR) MAR and (MONTH) (YEAR) MAR revealed 1,000 ccs fluid restriction daily. The nurses have initialed the MARs but the amount of fluids consumed are not documented. (10 NYCRR 415.12(j))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #74) of one resident reviewed for rehabilitation, the facility did not provide the treatment and services outlined in the resident's plan of care to maintain functional ability. Specifically, the resident was not ambulated per therapy recommendations. This is evidenced by the following: The current facility policy, Activities of Daily Living (ADL), included that the resident is to be encouraged to perform ADLs to the level indicated on the Certified Nursing Assistant (CNA) care profile. Resident #74 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/23/18, revealed that the resident had severely impaired cognition and required extensive assist of staff for ambulation. The Comprehensive Care Plan, dated 8/16/18, revealed that the resident had a history of [REDACTED]. Review of a Physical Therapy discharge note, dated 9/7/18, revealed that the resident was ambulating 150 feet with one staff assist and a rolling walker. The closet care plan, dated 9/7/18, included to ambulate the resident 150 to 200 feet with assist of one staff and a rolling walker two to three times daily. In an observation and interview on 9/19/18 at 2:18 p.m., a family member asked staff if they would walk the resident down the hall. The family was told that there was no one to walk the resident and instructed them to take her in a wheelchair. When interviewed at that time, the family member stated that they did not feel that staff were walking the resident. Review of the ADL Summary in the electronic medical record revealed that the resident had ambulated in the hallway on four occasions since discharged from therapy on 9/7/18. In an interview on 9/24/18 at 11:37 a.m., the Director of Rehabilitation stated that either nursing or the therapists docment their recommendations on the closet care plans for the CNAs. In an interview on 9/24/18 at 1:38 p.m., the CNA stated that the resident can ambulate from her room to the day room and usually does it once a day when her family visits, but staff only walk her in her room to the toilet and back. When interviewed on 9/25/18 at 2:27 pm., the Physical Therapy Aide said she does not walk the resident at all. In an interview on 9/26/18 at 10:01 a.m., the Occupational Therapy Assistant stated that therapist expect staff to inform them if a resident is unable or refuses to do tasks they have recommended on the care plan, so they can reassess the resident. (10 NYCRR 415.12(a)(1)(ii))

Based on resident and staff interviews, and record reviews, it was determined that for one of three residents reviewed for Range of Motion (ROM, extent of movement of a joint), the facility failed to ensure that a resident with limited ROM received appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM. Specifically, Resident #5 did not receive ROM as planned per therapy recommendations, which resulted in a decline in ROM. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/14/12 hospital discharge instructions included regular daily passive ROM to the legs to prevent further contractures. On 11/15/12 the Physical Therapist (PT) completed a Physical Therapy Initial Evaluation and documented that the resident had contractures of the lower legs and was unable to walk. Also, Certified Nursing Assistants (CNA) were instructed how to provide bilateral hip, knee, and ankle ROM exercises. The CNA Pocket Care Plan currently in place included to provide passive ROM for both legs. The Minimum Data Set (MDS) Assessment, dated 12/12/12, revealed that the resident was cognitively intact, had limitations of ROM, and full loss of voluntary movement of both legs. During interviews on 1/17/13 at 1:10 p.m. and again at 3:16 p.m., the PT stated that he taught the CNAs how to do ROM for the resident on 11/15/12 after he assessed the resident. He stated that nursing is responsible for executing the ROM program, and the resident should have had ROM daily. The PT stated he told the CNAs to do three sets of ten and that he wrote this in the CNA Clinical Accountability Record. Review of the forms at that time revealed "passive and active ROM to both legs daily"was written on the November 2012 CNA Clinical Accountability Record but not transcribed to the December 2012 or January 2013 CNA Clinical Accountability Records. Review of the November 2012 record shows that ROM is initialed as completed on the day shift for 11 of 16 opportunities, on the December 2012 record for 11 of 31 opportunities, and on the January 2013 record for 1 of 17 opportunities. Evening shift entries on all of these records lacked any signatures to show that ROM was provided. The PT also stated that the results of an assessment completed on 11/15/12 included deterioration in ROM. The left leg hip flexion active ROM decreased from 85 to 74 degrees, and the passive ROM decreased from 100 to 85 degrees. The left hip abduction (movement away from the body) went from 0 to negative 12 degrees (passive), and the internal rotation (passive) went from 40 to 68 degrees. The PT said that this is not good because the resident is consistently in that position, and she should be in the neutral position at 0 degrees. Knee extension (passive) went from negative 95 to negative 102 degrees, and the dorsiflexion (upward movement) of the ankle went from negative 10 to negative 20 degrees. The PT described these changes as significant deterioration and said this would have been avoidable if the resident received the prescribed ROM exercises. In an interview on 1/17/13 at 2:08 p.m., the resident stated that she only received ROM exercises from one CNA (#3) on occasion. The resident said that she is very upset because she does not know if she can get her legs to straighten out again. When interviewed on 1/17/13 at 3:34 p.m., the Director of Nursing (DON) stated that the PT had instructed CNAs multiple times on how to do the resident's ROM exercises. In an interview on 1/17/13 at 4:40 p.m. that day, the full time evening CNA (#1) stated she does not do ROM for this resident; it is done by Physical Therapy during the day shift. Interviews completed on 1/18/13 are as follows: a. At 8:00 a.m., the physician stated that he did not know the resident had not been receiving ROM exercises recommended by the PT. He verified that there is evidence that the resident has had a decline in ROM and said that he did not attribute these declines to changes in [MEDICAL CONDITION]. b. At 9:41 a.m., the full time day shift CNA (#2) stated the resident is not able to move her legs except to move her hips some. CNA #2 said she has not been doing ROM for this resident and did not know that she was supposed to. c. At 10:00 a.m., CNA #3 stated that she had not received any special instructions from Physical Therapy to do ROM exercises for this resident. CNA #3 said the resident could move her feet a little bit but was not able to move her legs. CNA #3 stated that when she did the ROM, she did about five repetitions of her knee only, not her hip or ankle. CNA #3 reported that the resident complained to her that no other CNA ever did ROM. CNA #3 could not remember if she reported this to anyone. d. At 11:20 a.m., the Registered Nurse (RN) Charge Nurse stated that the Unit Clerk transfers information from month-to-month on the CNA Clinical Accountability Record. She did not know who checks to see if the CNA Clinical Accountability Records are completed. The RN Charge Nurse explained that CNAs are responsible for checking the Pocket Care Plan daily. She stated that she assumes the residents are getting ROM unless she is told otherwise. e. At 11:33 a.m., the DON stated that information from the old CNA Clinical Accountability Records is no longer copied to the new month. However, when it was, the Unit Clerk did this. Currently a new record is used each month, and the information is not transcribed. The DON stated that the CNA Clinical Accountability Records should be checked by the shift nurse once a week. The DON was not sure this was being done because there are a lot of blanks on the forms. f. At 11:58 a.m., the Licensed Practical Nurse (LPN) stated she looks at the CNA Clinical Accountability Records infrequently and is not sure if there is anything specific about reviewing them. She stated she might refer to them, but does not review them to see if they are completed. The LPN stated that she did not know the resident was supposed to get ROM until 1/17/13. The facility's policy, "Range of Motion," dated July 2005, included that the purpose for providing ROM exercises is to ensure that the resident maintains his or her highest level of motion and to prevent avoidable decline of ROM. (10 NYCRR 415.12(e)(2))