Every finding on record at Taconic Rehabilitation And Nursing At Beacon

Based on record review and interviews during an abbreviated survey (NY00352881), the facility did not ensure a resident received care, consistent with professional standards of practice, to promote the healing of a pressure ulcers for 1 of 3 residents (Resident #1) reviewed. Specifically, (1) Resident #1 was admitted to the facility on [DATE] with a unstageable sacral wound measuring 6 x7cm. Physician orders and preventative measures ordered by the physician were not consistently provided by staff. There were omissions on the October 2023 treatment administration record on multiple days and shifts. Physician wound notes dated 10/24/2023 documented a sacral wound measured 12 x 6.5cm with 98% slough with non-blanchable peri wound with scant drainage; 2) preventative measures were not implemented according to the resident's care plan and/or physician's order. When requested, the facility did not provide documentation that Certified Nursing Aides provided preventative measures ordered by the physician; 3) In addition, there was no documented evidence that all Residents who are at risk for pressure ulcers or with actual pressure ulcers were being repositioned by the Certified Nursing Aides.The findings are:The facility's policy for documentation of pressure ulcer and chronic wounds last revised 6/2023 documented a skin inspection is completed weekly on a shower day. All pressure ulcers and chronic wound dressings will be inspected daily. Procedure 3 documented weekly skin inspections are documented on the treatment administration record/designated location. Skin is non-remarkable unless otherwise noted. Initials indicate that the following has been done: A skin inspection has been completed minimally on a weekly basis.The facility's policy for medication/treatment administration revised 6/2024 documented medications and treatments are checked against the prescription order before they are administered and will be administered per physician orders. Procedure 2 documented all medications and treatments are charted as administered by signature of initials in the electronic medication/treatment administration record. Resident #1 had diagnoses including but not limited to acute transverse myelitis in demyelinating disease of the central nervous system, Type II diabetes, history of malignant pressure induced deep tissue damage of left heel, and pressure ulcer of sacral region unstageable.An admission Minimum Data Set, dated [DATE] documented the resident had a Brief Interview Mental Score of 11/15 indicating moderate cognitive impairment with no behaviors present. Resident had impairments on both lower extremities. Resident required set up or clean up assistance with eating, dependent with toileting, dependent with bed mobility and transfers. Resident has an indwelling catheter in place, and always continent of bowel. The resident had a pressure ulcer and 1 deep tissue injury present on admission, resident is at risk for pressure ulcers, and had an unhealed pressure ulcer, 1 unstageable pressure ulcer with slough and or eschar. Skin and ulcer/Treatment injuries include a pressure reducing device for chair and a pressure reducing device for the bed with pressure ulcer care.Resident #1 was transferred to the hospital on [DATE] and did not return to the facility.A review of an undated skin integrity care plan closure date of 10/31/2023 documented Resident #1 had impaired skin integrity related to Type 2 Diabetes Mellitus. Interventions included to monitor for medication / treatment-related skin conditions, apply moisture barrier following incontinence care and as needed, turn and reposition every 2 hours and as needed, skin and feet check with daily care, document weekly on shower day, and administer treatment per Medical Doctor order, monitor, document progress.A nursing progress note dated 10/7/23 documented Resident was admitted with unstageable sacral wound measuring 6cm x7cm.The Physician Order dated 10/07/2023 documented Sacrum -unstageable: Cleanse wound bed with normal saline, allow time to dry, apply Santyl to wound bed, apply barrier film to peri-wound, cover with Opti foam silicone dressing x2 daily Report any signs/symptoms of deterioration and or infection to Medical Doctor/Nurse Practitioner two times a day for wound sacrum. The physician wound progress note dated 10/10/23 documented the sacral wound measured 8cm x 7cm and 75% slough and moderate amount of serosanguinous drainage. Skin intact and blanchable. Keep area clean and dry/offload/air mattressThe physician wound progress note dated 10/17/23 documented the sacral wound was 10cm x 5cm and 90% slough and non-blanchable peri-wound and scant drainage.The physician wound progress note dated 10/24/23 documented the sacral wound measured 12cm x 6.5cm and 98% slough with non-blanchable peri wound scant drainage Review of the October 2023 Treatment Administration Record revealed treatment was not provided on10/23/23 during the day shift; treatment was not provided on 10/10/23, 10/11/23, 10/12/23, 10/14/23, 10/17/23 and 10/20/23 during the evening shift; and treatment was not provided on 10/15/23, 10/18/23 and 10/19/23 during the day and evening shift. There was no Certified Nursing Aide documentation that offloading was rendered. During an interview on 7/28/2025 at 2:16pm, the Unit Manager # 1 stated that when a resident is a new admission with pressure ulcers, the resident would be placed on a wound care list and assessed by the nurses and nurse practitioner on the floor. Interventions for wounds will include orders for treatment, weekly wound rounds, skin inspections. Depending on the wound and location of the wound the facility will determine if the resident need an air mattress, off-loading of heel with a pillow or heel booties. Generic orders would be in the chart for air mattress. The nurse would be required to sign off on the Treatment Administration Record for heel booties and pillow. There is a wound provider that comes in every Thursday morning. Unit Manager # 1 stated Certified Nurse Aides do not document that they are turning and positioning the residents. The Certified Nurse Aide will know to turn and position a resident from reviewing the Kardex under bed mobility. Unit Manager #1 stated the facility determines if Certified Nurse Aides are conducting turning and repositioning by the wound size. If there is no changes in wound measurements, then turning and repositioning is been done. If the task is not completed, then there will be an increase in wound measurements. The nurses on the unit are responsible for documenting on the medication/treatment administration record any treatments for wounds. The Unit Manager would be responsible for reviewing the medication/treatment administration record for omissions and ensuring the nurses performed any treatments ordered. Unit Manager # 1 stated they monitor the completion of the plan of care on all medication/treatment administration records. They have issued disciplinary action after soft verbal warnings when they are not completed.During an interview on 8/1/2025 at 10:30am, the Interim Director of Nursing stated that if a resident is admitted with a pressure ulcer they are assessed on admission. If they come from the hospital then they may have orders in place to address the pressure ulcer, or the facility will add new orders, and the resident is placed on weekly wound rounds for continuous evaluation. Nurses sign off on the treatment administration record to indicate that treatments are being rendered and completed. The unit managers are responsible for checking that treatments are documented on the treatment administration record. Staff can also review the dashboard and the resident's profile to see if the treatments and medications are administered. The Interim Director of Nursing stated they do see the omissions in the medication administration record and treatment administration record. The Interim Director of Nursing stated that there was an issue with the skin inspection order because it is done weekly in the facility. The facility's current practice is for the Unit Manager, Director of Nursing, and Assistant Director of Nursing to check the dashboard for omissions and hold staff accountable when it's not completed. The Interim Director of Nursing stated, there is no designated area on the certified nurse aide assignment to document if turning and repositioning is being completed. The Interim director of nursing stated the facility determines if turning and repositioning is being done by the wound progressing in a positive direction, or resolving. The Interim Director of Nursing acknowledged after review of the October 2023 physician wound progress note that size of the sacral unstageable had increased. 10 NYCRR 415.12

Based on observation, record review and interview conducted during the recertification survey from 6/24/2024 through 7/01/2024, the facility did not ensure for 3 of 4 residents (Residents # 322, # 101 and #86) reviewed for urinary catheters, that care was provided in a manner to maintain dignity. Specifically, Residents #322, #101, and #86 had urinary catheter drainage collection bags that were not concealed to prevent direct observation, by other residents and their families. Findings include: 1. Resident #322 had diagnoses including urethral false passage, obstructive and reflux uropathy, and benign prostatic hyperplasia (BPH). The Admission Minimum Data Set (an assessment tool) dated 6/23/2024, documented Resident #322 had moderately impaired cognition, required partial to moderate assistance with activities of daily living and had an indwelling catheter for bladder drainage. The Bladder Appliance care plan dated 6/2024 documented Resident #322 had a urinary catheter related to urinary retention and interventions included catheter care every shift, change catheter bag as needed, and leg bag to be worn during day time hours. During observations on 06/24/2024 at 10:49 AM and 12:20 PM, 06/25/2024 at 08:30 AM and 10:26 AM, and 06/26/2024 at 08:37 AM the urine in the urinary catheter drainage collection bag was visible from the door without a privacy bag. The resident resided in a shared room. During an observation on 06/26/2024 at 01:17 PM, the urinary catheter drainage collection bag was attached to the resident's wheelchair and the resident was transported to the therapy room without a cover on the urinary collection bag. During an interview on 06/26/2024 at 10:00 AM, Staff #7 (Certified Nurse Aide) stated that a resident with a urinary catheter should have a privacy bag when they leave the room. During an interview on 06/26/24 at 10:08 AM, Staff #6 (Nurse Manager) stated resident's catheter bag should have been covered when they left the room to ensure the resident's privacy. The bag should be covered and not visible to other residents or visitors. During an interview on 06/26/24 at 10:15AM, the Director of Nursing stated residents with urinary drainage systems should have them covered with a privacy bag for dignity. 2. Resident # 101 was admitted to the facility with diagnoses including diabetes, left below knee amputation, and pressure ulcer sacral region. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 5/17/24, documented Resident #101 was cognitively intact, required assistance of one person with activities of daily living and had an indwelling urinary catheter. The care plan dated 4/15/24 documented the urinary catheter drainage collection bag to be covered while in bed and out of bed. When observed on 06/25/24 at 08:47 AM, Resident #101 was in bed with the urinary drainage collection bag hanging on bed frame visible from outside resident's room in the hallway, without a privacy cover. When interviewed on 6/27/24 at 3:20 PM, Staff #3(Licensed Practical Nurse Unit Manager) stated the residents should always have a privacy bag for their urinary drainage collection bags in bed or out of bed. When observed on 6/28/24 at 9:28 AM, the urine in Resident #101's urinary drainage collection bag was visible and there was not a privacy cover. The resident was observed while in bed and in a shared room. When interviewed on 6/28/24 at 9:34 AM, the Director of Nursing (DON) stated the urinary collection drainage bags only needed to be covered when the residents were out of their rooms. The Director of Nursing also stated they did not think it was okay for other residents or families to observe the uncovered bags. 3. Resident #86 was admitted to the facility with diagnoses including Parkinson's disease, obstructive/reflux uropathy, and dementia. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 4/1/2024, documented Resident #86 had severely impaired cognition, and required extensive assistance of two people for activities of daily living, and had an indwelling urinary catheter. The care plan dated 3/27/24 documented the urinary catheter drainage collection bag to be covered while in bed and out of bed. When observed on 06/25/24 at 08:39 AM, Resident #86 in bed having their breakfast with catheter drainage collection bag uncovered and on the floor. When interviewed on 06/25/24 at 08:44 AM, Staff # 4 (Certified Nurse Aide) stated they needed to cover the bag and remove it from the floor. 10NYCRR 415.3(d)(1)(i) 49364

Based on observation, record review and interviews conducted during a recertification survey (6/24/24-7/1/24), the facility did not ensure infection control prevention practices including hand hygiene, enhanced barrier precautions, and catheter care were maintained to help prevent the development and transmission of communicable diseases and infections for 4 ( #37,#61,#322, #86) of 32 sampled residents. Specifically, 1) Staff #11 (Licensed Practical Nurse) did not follow proper hand hygiene during a wound care treatment for Resident #37; 2) Enhanced barrier precautions were not implemented when Staff #9 (Registered Nurse) performed Resident #61's dressing change, and when Staff #8 (Physical Therapy Assistant) handled Resident #322's catheter drainage bag without gloves or a gown; and 3) Resident #86 urine catheter collection bag was observed on the floor. Findings include: 1) Resident #37 was admitted with diagnoses including Diabetes Mellitus, hemiplegia, Dementia, Hypertension and seizures. The Minimum Data Set (an assessment tool) quarterly assessment dated [DATE] documented the resident had severe cognitive impairment and was totally dependent on staff for all cares. A nursing progress note dated 4/11/24 documented Resident #37 developed a Stage 2 sacral pressure ulcer. The 6/20/24 physician order documented Santyl ointment applied to sacrum topically every day. Cleanse area with normal saline, apply nickel layer of Santyl to wound base and lightly pack at center. An observation was made on 6/26/24 at 10:26 AM of the sacral pressure ulcer dressing change with Staff #11 (Licensed Practical Nurse). Staff #11 washed hands and donned gloves. The old dressing was removed, and the dirty gloves were doffed and placed in the garbage pail. A second set of gloves was observed under the first and were not removed to perform hand hygiene. The wound was cleaned with normal saline and dabbed dry. The wet and dirty gloves were doffed and thrown in the garbage pail revealing another set of gloves already on Staff #11 hands. With gloves on, the Santyl ointment was applied, and a dry dressing was put in place. Staff #11 removed their gloves and threw them in the garbage pail. During an interview with Licensed Practical Nurse Staff #11 on 6/26/24 at 10:36 AM they confirmed that they donned 4 pairs of gloves prior to performing the dressing change and doffed a set at each interval. Staff #11 stated they were not aware they should not wear 4 layers of gloves or that they need to perform hand hygiene after removing gloves and donning a clean pair of gloves. During an interview with Staff #13 (Staff Development Licensed Practical Nurse) on 6/26/24 at 11:00 AM, they stated they coordinated a competency fair a few months ago and staff were able to perform return demonstrations for tube feeds, dressing changes, and medication administration. Staff #13 stated that wearing multiple layers of gloves and pulling off a set as it got soiled was not the way to perform dressing changes and it was not the facility policy. 2) Resident #61 had diagnoses including a fractured femur, Atrial Fibrillation, and Congestive Heart Failure An admission Minimum Data Set (an assessment tool) dated 5/14/2024 documented the resident's cognition was intact and had a Stage 2 pressure ulcer. The physician order dated 6/6/2024 documented Enhanced Barrier Precautions. During an observation on 06/26/2024 at 9:45 AM, Staff #9 (Registered Nurse) was changing the residents dressing to his right calf and was not wearing a gown. During an interview on 06/26/2024 at 9:50 AM, Staff #6 (Nurse Manager) stated if a resident was on Enhanced Barrier Precautions, the staff should have been following precautions and was expected to wear a gown during the dressing change. During an interview on 06/26/2024 10:00 AM, with the Director of Nursing stated staff were educated to use appropriate personal protective equipment when providing care for residents on enhanced barrier precautions, and should have been wearing a gown during a dressing change. During an interview on 06/26/2024 at 10:20 AM, Staff #9 stated they were aware they should have been wearing a gown, but the resident was leaving for an appointment and they needed to do it quickly. 3. Resident #86 was admitted to the facility with diagnoses including Parkinson's disease, obstructive/reflux uropathy, and dementia. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 4/1/2024, documented Resident #86 had severely impaired cognition, and required extensive assistance of two people for activities of daily living, and had an indwelling urinary catheter. The care plan dated 3/27/24 documented the urinary catheter drainage collection bag to be covered while in bed and out of bed. When observed on 06/25/24 at 08:39 AM, Resident #86 in bed having their breakfast with catheter drainage collection bag uncovered and lying directly on the floor. When interviewed on 06/25/24 at 08:44 AM, Staff # 4 (Certified Nurse Aide) stated they needed to cover the bag and remove it from the floor. 10 NYCRR 415.19 (b) (4) 47626 49364

Based on observation, interview, and record review during recertification survey conducted 6/24/2024 - 7/1/2024, the facility did not ensure menus were followed for 2 of 2 residents (Resident # 61 and # 71) reviewed for Nutrition. Specifically, 1. Residents #61 received fish that was not documented on the meal ticket and 2. Resident # 71 had a meal ticket that documented 4 ounces of mashed potatoes and 4 ounces of enriched mashed potatoes, the tray had 4 ounces of mashed potatoes and Resident #71 did not receive nectar thick apple juice as indicated on the tray ticket. Findings include: A review of the policy and procedure titled Dietary Department Admission Procedure, dated 1/1/2000 documented it is the policy that the dietary department will ensure that upon admission the nutritional care plan is developed. On admission the resident's dietary needs are identified. 1. Resident #61 had diagnoses including a fracture femur, atrial fibrillation, and congestive heart failure. An admission Minimum Data Set (an assessment tool) dated 5/14/2024 documented the resident's cognition as intact. The resident required set up assistance with eating and was dependent on staff for all other activities of daily living. The resident received a modified diet. A review of the eating/nutritional status care plan dated 5/28/2024 Goal stable weight, Therapeutic diet Chopped, honey thick liquids. Set up help, lip plate, supplement between meals. During an observation on 06/25/2024 at 11:59 AM, the resident was eating lunch in the day room. The resident's ticket documented stewed tomatoes chopped. The resident's tray had chopped stewed tomatoes and a piece of fish. When interviewed on 06/27/2024 at 12:52 PM, Staff #5 (kitchen supervisor) stated they knew the resident's ticket only documented stewed tomatoes, and it was because the resident was lactose intolerant, and the meal was macaroni and cheese. Staff #5 stated they knew to add a protein, and put fish on the tray but did not consult the dietitian. When interviewed on 6/27/2024 at 12:45PM the food service director said the kitchen staff should provide the resident with what was on the ticket, and if there was a question they should have consulted with the dietitian. When interviewed on 06/27/24 at 12:52 PM the Dietitian stated, they were unaware the ticket only documented stewed tomatoes, and the kitchen staff should have asked them or the food service director prior to adding additional food items on the tray. 2. Resident # 71 had diagnoses including metabolic encephalopathy, diabetes, and dysphagia (difficulty swallowing). An Admission Minimum Data Set (an assessment tool) 5/14/2024 documented the resident's cognition as moderately impaired, the resident was dependent with all care including eating. The resident has recorded on the admission 1 stage 2 Pressure Ulcer and 1 Deep Tissue Injury. The resident admission weight was 114, height 62 inches, and documented weight loss as no or unknown. A review of the current physician orders documented a regular, puree, nectar thick diet. The Nutrition Care Plan dated 5/28/2024 documented regular puree diet with nectar thick liquids with a goal to maintain a stable weight goal weight at 115 +/- 5% . During an observation on 06/24/2024 at12:14 PM in the day room, the staff were feeding the resident, the meal ticket documented apple juice but the resident did not receive apple juice. During an observation on 06/26/2024 at 09:29 AM the staff were feeding in bed. The tray ticket documented ketchup, but there was no ketchup on the tray. During an observation on 6/27/2024 at 12:34 PM the resident was being fed lunch, the tray ticket documented 4 ounces of mashed potatoes and 4 ounces of fortified mash potatoes, the tray had 4 ounces of mashed potatoes with gravy. During an interview on 06/26/2024 at 11:34 AM, the Food Service Director stated the software was interfaced with the electronic medical record, when the diet order was placed in the electronic medical record it flowed over to the dietary software. The tickets were printed out and the first staff on the food service line would call out to the cook what was needed on the tray based on the ticket. The second staff would put the cold food on based on the ticket and checked for accuracy. The Kitchen Supervisor was responsible to ensure all trays were sent to the unit with what was documented on the ticket and any discrepancy should be discussed with the dietitian. During an interview on 06/27/2024 at 12:42 PM, Staff #5 (kitchen supervisor) stated the resident had both mashed potatoes and fortified mash potatoes on the ticket. They did not know why they would both be on the ticket as all mashed potatoes were fortified. They provided the resident with 4 oz of mashed potatoes. During an interview on 06/27/2024 at12:41 PM, with the dietician stated they were unaware everyone got fortified mashed potatoes. They also stated a pre-thickened apple juice should have been on the tray if it was on the ticket. During an interview on 06/27/2024 at 12:56 PM, the Food Service Director stated fortified mashed potatoes and mashed potatoes were not made the same. The kitchen staff should have provided fortified mashed potatoes if that was what was ordered. They stated both mashed potatoes and fortified mashed potatoes should not have been on the meal ticket together, and kitchen staff should have clarified that with the dietitian. 10NYCRR 415.14(c)(1-3)

Based on observation, interview and record review conducted during the recertification and abbreviated (NY00330557) surveys from [DATE] -[DATE], it was determined for 2 of 6 residents (Residents #320 and #71) reviewed for Nutrition and Hydration, the facility did not ensure the residents were provided the necessary care to maintain an acceptable body weight. Specifically, 1) Resident #320 medical record documented a 24 pound weight gain and the medical provider was not made aware; the physician's orders documented daily weights but Resident #320's weight record did not reflect daily weights; and the facility did not have a system in place to accurately weigh, monitor and report weights. 2) Resident #71's medical record documented a 7.93% weight loss in 30 days with a physician order for a 3-day calorie count, and dietitian recommendations for fortified mash potatoes and to increase the supplement to 4 times a day; there was no documented follow through for the recommendations. The findings are: 1) Resident #320 had diagnoses which included congestive heart failure, hypertension, and diabetes mellitus. The admission Minimum Data Set (resident assessment tool) dated [DATE] documented a BIMs Score of 13 which indicated intact cognition. The Physician's order dated [DATE] documented to weigh the resident daily and to update the physician if over 3 pounds gained in a day or 5 pounds in one week. The Care Plan, Cardiac / Circulatory: Impaired cardiac function related to Congestive Heart Failure, Hypertension documented interventions which included to administer cardiac medications as ordered, labs obtained per orders, monitor blood pressure, pulse, respirations, breath sounds, edema, chest pain, intake and output, leg elevation, diet compliance, level of activity tolerance, shortness of breath. The [DATE] Nursing Admission Evaluation documented Resident #320 weight was 222 pounds. Resident #320's electronic medical record documented on: -[DATE] at 8:46 PM, weighed 200 pounds in the wheelchair. -[DATE] at 10:49 PM, weighed 200 pounds by mechanical lift. -[DATE] at 3:48 PM, weighed 200 pounds standing. -[DATE] at 10:35 PM, weighed 200 pounds sitting. -[DATE] at 11:34 PM, weighed 202 pounds by mechanical lift. -[DATE] at 8:31 PM, weighed 225 pounds standing. -[DATE] at 10:15 PM, weighed 124 pounds in the wheelchair. -[DATE] at 4:53 PM, weighed 224 pounds standing. -[DATE] at 9:27 PM, weighed 221.4 pounds by mechanical lift. -[DATE] at 6:06 PM, weighed 221.6 pounds standing. There were no weights in the resident's electronic medical record for ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Weights recorded in a binder on the unit where the resident resided documented on: - [DATE] weight was 226.1 pounds. - [DATE] weight was 226.0 pounds. - [DATE] weight was 225.0 pounds. The [DATE] Physician's note documented lungs were clear to auscultation bilaterally, decreased breath sound at bases. The Assessment/Plan was to administer oxygen to maintain saturation greater than 92%, weekly labs, and daily weights. The [DATE] Physician's note by the Physician's Assistant, documented breathing at baseline. No medical complaints. Lungs clear to auscultation bilaterally, decreased breath sound at bases. The Assessment/Plan was to administer oxygen to maintain saturation greater than 92%, weekly labs, and daily weights. The [DATE] Physician's note by the Physician's Assistant, documented breathing at baseline. The Assessment/Plan was to administer oxygen to maintain saturation greater than 92%, weekly labs, and daily weights. Weight 225 pounds on [DATE]. The [DATE] Physician's note by the Physician's Assistant, documented seen for acute visit, breathing at baseline. The [DATE] Nurse's note documented chest X-Ray result was indicative of fluid overload as well as tuberculosis. The results were called to the Primary Physician and orders for Lasix were received. The [DATE] Physician's note by the Physician's Assistant, documented increasing shortness of breath and 24 pound weight gain recorded. Weight 224 pounds on [DATE]. Oxygen saturation 96% on oxygen via nasal cannula. Inspiratory crackles bilaterally, no edema. The Assessment/Plan was oxygen to maintain saturation greater than 92%, weekly labs, daily weights, Lasix twice a day for 7 days, Zaroxylyn for 3 days, and fluid restriction. The [DATE] Nurse's note documented resident alert and verbal, denied pain, no shortness of breath, no cough noted, declined bipap complained hard to breath with bipap mask. 1500 ml fluid restriction for fluid overload. The [DATE] Medical Visit note by the Physician's Assistant, documented resident with shortness of breath. Chest x-ray was positive with bilateral multifocal infiltrates consistent with fluid overload or tuberculosis. Discussed with the physician and continue diuretics for 24 pound weight gain. Most recent weight 221.4 pounds on [DATE]. The [DATE] Physician's note by the Physician's Assistant, documented the resident was found unresponsive and pronounced expired this morning. During an interview on [DATE] at 1:30 PM, the Physician's Assistant stated that if they had been made aware of a weight gain on [DATE], they would have immediately entered new orders on [DATE] or [DATE] to address the weight gain, such as extra Lasix and Zaroxylyn, Chest X-Ray, and 1500 ml fluid restriction. During an interview on [DATE] at 1:52 PM Staff #14 (Registered Nurse) stated they entered the resident's weight of 225 pounds on [DATE]. Staff #14 (Registered Nurse) stated they were aware of the Physician's order to weigh the resident daily every evening and to notify the Physician if the resident's weight increased more than 3 pounds in one day or more than 5 pounds in a week. They stated Resident #320's weight was 226 pounds on [DATE] on admission on the paper weight log sheet, so they were not concerned about a weight of 225 pounds on [DATE]. They stated they could not find a note which documented that they notified the Physician's Assistant or the Physician. During an interview on [DATE] at 2:16 PM the Assistant Director of Nursing stated that in the Evaluation Notes Template in Point Click Care, the most recent weights and vitals will populate in each new Evaluation Note. The Assistant Director of Nursing stated that the nurse who entered the weight in the Medication Administration Record did not see Resident #320 previous weights. They stated the nurse was responsible to notify the Physician of a weight increase, as per Physician's order, and was responsible to notify the Nursing Supervisor. The Assistant Director of Nursing reviewed the Medication Administration Record and observed the Resident's weight of 225 on [DATE] which was entered by Staff #14 (Registered Nurse). The Assistant Director of Nursing stated that the nursing staff were trained to document resident's weights on a paper weight log sheet in the weight binder, and the nurse responsible for entering the weights into the Electronic Medical Record must record the weight from the paper weight log sheet into the computer. The Assistant Director of Nursing stated that the nurse recording the weight into the Electronic Medical Record was responsible to check the previous weight on the paper weight log sheet, and notify the Physician as ordered if there is a weight increase. They stated that the paper weight log sheet did not document a weight change of 24 pounds. During an interview on [DATE] at 2:35 PM with the Physician, they stated the Physician's Assistant was at the facility every day and the either the Physician or the Physician's Assistant should have been notified if there had been a weight increase. The Physician stated they were not made aware of a weight gain. They stated they would have done something for Resident #320 if they had a weight gain. The Physician stated they were on call every night for the unit and stated they should have been notified with the Resident #320's change in status. During an interview on [DATE] at 3:45 PM, the Director of Nursing stated Resident #320 did not gain 24 pounds. The Director of Nursing reviewed the paper weight log sheets from the weight binder with this surveyor, which documented the Resident weighed 226 pounds on admission on [DATE], and on [DATE] the weight was 225.0 pounds. They stated the weights of 202 and 200 in the electronic medical record were erroneous and the nurse must have accidentally entered 202 pounds instead of 220 pounds (5 entries for 200 or 202 pounds). The Director of Nursing stated the resident was seen regularly by the Physician's Assistant and was being monitored for shortness of breath. The Director of Nursing stated the resident was treated on [DATE] for symptomatic heart failure. 47626 2. Resident #71 with diagnoses of Metabolic Encephalopathy, Diabetes, and dysphagia (difficulty swallowing). An Admission Minimum Data Set (an assessment tool) dated [DATE] documented the resident's cognition was moderately impaired, and the resident was dependent with all care including eating. The resident's admission weight was 114 pounds, height was 62 inches, and weight loss as no or unknown. The resident's Care Plan: Eating Nutrition, dated [DATE], documented the goal was for weight to be stable 115 pounds, plus or minus 5%. Resident #71's weight record documented on [DATE] the resident weighed 112.2 pounds, on [DATE] weighed 113.8 pounds, on [DATE] weighed 110. 6 pounds, on [DATE] weighed 105.6 pounds, on [DATE] weighed 103.3 pounds, on [DATE] weighed 103.3 pounds and on [DATE] weighed 102 pounds. The resident's interdisciplinary team note dated [DATE], documented the dietitian recommendations included adding fortified cereal for breakfast, fortified mash potatoes for lunch and dinner, and to consider decreasing diabetic medications. The dietary progress note dated [DATE], documented the resident had poor oral intake and weight loss. The plan was a 3-day calorie count, increase Glucerna (supplement) to 4 times a day, and discuss with insulin dosage with the physician. The dietary progress note dated [DATE] (entered on [DATE] as a late entry) documented the resident had a significant weight loss with no new interventions were documented. A review of the [DATE] Medication Administration Record documented a calorie count on ,d+[DATE], ,d+[DATE], and [DATE]; however, the results could not be located for review. An observation on [DATE] at 12:14 PM, the resident was in the day room, staff was feeding the resident. The tray ticket documented apple juice however the resident did not receive apple juice. During an interview on [DATE] at 11:34 AM, the Food Service Director stated the Kitchen Supervisor was responsible for ensuring all trays were sent to the unit with the items on the ticket. They were unaware the resident did not receive the apple juice. During an observation on [DATE] at 12:34 PM the resident was being fed lunch, the tray ticket documented 4 ounces of mashed potatoes and 4 ounces of fortified mash potatoes, the tray had 4 ounces of mashed potatoes with gravy. During an interview on [DATE] at 12:42 PM, Staff #5 (Kitchen Supervisor) stated the resident had both mashed potatoes and fortified mash potatoes on the ticket and they did not know why. They stated all mashed potatoes were fortified and they provided the resident with 4 ounces of mash potatoes. During an interview with the dietitian [DATE] 12:41 PM, they stated they were only at the facility on Thursdays and as needed, and depended on the Director of Nursing to discuss nutritional issues with the medical provider and obtain orders for the recommendations. The supplements should have been ordered 4 times a day, and they did not know why it was not ordered. They also stated fortified mash potatoes were ordered for residents that needed more calories. When requesting a calorie count they would send an email to the unit manager, they were not sure why they did not follow up on the calorie count. During an interview on [DATE] at 12:56 PM, the Food Service Director stated fortified mash potatoes and mash potatoes were not made the same, they had 2 different recipes. During an interview on [DATE] at 3:49 PM, Staff # 6 (Nurse Manager) stated they were aware the resident was losing weight, and had a meeting and the dietitian was involved. The medical provider saw the resident on [DATE] and was aware of the weight loss and did not want to change the residents insulin's. They stated the calorie count was done but they were unable to find it. Staff #6 did not know why the supplement was not increased to 4 times a day or if the recommendation was communicated to the physician. 10 NYCRR 415.12 (g)(1)

Based on observations, record reviews, and interviews conducted during the recertification survey 6/24/24-7/1/24, the facility did not ensure for 1 (Resident #61) of 7 residents reviewed for pressure ulcers, received care and services to promote healing and to prevent new pressure ulcers from developing. Specifically, Resident #61 developed a Stage 2 pressure ulcer that was not present on admission and there was no documentation turning and positioning was performed as planned. The findings are: The facility policy for Documentation of Pressure Ulcer and Chronic Wounds dated 6/2023 documents weekly skin inspections are documented on the Treatment Administration Record. Skin is non remarkable unless otherwise noted. Resident #61 was admitted with diagnoses including Diabetes Mellitus, hemiplegia, Dementia, Hypertension and seizures. The Minimum Data Set (an assessment tool) quarterly assessment dated [DATE] documented the resident had severe cognitive impairment, total dependency on staff for all cares, was incontinent of bladder and bowel and had a gastrotomy tube for enteral feeding. There were no unhealed pressure ulcers documented. The Skin Risk assessment dated [DATE] documents the resident was at risk for developing pressure ulcers and the following interventions were put on the care plan: monitor for edema, reposition every 2 hrs as needed, offload heels while in bed, heel booties, podiatry consult. The Physician orders dated 1/4/24 document shower skin inspection every Thursday 7-3 shift, complete skin inspection and complete nursing weekly skin status documentation. The Treatment Administration Record from April 2024 was reviewed and documented inspections were made on 4/4/24 and 4/11/24. There were no additional notes for 4/4/24 and according to the facility policy, indicating there was no skin issues. A corresponding Weekly Skin Status assessment dated [DATE] documented a new sacral pressure injury had developed between 4/4/24 and 4/11/24, Stage 2, and measured 2.5 centimeters x 3 centimeters x .1 centimeters, hydrocolloid dressing applied. The plan included Wound Care physician to see the resident, offloading with turn and positioning every 2 hours and side to side with head of bed at 30-45 due to gastrostomy and tube feeds degrees The Wound Care Consultant Note dated 4/18/24 documented Stage 3 Pressure wound on sacrum measured 5.9 centimeters x 8.1 centimeters x .1 centimeters. Recommendations included limiting sitting to 60 minutes, off load wound, reposition per facility policy, turn side to side in bed 1-2 hours if able, group 2 mattress and Santyl apply once daily with gauze island. The Treatment Administration Record for the month of April 2024 documented nurses' initials for wound dressing changes, air mattress, offloading heels with heel booties. There was no documentation of turning and positioning side to side prior to the development of the new Stage 3 pressure ulcer or after it was discovered. The Certified Nurse's Assistant [NAME] (care instructions) was reviewed and documented skin integrity instructions including reposition every 2 hours as needed (prior to April 11, 2024) and after April 11, 2024, reposition every 2 hours as needed with attempts to offload sacrum region. The Certified Nurse's Assistant accountability documentation in the electronic record showed documentation for Activities of Daily Living, behaviors, and bowel records. There was no documentation of interventions provided on the [NAME] for skin integrity including turning and positioning. Observations of Resident #37 were performed on: - 6/26/24 at 09:50 AM Resident was observed in bed on back, heels were offloaded with booties. - 6/27/24 at 09:25 AM Resident in bed on back. - 6/28/24 at 08:49 AM and 10:52 AM, Resident in bed on back in same position on both observations. - 7/01/24 10:47 AM in bed, on back, boot on feet. When interviewed on 06/27/24 at 09:25 AM, Staff#14 (Certified Nurse's Assistant) stated the [NAME] was located in the residents rooms on the inside of the residents closet door. The [NAME] has special instructions for hand splints, showers, booties, pillows. When asked where they document the instructions on the [NAME], Staff #14 stated there was no place it was just expected that it would be done. When interviewed on 06/27/24 at 09:38 AM, Staff #15 (Certified Nurse's Assistant) stated they would reposition if a resident needs to be sitting up in bed for breakfast. If a resident was lying flat they would move them off to the side a little. They stated the [NAME] had bathing instructions and from there they got an idea what needed to be done for the resident that day. Staff #15 stated there was no place to document work that was done. They used to able to put on kiosk, but they did away with that. Now the facility used an iPad but that only had a place to document behaviors, activities of daily living and bowel movements. There was no other place to document turning and positioning. When interviewed on 06/27/24 at 09:47 AM, Staff #12 (Registered Nurse Unit Manager) stated there was no investigation into the root cause of the sacral pressure ulcer but it was discussed at morning meeting then the wound care physician was consulted. Staff #12 stated the new pressure ulcer was a reopened sacral wound first noted on 4/11/24. The wound was treated with hydrocolloidal dressing until the wound care physician saw the resident on 4/18/24 and changed to Santyl with gauze island. Now the wound care physician is seeing them weekly. Staff#12 stated there was no place in the record to document the interventions implemented by Certified Nurses Assistants. 415.12(c)(1)

Based on record review and interviews conducted during the recertification survey from 6/24/2024-7/1/2024, the facility failed to ensure that for 1 of 26 residents, screened for mental disorder or intellectual disability, had an identification number documented on their pre-admission screening and resident review assessment prior to their admission to the facility. Specifically, Resident #420's electronic medical record revealed that the pre-admission screen and resident review (PASRR) assessment dated [DATE] did not include an identification number prior to admission. Findings include: Review of the facility policy for Pre-Admission Screening & Resident Review, dated 1/1/2000 and revised 11/2023, documented that a screen was required for every patient/resident prior to admission regardless of length of stay. Resident #420 was admitted with diagnoses which included dementia, muscle weakness, and dysphagia (difficulty swallowing). Review of Resident #420 electronic medical record revealed that the pre-admission screen and resident review assessment dated [DATE] was signed but did not include an identification number prior to admission. During an interview on 07/01/2024 at 10:30 AM, Staff #10 stated new admission screens were sent to them and reviewed. The resident screens were found under miscellaneous in the electronic medical record. Staff #10 stated they kept a log for all admissions. The process was to review the screen and check to see if there was an identification number on the screen. If the screening was missing any information, it would be sent back to Admissions. Staff #10 stated that they would review Resident #420 ' s screening form further to find out why it was incomplete. 10NYCRR 415.11(e) During a follow up interview on 07/01/24 at 11:26 AM, staff #10 stated they called the hospital about Resident #420 screen form. The screener was not picked up in the hospital's internal system. The internal system does not pick up the screener's identification number. Staff #10 acknowledged that it is their responsibility to review the screening form for a documented resident's signature, screener signature, and screener's identification number. Staff #10 states, I ' m not sure why it's missing on the screen.

Based on interviews and record review conducted during the Recertification survey from 06/24/2024 to 07/01/2024, the facility did not ensure the resident and the resident's representative were given the opportunity to participate in the development and implementation of the residents person-centered plan of care. This was evident for 1 (Resident #41) of 32 total sampled residents. Specifically, the facility did not include the resident's representative during the planning of their care plan meeting as requested. The findings are: The facility policy titled Comprehensive Care Planning dated 10/2016 documents each resident and his/her family members and/or legal to participate in the development and implementation of his/hers plan of care including the initial planning process and changes to the plan of care. The resident/representative has the right to participate in the planning process including the right to individuals or roles to be included in the planning process. Resident #41 had diagnoses of functional quadriplegia, primary adrenocortical insufficiency, and Diabetes Mellitus. The Minimum Data Set assessment dated [DATE], documented Resident #41 was cognitively intact. During the interview for daily preferences the resident indicated that it was very important for their family to be involved in discussions of the resident's care. The resident needed set up assistance with meals and dependent on staff for assistance with toileting, bathing, and transfers. During an interview with the resident on 6/24/24 at 3:40 PM, they stated they usually went to their care plan meeting but not the last one in April because their sister could not make the meeting and there was no alternate date or time given. The resident stated they wanted to be at the meeting since it was about them and their care, and was disappointed it could not be arranged. The Social Worker note dated 4/3/24 documented the resident was invited to their care plan meeting but family was unable to attend. The resident stated they did not want the meeting without their family and it would be reschedule. A second Social Worker note dated 4/8/24 documented the resident's care plan meeting was held 4/4/24 without the resident or their representative. The resident stated they will attend only if the resident's representative attends. Will reschedule for another date. There was no documented evidence a rescheduled meeting occurred with the resident or their representative. During an interview with Staff #10 Social Worker, on 6/27/24 at 2:35 PM, they stated they knew about the care plan meeting conflict and must have forgotten to reschedule it with the resident's family. Staff #10 stated they should have called the resident's representative and rescheduled for a more convenient time but got busy and did not do it. 415.11(c)(2)(i-iii)

Based on interview and record review during an abbreviated survey (NY00299510), the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 3 residents (Resident #1) reviewed for accidents. Specifically, the facility did not have a system in place to routinely monitor the safety and working manner of facility shower chairs. The findings are: The Facility Policy Shower Chair and Shower Bed Cleaning dated 1/2000, revised 1/2010 documented that the nursing department will disinfect the shower chair and the shower bed after each use. Resident #1 was admitted to the facility with diagnoses that included Polyneuropathy, Chronic Pain, and Poly Osteoarthritis. The Minimum Data Set (MDS, an assessment tool) dated 07/08/2022 documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 14/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The resident required physical help in bathing with one-person assistance. Event/Incident report dated 7/23/22 at 10:00 AM documented Resident #1 was taking a shower and fell through the seat of the chair. Injury noted abrasion to left chest shoulder. During an interview conducted with the Director of Facility Maintenance (DOFM) on 03/09/2023 at 12:42 PM, the DOFM stated that prior to the incident with resident #1 falling through the shower chair there was no actual detailed log to ensure that the chairs were checked for safety. During an interview conducted with the Administrator (ADM) on 03/08/2023 at 3:10 PM, the ADM (not the one who reported to the NYSDOH) stated they only started as administrator in November 2023. The ADM stated that maintenance is responsible for the maintenance of shower chairs, and that their expectation is for all equipment to be working and in a safe and functional manner. The ADM stated now (after the incident) there is a monthly audit of shower chairs that is conducted by maintenance and the results are reported during the Quality Assurance meetings. 415.29(b)

Based on interview and record review during an abbreviated survey (NY00299510), the facility failed to ensure that the resident environment remains free of accident hazards as possible for 1 of 3 residents (Resident #1) reviewed for accidents. Specifically, resident #1 had a fall sustaining an abrasion to left chest and shoulder when a shower chair broke in the middle of care. The findings are: The Facility Policy Shower Chair and Shower Bed Cleaning dated 1/2000, revised 1/2010 documented that the nursing department will disinfect the shower chair and the shower bed after each use. There is no documented evidence of a system in place in keeping the shower chairs in safe operating condition. Resident #1 was admitted to the facility with diagnoses that included Polyneuropathy, Chronic Pain, and Poly Osteoarthritis. The Minimum Data Set (MDS, an assessment tool) dated 07/08/2022 documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 14/15, associated with intact cognition (00-7 severe impairment, 08-12 moderate impairment and 13-15 cognitively intact). The resident required physical help in bathing with one-person assistance. Review of the Event/Incident report dated 07/23/2022 at 10:00 AM documented that resident #1 was taking a shower and fell through the seat of the chair. Injury noted an abrasion to left chest and shoulder. During an interview conducted with CNA #2 on 03/08/2023 at 12:59 PM, CNA #2 stated before they went to give resident #1 a shower, they checked the chair. CNA #2 stated while showering resident #1 in the chair they stated they were sliding, and then was falling through the chair. CNA #1 stated they protected the back of resident #1's head and pulled the string for assistance. During an interview conducted with the Assistant Director of Nursing (ADON) on 03/08/2023 at 2:54 PM, the ADON stated it is their expectation for staff to ensure the safety of the shower chairs before use and if there are any issues to remove it and notify maintenance. During an interview conducted with the Administrator (ADM) on 03/08/2023 at 3:10 PM, the ADM (not the one who reported to the NYSDOH) stated they only started as administrator in November 2023. The ADM stated that maintenance is responsible for the maintenance of shower chairs, and that their expectation is for all equipment to be working and in a safe and functional manner. The ADM stated now (after the incident) there is a monthly audit of shower chairs that is conducted by maintenance and the results are reported during the Quality Assurance meetings. 415.12(h)(1)

F 689 Based on record review and interview conducted during an abbreviated survey (NY 692) conducted on 9/821, the facility did not ensure that the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 1of 3 residents reviewed for accident. Specifically, Resident #1 who was severely impaired was placed on toilet by CNA#1. CNA#1 stated walked out to check on another resident and left Resident #1 on the toilet unsupervised or unattended to check on another resident. As a result, Resident #1 fell and sustained a right [CONDITION(S)]. This resulted in actual harm that is not immediate jeopardy. The findings are: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Dementia, Cardiovascular Accident ([CONDITION(S)]-Stroke) with left paralysis, Status Post fall with L2 vertebral compression fracture and with a lumbar-sacral orthotic (LSO) brace in place for all activities. The Admission Minimum Data Set (MDS) - a resident assessment tool dated 9/10/2019, documented a BIMS (Brief Interview for Mental Status) score of 2/15 which indicated that the resident was severely cognitively impaired; required extensive assistance of 1 person for dressing, toilet use, personal hygiene, extensive assistance of 2 with transfer and bed mobility; use wheelchair for mobility; was always continent of bowel and occasionally incontinent of urine. Falls Risk Assessments dated 9/3/2019 and 9/6/2019 had Resident #1 scored at 14 which indicated that Resident #1 was at high risk for falls. Interim Care Plan for fall risk dated 9/3/2019 had a goal that resident will be free of injury from fall. Interventions included call bell within reach, assist with transfers, chair and bed alarm and assess psychological needs. Care plan was updated 9/6/2019 and documented Resident #1 should not be left unattended in the bathroom. Comprehensive care plan initiated 9/4/2019 documented that Resident #1 had limited physical mobility secondary to fall and a stroke with left paralysis with goal for Resident #1 to return to prior level of functioning with supervision with rolling walker in 30 days. Interventions included Resident #1 required limited assistance of 1 with transfer out of bed and limited assistance of 1 with transfers into bed. Comprehensive Care Plan updated 9/27/2019 documented interventions that included Resident#1 required extensive assistance of 2 person for out of bed transfers; resident required extensive assistance of 2 for toileting using grab bar and raised toilet seat. Certified Nurses' Aide (CNA) care card dated 9/3/2019 and updated 9/6/2019 documented Resident #1 needed assist of 1 with non-skid socks for transfer and assist of 1 with supervision with toileting. Event/Incident Report dated 9/20/2019 and signed by Director of Nursing (DON), documented DON was called to Resident #1's room at 4:30pm on 9/20/2019 where Resident #1 was found on the bathroom floor. CNA #1 wrote in their statement dated 9/20/2019 at 4/20pm, I put Resident #1 on the toilet, walked out to check on another resident and as I walked back in her room and family member said, I think she is on the floor and she was. Resident #1 was lifted from the floor with 2 persons assist and placed into wheelchair. Registered Nurse's (RN) Note dated 9/20/2019 signed by Registered Nurse Supervisor (RNS) #1 documented that RNS #1 was called to Resident #1's room to assess the resident. RNS #1 observed Resident #1 sitting on the floor disoriented and confused. Gross motor and sensory function were intact. Lungs clear, no respiratory distress, no swelling noted, no complain of pain, no injury noted. Resident was assisted into wheelchair. Licensed Practical Nurse's Notes dated 9/21/2019, documented Resident #1 was in wheelchair, awake and alert. Resident #1 complained of right hip pain after a fall on 9/20/2019 at 4:40pm. X-ray ordered and obtained as per orders from Medical Director (MD). Tylenol extra strength given for complaint of pain to right hip with relief. Resident left in bed with call bell within reach. There was no other documentation of pain. Registered Nurses' Notes dated 9/21/2019 signed by RN#1 at 6:15pm documented that Resident#1 was transferred to hospital per telephone order from MD due to X-ray results of the right hip. Findings documented Acute nondisplaced sub capital fracture identified with impaction suspected. [CONDITION(S)] is noted. Impression: Impaction fracture right femoral neck. Family made aware. During an interview with the DON on 7/28/2021 at 8:35am, the DON stated that CNA #1 was let go because CNA#1 did not follow the care plan. DON stated that CNA#1 placed the Resident #1 on the toilet and left Resident #1 in the bathroom unattended. Resident #1 fell and broke their hip. Several attempts to contact CNA #1 on 7/29/2021, 8/31/2021 via phone and was unsuccessful. A follow-up letter was sent to CNA #1 on 7/29/202 to contact CNA #1 with no response. During an interview with the Medical Director (MD), on 9/8/2021 at 3:28pm, MD stated that Resident #1 was admitted to the facility for rehabilitation due to compression fracture of L2 (second lumbar vertebrae) secondary to a fall at home. Resident #1 had left [CONDITION(S)] (weakness of the left side) secondary to a stroke. MD stated Resident #1 was basically taken to the bathroom by CNA #1, left unattended and when CNA#1 returned to the bathroom, Resident #1 had fallen on the floor. MD stated Resident #1 was assessed by RNS #1 and with no complain of pain and placed in bed. MD stated Resident #1 complained of pain the next day and X-ray of the right hip was ordered. X-ray results obtained by MD documented a right [CONDITION(S)]. MD ordered Resident #1 to be transferred to the hospital. 483.25(d)(1)(2)

Based on interviews and record reviews during a Recertification Survey, the facility did not ensure that Comprehensive Care Plans (CCP) were reviewed and revised after each assessment and as needed for changes in the residents' care needs. Furthermore, the facility did not ensure residents/resident representatives were invited to participate in care planning meetings. Specifically, 1) Resident #11's Activities of Daily Living (ADL) Care Plan was last updated on 08/18/2020; 2) Resident #12's ADL Care Plan was last updated on 12/09/2020 and resident #12's daughter stated that she has not been invited to any care plan meetings; and 3) Resident #75 stated that he/she is not familiar with Care Plan Meetings. This was evident for 3 of 22 sampled residents. The findings are but not limited to: (1) Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, an assessment tool) dated 03/17/2021, documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation and ability to recall information) score of 14/15, associated with intact cognition. The resident required extensive two-person assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. The resident used a wheelchair as a mobility device. Review of Resident #11's ADL Functional / Rehabilitation Potential dated 08/18/2020 documented interventions that included to assist with bathing body parts that the resident is unable to reach, provide assistance with personal hygiene, bathing and to complete tasks. Resident #11 was also to be allowed sufficient time for dressing, undressing and other ADL tasks. During an interview conducted with the Licensed Practical Nurse Unit Manager (LPNUM) on 06/08/2021 at 10:30 AM, the LPNUM stated that all Care Plans are computerized and Resident #11's ADL Care Plan was not updated. The LPNUM stated that the resident refuses care at times, but he/she did not document that in the progress notes nor did he/she update the Care Plan. (2) Resident #12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented that the resident had a BIMS Score of 10/15 denoting moderate cognitive impairment. The resident required total dependence, one-person assistance for bathing as well as extensive two-person assistance for bed mobility and transfers, extensive one-person assistance for dressing, toilet use and personal hygiene. The resident uses a wheelchair as a mobility device. Review of Resident #12's ADL Functional / Rehabilitation Potential dated 12/09/2020 documented interventions that included to allow sufficient time for all ADLs, involve resident / family in plan of care, provide substantial / maximum assist with dressing, bed mobility, bathing, wheelchair mobility and toileting needs. During an interview conducted with Resident #12's daughter on 06/02/2021 at 12:23PM (initial pool process), the daughter stated that she is the next of kin and was only invited to a Care Plan meeting one time, when the resident transitioned to the Long Term Care unit. During an interview conducted with the Social Worker (SW) on 06/09/2021 at 03:01PM, the SW stated that he/she remembered inviting Resident #12 to a care plan meeting, but she did not invite the family member. She further stated that she did not document anything in the progress note about inviting the resident or the resident's family. During an interview conducted with the Registered Nurse Unit Manager (RNUM) on 06/10/2021 at 11:12AM, the RNUM stated that he/she knew that Resident #12's ADL Care Plan had not been revised since 2020. He/She stated that she has been employed at the facility for one month and he/she anticipates that there will be a lot of Care Plans that have not been updated since 2020. The RNUM stated that he/she has been trying to go through all the care plans that were not updated since 2020 methodically. (3) Resident #75 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] documented a BIMS score of 15/15 denoting intact cognition. The resident required extensive two-person assistance for bed mobility, transfers and toilet use as well as extensive one-person assistance for dressing and personal hygiene. During an interview with Resident #75 on 06/03/21 at 02:29PM (initial pool process), Resident #75 stated she is not familiar with Care Plan Meetings. Review of the Comprehensive Care Plan (CCP) Meeting / Signature Sheet revealed that on 11/02/2020 and 03/2021 (no day specified) Care Plan meetings were held for Resident #75 but the resident and the resident's family did not attend. During an interview conducted with the Social Worker (SW) on 06/10/2021 at 11:30AM, the SW stated that Resident's #75's last CCP meeting was held on 06/03/2021, but he/she had not documented it in the Electronic Medical Record (EMR) or the CCP Meeting/Signature Sheet yet. The SW stated that he/she did not invite the resident or the resident's family to that meeting. The SW stated that he/she was the only SW in the facility for the last four months and has fallen behind on documentation. During an interview conducted with the Assistant Director of Nursing (ADON) on 06/10/2021 at 10:07AM, the ADON stated that Unit Managers were responsible to update the Care Plans. The LPNUMs do it under the direction of the Director of Nursing (DON). The ADON stated that Care Plans were revised quarterly, annually, as needed or as changes occur. The ADON also stated that the RNUM has been working in the facility for one month. During an interview conducted with the DON on 06/10/2021 at 10:44AM, the DON was aware that the ADL Care Plans for Resident #11 and Resident #12 had not been updated. The DON stated that all Care Plans were computerized and initiated by the MDS from Admission. The DON further explained that the Unit Managers were to update them quarterly, annually, and as needed or when changes occur. The DON stated that the facility has been actively hiring. The DON also stated that the LPNUM must update the care plans under his/her supervision. During an interview conducted with the MDS Coordinator on 06/10/2021 at 12:54PM, the MDS Coordinator stated that their department triggers appropriate care plans that come up during the Admission process. The MDS Coordinator stated that the MDS Coordinators do not update the care plans which must be completed quarterly, annually and during any changes in the residents condition. 415.11(c)(2)(i-iii)

Based on observations, interviews and record review during a Recertification Survey, the facility did not ensure residents have a right to a dignified existence for 3 of 3 residents screened for dignity. Specifically, Resident #77 was identified by a Certified Nursing Assistant (CNA) using a term that described a symptom of his/her medical condition, Resident #186 received services by a Radiology Technician who did not knock on the residents door before entering, identify himself or the anticipated procedure and Resident #9 who also received radiology services by a technician who entered the resident's room without identifying himself. The findings are: Resident #77 was admitted from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission Minimum Data Set (MDS; a resident assessment tool) dated 5/17/2021 documents the resident has a Brief Interview for Mental Status (BIMS; an assessment tool) of 15/15 indicating that the resident was cognitively intact . The resident required extensive assistance of 2 persons for bed mobility, transfer, extensive assistance of 1 for dressing and eating. The Nursing Admission assessment dated [DATE], documented that the resident had tremors secondary to the [CONDITION(S)] diagnoses. An observation was made on 6/2/2021 at 12:42PM where CNA #3 was passing out lunch trays. While walking past, CNA #3 called Resident #77 Mr. Wiggles while in his/her wheelchair. On 6/2/2021 at 1:31PM, CNA#3 was overheard speaking to Resident #77 in the hallway in front of the nurses station and said ok, Mr. Wiggles, I'll get you back to bed. An interview was conducted with the resident on 6/2/2021 at 12:45PM who stated h/she does not like to be called Mr. Wiggles. The resident stated that sometimes his/her movements are uncontrollable and can't be helped. An interview was conducted on 6/08/2021 at 12:40PM with CNA #3 who stated that she has received training about speaking to residents respectfully and stated staff are not allowed to call residents by a nickname. CNA #3 explained that he/she called Resident #77 Mr. Wiggles because he/she moved around so much. CNA #3 further explained that he/she thought he/she was being sweet but realized later it was not the right thing to do. An interview was conducted on 6/8/2021 with the Licensed Practical Nurse Unit Manager (LPNUM #2) at 1:50PM who stated that he/she instructed his/her staff to address the residents professionally by calling each resident either Mrs. or Mr. If a resident has requested to be called a nickname, staff have been instructed to let him/her know so he/she can look into it and incorporate it into the resident's plan of care if needed. Resident #186 was admitted on [DATE] from an acute care facility after a fall with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] indicated that the resident was cognitively intact with a BIMS of 15/15. Resident #186 also required limited assistance of 1 person for transfer from bed, dressing and supervision only for eating. On 6/2/2021 at 11:13AM Resident #186 was being interviewed in his/her room. Without knocking, asking permission to enter or self-identification, the Radiology Technician walked into the room with a large portable X-Ray machine and started to set/plug in machine. The Radiology Technician interrupted the interview and proceeded to remove Resident #186's over bedside table from its position (over the bed in front of the resident) and move it to the window. The Radiology Technician then positioned the X-Ray machine in its place without explanation or permission to do so by the resident. The Radiology Technician was stopped and asked twice to wait outside of the room. Resident #186 was interviewed at this time and stated that the Radiology Technician comes in whenever he/she needs to without knocking, identifying who he/she is or what he/she is doing . The resident stated that he/she does not like that. Resident #186 further stated that he/she lives alone and feels uncomfortable that the Radiology Technician comes into the room when he/she is only wearing pajamas. The resident verified that he/she has had a chest X-Ray and knee X-Rays by this Radiology Technician in the past. An interview was conducted with the Radiology Technician on 6/2/2021 at 11:17AM who stated that he/she did not think he/she had to knock, introduce himself/herself or ask for permission to enter the resident's room because he/she has been there before and the resident knew him/her already. Resident #9 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission MDS dated [DATE] documented that the resident is cognitively intact with a BIMS score of 14/15. Resident #9 required extensive assistance of 2 persons for bed mobility, transfers as well as extensive assistance of 1 for dressing and tray set up only for eating. Resident #9 was interviewed 6/2/2021 at 12:03PM and stated that the Radiology Technician barges into his/her room whenever he/she needs an X-Ray. Resident #9 said that the Radiology Technician does not knock, just barges in to do his/her thing. The resident stated that he/she does not like when the Radiology Technician does that and one time he/she was washing up in his/her nightgown. The resident stated, I was so embarrassed. LPNUM #2 was interviewed on 6/8/2021 at 12:15PM and stated that the Radiology Technicians are to knock on doors and ask for permission to enter a room. LPNUM #2 has had many complaints from other residents about the Radiology Tecnician not knocking or announcing himself/herself prior to entry into a room. LPNUM #2 further indicated that the old Administrator was aware. LPNUM #2 stated that the Radiology Technician had no boundaries and continuously barges in to residents' rooms. On 6/9/2021 at 11:30AM an interview was conducted with the Administrator who stated the Radiology Technician should not be walking in to resident rooms without knocking and asking for permission to enter. The Administrator explained that he/she was aware that this has occurred and that the Radiology Technician has received additional training. §483.10(a)(1)

Based on observations, interviews and record reviews conducted during an Abbreviated Survey (#NY 5627) it could not be ensured that the facility thoroughly investigated all alleged violations of abuse, neglect and mistreatment for 1 of 3 residents reviewed. Specifically, the facility did not rule out a Comprehensive Care Plan (CCP) violation when CNA #1 transferred a resident alone, resulting in a fall, when the care plan required a 2-person transfer. The Findings are: Resident #1 is a [AGE] year-old male admitted for short term rehab with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS; a resident assessment tool) dated 9/18/2020 indicates that Resident #1 requires extensive assistance from 2 persons for transfers and locomotion on the unit. Review of the facility's Policy and Procedure for Incident Reports revised November 2015 documents that a licensed nurse is to document a factual account of incidents and completes the incident report. Review of a facility Incident Report dated 10/8/2020 showed that CNA #1 attempted to transfer Resident #1 from the toilet to the wheelchair using the sit and stand method when a 2-person transfer is indicated. Further review of the facility incident report showed that the investigation did not have a conclusion, nor did it examine that CNA #1 not adhering to Resident #1's CP by transferring him without assistance. Review of the Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) specifically for Transfers which was initiated on 9/13/2020 showed that Resident #1 is to utilize the Sit and Stand method with assistance from 2 persons for transfer from toilet to wheelchair. Review of a Written Warning dated 10/8/2020 showed that on 10/8/2020 CNA #1 was counseled for independently transferring Resident #1 utilizing the Sit to Stand method which violated the facility policy requiring 2-person assistance for transfers when using a mechanical lift. During interview with CNA #1 on 11/2/2020 at 2:00pm, she indicated that she had help assisting Resident #1 onto the toilet utilizing the Sit to Stand method but was unable to find a second person to assist when it was time to get Resident #1 off the toilet. She stated that she transferred Resident #1 without a second person providing assistance as indicated. When CNA #1 was asked if she had received training on the Sit and Stand transfer method, she indicated that she received it a few days after the incident on 10/8/2020. During interview with Resident #1 on 11/2/2020 at 2:15pm, he indicated that he remembers the fall on 10/8/2020. He further explained that CNA #1 had someone to help her get him on the toilet. He went on to say that CNA #1 removed him from the toilet alone and that is when he fell . During interview with the Director of Nursing on 11/2/2020 at 3:30pm, she indicated that a competency review was not completed on CNA#1. She further stated that staff education is not provided by any specific staff; it is done by whomever is available. 483.12(c)(2)-(4)

Based on observations, record reviews and interviews conducted during an Abbreviated Survey (NY# 5627), the facility did not ensure that a Certified Nursing Assistant demonstrated competency to provide safe care and appropriate response to individual needs as identified in the assessment and Comprehensive Care Plan (CCP) for 1 of 3 residents (Resident #1) reviewed for accidents. Specifically, CNA #1 independently transferred a resident utilizing the Sit and Stand method which requires 2 persons to assist for transfers with a mechanical lift. CNA #1 had not received the required competency training to perform the task. The findings are: Resident #1 is a [AGE] year-old male admitted for short term rehab with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS; a resident assessment tool) dated 9/18/2020 indicates that Resident #1 requires extensive assistance from 2 persons for transfers and locomotion on the unit. Review of a facility Incident Report dated 10/8/2020 showed that CNA #1 attempted to transfer Resident #1 from the toilet to the wheelchair using the sit and stand method when a 2-person transfer is indicated. Review of the Comprehensive Care Plan (CCP) for Activities of Daily Living (ADLs) specifically for Transfers which was initiated on 9/13/2020 showed that Resident #1 is to utilize the Sit and Stand method with assistance from 2 persons for transfer from toilet to wheelchair. During interview with CNA #1 on 11/2/2020 at 2:00pm, she indicated that she was unable to find a second person to assist when it was time to get Resident #1 off the toilet on 10/8/2020. She stated that she transferred Resident #1 without a second person providing assistance as indicated. When CNA #1 was asked if she had received training on the Sit and Stand transfer method, she indicated that she had not received it until a few days after the incident of 10/8/2020. During interview with Resident #1 on 11/2/2020 at 2:15pm, he indicated that he remembers the fall on 10/8/2020. He further explained that CNA #1 had someone to help her get him on the toilet. He went on to say that CNA #1 removed him from the toilet alone and that is when he fell . During interview with the Director of Nursing on 11/2/2020 at 3:30pm, she indicated that a competency review was not completed for CNA #1. She further stated that staff education is not provided by any specific staff; it is done by whomever is available. 415.26(c)(1)(iv)

Based on interviews and record review during an abbreviated survey (NY 312), the facility did not ensure that personal privacy was protected for one of three residents reviewed for resident rights (Resident #1). Specifically, a staff member used her cell phone to take the resident's picture and posted the resident's name, picture and story on a social media page without obtaining written consent from the resident. The findings are: Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the comprehensive admission Minimum Data Set (MDS) assessment dated [DATE], the resident had a Brief Interview for Mental Status (BIMS, a test used to measure memory and recall) score of 14 out of 15, suggesting the resident was cognitively intact and able to make decisions independently. RN #1 signed an acknowledgement statement on 12/11/17 that she received and read the facility policy dated 8/18/15 for electronic devices. RN #1 signed an acknowledgement on 12/12/17 that she received and read the policy dated 9/23/13 on social media. A facility investigation included a written statement by the Assistant Director of Nursing (ADON) that stated the Unit Manager informed the ADON on 1/8/18 that RN #1 took a picture of Resident #1 that was posted on social media. The Director of Nursing (DON) was called immediately regarding the incident. The Social Worker (SW) wrote in a written statement that Resident #1 was alert and oriented times three and able to make his needs known and that the SW interviewed the resident about the incident. The resident stated to the SW that he did not give any staff member permission to take his photo recently. He consented to a picture on admission and a picture at a holiday party. RN #1 wrote a statement dated 1/11/18 that she asked the resident if she could take his picture as she felt for him after listening to his story of his life. He was one of the most intriguing people with tremendous strength. RN #1 documented that the resident gave her permission to post the picture on social media. There was no evidence that written consent was obtained from the resident. The SW was interviewed on 4/3/2019 at 2:30 PM and stated, when she interviewed the resident, he could not recall if he agreed to the picture. RN #1 was interviewed by phone on 6/17/2019 at 1:30 PM and stated she meant no harm to the resident by posting his picture, his story and his name on face book. She stated she wasn't thinking at the time. RN #1 stated she did not obtain written consent from the resident. The Director of Nursing was interviewed on 4/3/2019 at 3:00 PM and stated that she and the SW had viewed RN #1's cell phone with the photo of the resident. 415.3(d)(1)

Based on interview and observation conducted during a recertification survey, the facility did not develop person-centered care plans with measurable objectives, time frames and interventions for 7 of 18 residents reviewed for care planning to address: - monitoring of daily weights for 1 of 1 resident (#52) reviewed for activities of daily living; - use of medication given for elevated cholesterol for 1 of 6 residents (#45) reviewed for unnecessary medications; - pressure ulcers for 1 of 4 residents (#86) reviewed for pressure Ulcer/Injury; - [MEDICAL CONDITION] and use of [MEDICAL CONDITION]-embolic deterrent (TED) stockings for 1 of 1 residents (#124) reviewed for positioning and mobility; - pain management for 1 of 1 residents (#108) reviewed for pain management; - the use of a restraint for 1 of 1 resident (#96) reviewed for physical restraints; and - accidents for 1 of 4 residents (#130) reviewed for accidents. The findings include, but are not limited to: 1. Resident # 86 has [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set; a resident assessment tool) dated 8/3/18 documented that the resident had a moderately impaired cognitive skills for daily decision making, required supervision of one person for most aspects of activities of daily living (ADL); was occasionally incontinent of bladder and bowel; was at risk for developing pressure ulcers; and had one Stage 3 pressure ulcer (sacral region) measuring 1.4 x 0.5 x 0.5 cm. There was no documented evidence that a person-centered care plan with measurable objectives, timeframes and interventions was initiated to address the resident's risk for developing pressure ulcer and the care of the resident's existing pressure ulcer. The resident was interviewed on 9/18/18 at 1:45 PM and stated that she has a sore on her 'behind for 5 months and it is uncomfortable but not painful. The physician's wound progress notes and the nursing notes revealed that the pressure ulcer was noted on 8/7/17 as a Stage II on the right inner buttock and was treated and healed as of 10/2/17. The wound reoccurred on 3/15/18 as a Stage II which deteriorated to a Stage III on 4/23/18. The physician's wound progress notes of 9/18/18 revealed that the pressure ulcer is currently a healing Stage III. The unit Registered Nurse Manager (RN #3) was interviewed on 9/25/18 at 12:25 PM and was unable to provide a care plan that addresses the existing pressure ulcer to include interventions to prevent development of further pressure ulcers. 2. Resident #124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS of 8/21/18 indicated the resident had severely impaired cognitive skill for daily decision making and required extensive assistance to being totally dependent on 1-2 person assistance for most activities of daily living. The Physician order [REDACTED]. The PO order of 9/6/18 included the use of venodynes (a device placed around the legs that inflates and deflates to keep blood circulating in the legs to help prevent the formation of blood clots) and a hematology consult for a [DIAGNOSES REDACTED]. The nursing progress note of 9/7/18 documented that the resident was positive for [MEDICAL CONDITION] of the RUE, venodynes for the legs were ordered, and to apply TEDs stockings until the venodynes arrive. There was no care plan with measurable objectives, time frames and interventions to address the Acute RUE [MEDICAL CONDITION], the use of venodynes, and the use of TED stockings. Observations were conducted on 9/20/18 at 12:30 PM, 9/21/18 at 9:30 AM and 9/21/18 at 12:39 PM. At the time of these observations, the resident was in bed and there were no TED stockings applied to the resident's lower extremities. During an interview on 9/21/18 at 10:56 AM with the Director of Nursing, she stated that the Physician Assistant requested TED stockings to be worn 12 hours on and 12 hours off, even when the resident was in bed. When asked who was responsible for initiating care plans, she said the nurse managers were responsible but since the nurse manager resigned, she was responsible. She said there did not appear to be a care plan in place to address the [MEDICAL CONDITION] and the use of the TED stockings, and she would put one in place. 3. Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS of 8/1/6/18 documented that the resident had severely impaired cognitive skills for daily decision making; required extensive assistance of one person for most aspects of activities of daily living; had a fall in the last 2-6 months prior to admission and was receiving 6 days of physical therapy and occupational therapy. This MDS further indicated the resident used a bed alarm daily and there were no physical restraints used. The Physician order [REDACTED]. The nursing progress notes (NPN) of 9/2/18 documented that the resident was non-compliant with transfers, and walking alone with shoes untied. The NPN of 9/5/18 indicated the resident was walking without assistance, frequently standing, chair alarm was put in place, and a self-release seatbelt was applied and the resident demonstrated ability to release the seat belt. Observations were conducted on 9/18/18 at 10:45 AM and 2:00 PM. The resident was standing in front of his wheelchair and was attempting to lift his right leg up and over the wheelchair seatbelt which was around his legs at knee level and clipped together (unopened). There was no documented evidence that the following were done: - a doctor's order to address the use of the seat belt including the reason(s) for its use was done, - an assessment to determine options prior to the use of the seat belt; - a care plan with measurable objectives, time frames and interventions to address its use. The 8/18/18 care plan initiated for at-risk for falls only addressed the use of bed and chair alarm. The Director of Nursing (DON) was interviewed on 9/25/18 at 11:20 AM and she stated there should have been a physician's orders [REDACTED]. Following surveyor intervention, physician orders [REDACTED]. The care plan was then initiated for the use of the self-release seatbelt and two quarter side rails with interventions including self-release seatbelt applied as ordered, encourage resident to self- release on command, monitor response to self-release seatbelt, assess for reduction quarterly and prn (as needed), and monitor for changes in behaviors and ADL (Activities of Daily Living). The resident's wife also initiated an Informed Consent for the Use of Physical Restraints Assistive Device for the use of an alarmed self-release seatbelt. 415.11(c)(1)

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that foods brought in from outside sources were stored according to professional standards of food safety practice on 2 of 4 facility units (Putnam and Dutchess). Specifically, multiple containers of food brought in for residents by family members were observed to be out dated. The facility policy did not indicate how long the food could be kept in the refrigerators. The findings are: The refrigerators on the units were observed on 9/25/18 between 1:30 PM to 2:00 PM: 1. Putnam - Multiple outdated food items; - Plastic container of an unidentified food dated 9/6/18 - 19 days; - Plastic container of rotisserie chicken dated 9/16/18 - 9 days; - Sandwich and salad that came from the kitchen dated 9/18/18 - 7 days; - Two store bought cakes with no date; and - A bag of plums with an (MONTH) date. The refrigerator was sticky on the inside. The Registered Nurse present at the time of observation stated she would throw out all the outdated and undated food. When asked who was responsible for cleaning the refrigerators she stated she wasn't sure and thought it was the kitchen department. 2. Dutchess - A plastic bag of potato salad had no label and was undated. The Licensed Practical Nurse who was present at that time stated she would throw it away. There were no instructions indicating how long the foods can stay in the refrigerators before being discarded. The Food Service District Manager (the Food Service Manager was not available) was interviewed at 2:00PM on 9/25/18 and she stated that the kitchen was responsible for cleaning the unit refrigerators and discarding outdated food. When asked how long food can be kept in the unit refrigerators, she stated she thought it was 3 days. Review of the Policy and Procedure for Food from Outside Sources dated (MONTH) (YEAR) included the following statement: Perishable food should be sealed, labeled with the resident's name and room number, dated with a use by date and placed in the refrigerator. There is no indication in the policy of how long foods brought in from outside for the resident can be kept in the refrigerator. 415.14(h)

Based on interviews and record review conducted during the most recent recertification survey, the facility did not ensure that sufficient staff was available to meet the needs of residents on all units and on all shifts. This was evidenced by (1.) multiple residents reporting during confidential interviews and the group meeting of lack of Certified Nurse Aides (CNAs) to respond to call bells and provide assistance with activities of daily living; (2.) multiple nursing staff members reporting lack of sufficient staffing on all units; and (3.) analysis of the actual staffing schedule showing that on multiple occasions the facility was below its required levels for CNAs on all units. The findings include: 1. Confidential interviews were held on 9/18/19, 9/19/19 and 9/20/18 and four residents reported the following: - There was not enough staff. Frequently, there were three CNAs on the unit and when this was the case, showers were not done; - When the call bell is pressed, it takes an hour to get a response, and that staff has to work a lot of overtime; - one of the residents stated she needed help to get off the toilet and it takes a long time for the staff to come, more than 20 minutes; - After having a bowel movement, another resident stated it takes a long time for the staff to respond to call for assistance, up to one and one-half hours. 2. There were five residents at the group meeting conducted by a surveyor on 9/19/18 at 11:00 AM. The residents stated that there should be four aides on each unit, which frequently does not happen. They stated that sometimes you have to wait a long time because the aides are with other residents. Two aides were needed for the use of a Hoyer lift and on the Putnam unit there were about 15 residents that needed to be transferred with this lift. Call bells were answered in about one-half hour. 3. Seven nursing staff members including 5 CNAs and 2 licensed nurses, were interviewed from all units (Putnam, Orange, Ulster and Dutchess) regarding staffing. Their responses included as follows: - CNA #1 assigned to the evening shift stated on 9/19/18 at 3:35 PM that frequently there are three CNAs on the shift. Sometimes scheduled showers are not done; - Two licensed nurses stated on 9/19/18 at 4: 00 PM that there are usually three CNAs on the evening shift and it is more difficult to complete assignments. Residents complained of lack of sufficient staff; - CNA #2 assigned to the evening shift stated on 9/19/18 at 4:00 PM that there were only three aides on the unit 6 out of 7 days. When this happens, call bells were not answered promptly and showers were not always done as scheduled; - CNA #3 assigned to the day shift stated on 9/21/18 at 2:07 PM that during orientation she was told there was supposed to be four CNAs on the day shift however there are usually three. She stated further she is usually assigned 13 residents, resulting in her missing breaks, rushing, not being able to respond to call bells timely, and some residents get upset when they missed their showers. While the Department of Health is here, CNA #3 stated they have been having four CNAs; - CNA #4 assigned to the day shift stated on 9/21/18 at 2:17 PM that when there are three CNAs on the shift she may not be able to take breaks and has difficulty responding to call bells. She is asked to work overtime a lot. She comes in and is afraid that she is going to be stuck, that is, she may be asked to work overtime). - CNA #5 assigned to the day shift stated on 9/24/18 at 2:29 PM that when there are three CNAs on the unit, which is usually the case, she is responsible for up to 14 residents. This is a big problem. CNA #5 stated she gets stressed, pressured and tense. Sometimes baths have to be given instead of showers and some residents have to stay in bed until 11: 00 AM. She stated she spoke to administration about it and they said they are doing their best. 4. Facility Assessment and Staffing Schedule The Facility Assessment (FA; an assessment that determines the needs of the residents and the amount of staff required to meet those needs) dated 11/3/17, actual nursing staff schedule, and a list of CNAs on the payroll were reviewed. The resident census and condition report was used as the basis for the staffing requirements in the FA. The resident census and condition report indicated that the number of residents who either needed assistance or were totally dependent on staff in the following areas included: - Bathing - 139 - Dressing - 139 - Transfer - 125 - Toilet use - 123 - Eating - 57 A review of the current Resident Census and Conditions dated 9/20/18 showed the conditions of the residents to be similar to those noted in the FA above and the current data showed: - Bathing - 140 - Dressing - 137 - Transfer - 129 - Toilet use - 125 - Eating - 144 According to the FA, the facility requires a ratio of one CNA to 10 residents (or four CNAs per unit) and a total of 80 CNAs. The actual nursing schedule for 8/22/18 to 9/20/18 showed that the average ratios per unit for this period based on 3 CNAs were as follows: Putnam - 12.9 (21 times with 3 CNAs) Ulster - 12.26 (19 times with 3 CNAs) Orange - 11.8 (23 times with 3 CNAs) Dutchess - 11.3 (22 times with 3 CNAs) The Administrator, Director of Nursing (DON), Director of Human Resources (DHR) and the staff member responsible for making up the schedule (scheduler) were interviewed on 9/25/18 between 2:30 PM and 4:30 PM. These interviews revealed that the facility did not have sufficient staff. - The Administrator stated that several CNAs were recently hired but changed their status to per diem after they completed their orientation. The Administrator also stated there is a radio campaign in progress to get more staff in. - The Director of Nursing (DON) stated that she knows that it is hard to work with three CNAs on a unit. The DON further stated that three CNAs on each unit is the minimum on the day and evening shifts and two on the night shift. Further review of the schedule during this interview with the DHR and the scheduler showed that the facility was below minimum staffing on five occasions. The scheduler stated that the following was due to a lack of sufficient staff. - 8/24/18 and 8/31/18, there was one CNA on Dutchess and Ulster respectively on the night shift, the census was 35. - 8/29/18, there were two CNAs on the day shift on Dutchess with a census of 36 - 9/09/18, there were two CNAs on the day shift on Putnam with a census of 37, and on 9/19/18 two CNAs on Dutchess. Additionally, the list of the CNAs on the payroll was reviewed with the DHR while she was being interviewed. This review showed that the facility currently employs 34 full time CNAs and 10 part time CNAs, which was below the number of CNAs the FA determined to be necessary to meet the needs of the residents. Twenty nine per diem CNAs were on the list. The scheduler stated that these CNAs are placed on the schedule based on their availability. 415.13(a)(1)(i-iii)

Based on observation, record review and interviews conducted during a recertification survey, the facility did not ensure that residents were free from physical restraints. It was determined for 1 of 1 resident (#96) reviewed for physical restraints that: (1) thorough assessment and re-evaluation were not conducted to address the use of a self-release seatbelt while in the wheelchair that may possibly restrict the resident's movement, and (2) the physician's orders [REDACTED]. The facility policy and procedure for Restraints, revised on 02/28/17, stated that the decision to apply a restraint required the collaborative opinion of the resident's physician, the resident/health care agent or responsible person, and appropriate interdisciplinary team members. For residents utilizing a Velcro Seatbelt or clip belt as a device that does not meet the definition of a restraint, the resident will be assessed weekly by the licensed nurse for the ability to remove the device upon request. The policy and procedure further stated that all restraints will have a specific physician's orders [REDACTED]. The findings are: Resident #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (a resident assessment tool) of 8/1/6/18 documented that the resident had severely impaired cognitive skills for daily decision making; required extensive assistance of one person for most aspects of activities of daily living; had a fall in the last 2-6 months prior to admission; and was receiving 6 days of physical therapy and occupational therapy. This MDS further indicated the resident used a bed alarm daily and there were no physical restraints used. The Physician order [REDACTED]. There were no further orders that included the use of a self-release seatbelt. The Nursing Progress Notes (NPN) of 8/18/18 documented that resident attempted to stand up out of the wheel chair and sometimes toilets himself or just stands up, chair and bed alarms were in place. The NPN of 9/2/18 documented that the resident was non-compliant with transfers, and walking alone with shoes untied. The NPN of 9/5/18 indicated the resident was walking without assistance, frequently standing, chair alarm was put in place, and a self-release seatbelt was applied and the resident demonstrated ability to release the seat belt. An 8/18/18 care plan was initiated for at risk for falls with interventions including bed alarm/chair alarm, encourage the use of a walker when ambulating, provide call bell, provide low bed, monitor for changes in cognition. This care plan was not updated to include the use of self-release seatbelt that was initiated on 9/5/18. There was no documented evidence that a doctor's order was initiated to address the use of the seat belt including the reason(s) for its use; an assessment to determine options other the use of the seat belt and a care plan with measurable objectives, time frames and interventions to address its use. The 8/18/18 care plan initiated for at-risk for falls only addressed the use of bed and chair alarm. The 8/9/18 CNA (Certified Nursing Assistant) Care Guide was updated on 9/19/18 to include restraint/device and self-release seat belt, following review by the surveyor and after an incident of fall. The CNA guide did not include directions for monitoring the use of the seatbelt. Observations were conducted on 9/18/18 at 10:45 AM and 2:00 PM. The resident was standing in front of his wheelchair and was attempting to lift his right leg up and over the wheelchair seatbelt which was around his legs at knee level and clipped together (unopened). An interview was conducted on 9/18/18 at 10:30 AM with the wife of resident #96. When she was asked if she had been educated and informed about the use of the seatbelt, she said she was never informed about the use and had never signed a consent. She said it had just appeared one day. An interview was conducted on 9/25/18 at 11:28 AM with CNA #1 and she stated that the seatbelt was applied when the resident was in the wheelchair, was removed for toileting and when the resident went to bed. She stated that the seatbelt was not removed during meals and that the resident was not able to open the seatbelt at all times when directed. CNA #1 stated that she had witnessed the resident standing with the seatbelt around his legs with the clip unopened and that she felt the seatbelt could cause a fall. The Director of Nursing (DON) was interviewed on 9/25/18 at 11:20 AM and she stated there should have been a physician's orders [REDACTED]. The unit Registered Nurse (RN #1) was interviewed 9/25/18 at 11:33 AM and was asked if she had the wheelchair seatbelt placed on the resident's wheelchair. RN #1 stated she was instructed by a supervisor to have the seatbelt put on the resident's wheel chair and that she did not obtain a physician order's for the use of the seatbelt. RN #1 stated she had seen the resident stand at times with the seatbelt fastened (unopened) and resting around his legs. She said she had spoken with the other nurses and they were aware the resident was able to stand even when the seatbelt was fastened and that it posed a fall risk. The Director of Therapy was interviewed on 9/25/18 at 1:45 PM and he stated that physical therapy was not involved with the assessment and implementation of the seatbelt. He stated that the resident could ambulate with a rollator and staff supervision. Following surveyor intervention, physician orders [REDACTED]. The care plan was then initiated for the use of the self-release seatbelt and with two quarter side rails. Interventions included self-release seatbelt applied as ordered, encourage resident to self-release on command, monitor response to self-release seatbelt, assess for reduction quarterly and prn (as needed), and monitor for changes in behaviors and ADL (Activities of Daily Living). The resident's wife also initiated an Informed Consent for the Use of Physical Restraints Assistive Device on 9/25/18 for the use of an alarmed self-release seatbelt. 415.4(a)(2-7)

Based on record review and interview, the Governing Body failed to establish written policies/competencies for emergency care of tracheostomies (trachs) and the reinsertion of Gastrostomy tubes. They failed to ensure that the volume [MEDICAL CONDITION] were at an acceptable level, failed to have documentation to support oxygen titration, failed to ensure trachs were changed per MD order, and failed to ensure that an [MEDICAL CONDITION] at the residents bedside, easily accessible in the case of emergency. In addition they failed to ensure that MD orders, were consistently obtained , for the reinsertion of gastrostomy tubes and the changing of the size of gastrostomy tubes. This resulted in no actual harm with a potential for serious harm that is IMMEDIATE JEOPARDY. See F 322, F328, F490, F501 Findings are: Interview with the Administrator and written memo from the Administrator , on 8/13/12, revealed : (1) " Policy for care of residents [MEDICAL CONDITION] does not exist; system of emergency practice [MEDICAL CONDITION] dislodged use Perry & Potter Manual". During an interview with the Director of Nursing on 8/13/12 she stated that there are no written policies and procedures for the care of residents with tracheostomies and gastrostomy tubes; she stated We use Perry and Potter Manual". During further interview with the Administrator, on 8/13/12, he stated that no competencies had been done for reinsertion of [MEDICAL CONDITION], should they become dislodged, or for the reinsertion of gastrostomy tubes. During further interview with the Administrator on 8/17/12 , he stated that he had consulted with the corporate office in Needham, Massachusetts, and was advised that there was no policy for tracheostomies and Gastrostomy tube replacement and " we use Perry and Potter". This interview also revealed that the Administrator was of the opinion that policies and procedures were not required as the protocol in the Perry and Potter Manual was sufficient. Interview with 2 Registered Nurses and 3 Licensed Practical Nurses, on 8/13/12 and 8/17/12(respectively) , revealed that they did not demonstrate an understanding regarding emergency care of tracheostomies or gastrostomy tubes. The Perry and Potter Manual fails to delineate staff accountability, does not designate staff responsibilities and does not indicate a system for measuring staff competency. 415.26 (b)(3)(1) . .

Based on observation, interview and record review, the facility failed to have written Policy and Procedure for Change of Gastrostomy Tube, failed to ensure staff were trained to reinsert gastrostomy tubes, failed to ensure nurse competencies were complete for the reinsertion of gastrostomy tubes. This was evident for 5 of 5 residents with gastrostomy tubes (#5,#8, #12, #31, #34). This resulted in no actual harm with potential for serious harm that is IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE.Findings include but are not limited to:1. Resident #5 is a [AGE] year old female with [DIAGNOSES REDACTED]. According to the 7/13/12 Minimum Data Set (MDS-assessment tool) this resident's cognitive status is comatose, resident is totally dependent upon staff for all aspects of activities of daily living and is unable to eat, resulting in being fed by a gastrostomy tube ([DEVICE]-a surgically placed tube directly into the stomach by which liquid nourishment is provided).Observation of Resident #5 on 8/13/12 at 2:30PM revealed this resident to be lying on her back in bed, unresponsive to verbal stimuli. A tube feeding formula of [MEDICATION NAME] 1.2 was in place on an automatic pump delivering the feeding at 50ml/hour to this resident via [DEVICE]. Review of the most recent physician's orders [REDACTED]. 25ml/hour...maximum fluids/24 hours to equal 2690ml with maximum calories/24 hours to equal 1620 calories to run continuously". In addition, "change [DEVICE] (Gastrostomy tube) per policy and reinsert 20[DEVICE] (size of the [DEVICE]) as needed."In an interview with the Director of Nursing (DON) on 8/13/12 at 2:00PM, the DON stated she was "unable to locate a policy and procedure for [DEVICE] reinsertion, we use the Perry and Potter Manual". The DON stated that she was not aware of any formal training for the nursing staff on how to reinsert [DEVICE]s; nor was she aware of a system to evaluate the competency of nurses performing the reinsertion of [DEVICE]s.In an interview with the Administrator on 8/13/12, he provided a written statement at 2:30PM that revealed "P/P do not exist for [DEVICE]s and to use the Perry and Potter Manual." Observation on 4 of 4 nursing units revealed that these manuals were not present on any of these units.2. Resident #8 has [DIAGNOSES REDACTED]. Review of the 8/10/12 Nutrition Care Plan revealed that this resident has a [DEVICE] in place to supplement calorie and protein intake.Review of current physician orders [REDACTED]. Further review of this care plan revealed no approach to change this [DEVICE]. Nurses notes revealed that this [DEVICE] has been changed by nursing staff on an as necessary basis. Nursing note of 8/7/12 stated that the [DEVICE] was changed without a physician order; a #20fr [DEVICE] was not tolerated by the resident who complained of pain upon insertion, so a #14fr [DEVICE] (smaller tube) was re- inserted. In an interview with the RN on 8/14/12 who re-inserted the [DEVICE], she stated that she had no training on re-insertion of [DEVICE]s. There is no documented evidence that the physician was notified of the resident's complaint of pain or re-insertion of a #20fr [DEVICE], or that a physician order [REDACTED].In an interview with the DON on 8/13/12 at approximately10:50AM, she stated she was no able to locate policies and procedures for re-insertion of [DEVICE]s; and was not aware of any formal training of the nurses to re-insert [DEVICE]s. She further stated she did not know of any system to evaluate the competency of nurses performing the re-insertion of [DEVICE]s.In an interview with the Administrator on 8/13/12 at approximately 2:30PM, he provided a written statement that revealed that a policy and procedure for [DEVICE]s does not exist " use Perry and Potter Manual." Observation on 4 of 4 nursing units revealed that these manuals were not present on any of these units.3. Resident #12 is a [AGE] year old male with [DIAGNOSES REDACTED].Observation of Resident #12 on 8/13/12 at 9:35AM revealed this resident to be lying on his back, non-responsive to verbal stimuli. A formula of Glucerna 1.5 tube feeding was being administered to the resident by a monitored pump via [DEVICE] at 50ml/hour. Physician orders [REDACTED]. Check residual formula in stomach every 8 hours and hold feeding if residual is over 100 ml and call physician. Keep the resident's head of bed 30 degrees or more during tube feeding". A further review of physician orders, progress notes, history and physical and nurses notes and the current care plan reveal no indication of the size of the [DEVICE]. In addition, there was no documentation regarding when to change the [DEVICE].In an interview with the DON on 8/13/12, she stated she was not aware that there was no order to change the [DEVICE]. Following surveyor intervention, the physician wrote an order on 8/13/12 "change [DEVICE] every 3 months and when needed and change [DEVICE] today." In further interview with the DON on 8/13/12, she stated that she was not aware of any policies and procedures regarding re-insertion of [DEVICE]s.We use "Perry-Potter Manual" . The DON was not aware of any formal sytem to evaluate the competency of nurses performing the re-insertion of G-tuubes.In an interview with the Administrator on 8/13/12 at approximately 2:30PM, he provided a written statement dated 8/13/12 that "P/P do not exist for [DEVICE]s and to use the Perry Potter Manual". Observation on 4 of 4 units revealed none of these units had the manual available.415.12(g)(2)

Based on observation, record review and interview, the Administrator failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident. Specifically, the Administrator failed to ensure that written policies and procedures were developed and implemented for the care of residents with tracheostomies and gastrostomy tubes. In addition, competencies had not been done for nursing staff who provided [MEDICAL CONDITION] care and re-inserted gastrostomy tubes. This resulted in no actual harm with a potential for serious harm that is IMMEDIATE JEOPARDY. See F 322, F328, F 501 Findings are: In an interview with the Administrator on 8/13/12 as well as a written memo from the Administrator on 8/13/12 it was revealed : (1) " Policy for care of residents [MEDICAL CONDITION] does not exist, use Perry & (and) Potter Manual ; system of emergency practice [MEDICAL CONDITION] dislodged use Perry & Potter Manual, (2) Policy of G (gastrostomy)Tubes does not exist, use Perry & Potter Manual ". Observations on 8/13/12 revealed that there were no Perry & Potter Manuals on 4 of 4 units ( Ulster, Dutchess, Putnam, Orange). The one Perry & Potter Manual was in the office of the Director of Nursing. During the interview with the Administrator, on 8/13/12, he stated that no competencies had been done for insertion of [MEDICAL CONDITION], should they become dislodged, or for the re-insertion of gastrostomy tubes. During further interview with the Administrator , on 8/17/12, he stated that he was of the opinion that policies and procedures are not required as the protocol in Perry & Potter Manual is available. (He was not aware that there were no Perry & Potter Manuals on the units.) During this interview, he stated that he had consulted with the corporate office, in Needham, Massachusetts, and was advised that there was no policy for tracheostomies and [DEVICE] replacement: "we use Perry and Potter". At that time regarding the current Quality Assurance (QA) practice in relation to this problem, he then stated that QA had not identified a problem. The Administrator stated that the facility did not have a problem with policies and procedures as the corporate office had informed him that use of a Perry and Potter Manual was sufficient. In an interview with the Director of Nursing on 8/13/12, she stated that there are no written policies and procedures for the care of resident with tracheostomies and gastrostomy tubes; she stated "we use Perry and Potter Manual". The Perry and Potter Manual fails to delineate staff accountability, does not designate staff responsibilities and does not indicate a system for measuring staff competency. 415.26

Based on record review and interview, the Medical Director failed to ensure that the facility had written policies and procedures related to [MEDICAL CONDITION] care and re-insertion of gastrostomy tubes; failed to ensure that nursing care services reflected current standards of care and were consistent with regulatory requirements; and failed to ensure that a system existed to monitor the performance and practices of the nursing staff providing care to [MEDICAL CONDITION] residents or those residents requiring re-insertion of gastrostomy tubes. This resulted in no actual harm with the potential for serious harm that is IMMEDIATE JEOPARDY. See F322, F 328 Findings are: The Medical Director failed to be involved in the implementation and oversight of policies, procedures, and competencies related to [MEDICAL CONDITION] care and [MEDICAL CONDITION] tube re-insertion. This was confirmed by an interview with the Medical Director on 8/15/12 which revealed that he was unaware of any policies, procedures, or competencies related to [MEDICAL CONDITION] care or re- insertion of gastrostomy tubes and had not had any input into developing or implementing policies. Interviews with an RN (Registered Nurse), 2 LPN's (Licensed Practical Nurse), and the Director of Nursing on 8/13/12 stated that they were uncertain as to how to respond in an emergency, should [MEDICAL CONDITION] become dislodged. Interviews on 8/15/12 with 2 LPN's and the Director of Nursing stated that they had received no training and had no competencies related to the re-insertion of gastrostomy tubes. During interview with the Medical Director on 8/15/12, he stated he was unaware that the LPN's, RN's, and the Director of Nursing had received no training and had had no competencies performed related to [MEDICAL CONDITION] care and re-insertion of gastrostomy tubes. 415.20

Based on observations, record review and interview the facility did not ensure that staff followed acceptable standards of nursing practice. The facility failed to ensure that; 1) the resident received the appropriate dietary consistencies and supervision in accordance with physicians orders. 2) Resident care plans, dietary flow sheets and Certified Nursing Assistant (CNA) Care Cards were consistently updated 3) Physician's Monthly Orders were transcribed to resident care plans and forwarded to the appropriate facility departments (i.e. Dietary).This was evident on 4 of 4 facility Units (Orange, Putnam, Ulster and Dutchess) and for 5 of 5 sampled residents. Specifically, Resident # 1 with a history of difficulty swallowing was not provided the supervision ordered by the Physician from ,[DATE] through 12/ 10. She subsequently expired due to choking and aspiration of a hard-boiled egg. Further, her level of assistance was upgraded on [DATE] without an order for [REDACTED].# 2 documented that he was to be supervised at all times during meals. During surveyor observation on [DATE] at 5:45pm he was observed in his room with his tray in front of him with no staff present. This resulted in actual harm for Resident #1 with the potential for serious harm for 94 residents with swallowing difficulties, mechanically altered diets that is Immediate Jeopardy for residents' health and safety and Substandard Quality of Care. Findings are: Complaint # NY 716 Resident # 1 is a [AGE] year old female with [DIAGNOSES REDACTED]. This resident had a choking episode on [DATE] that required the [MEDICATION NAME] maneuver after choking on a large amount of " magic cup " (a thick ice cream-like substance). A physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the facility In-service records provided by the facility Pharmacy regarding transcribing orders documents that "the entire ancillary orders (orders regarding diets, treatments, and Do Not Resuscitate orders) match exactly and a second edit must be done just prior to turnover (a change in monthly orders). This edit involves a second nurse checking the new Medication Administration Records (MARS) and Treatment Administration Records (TARS) to the previous ones looking for any discrepancies". Review of the resident's Annual Care Plan Meeting that took place on [DATE] revealed that the RN (Registered Nurse) Unit Manager and the SW (Social Worker) independently upgraded the resident's feeding needs and revised the CNA Care Card to reflect that the resident was independent with set up and could feed herself finger foods and required physical assistance with feeding only as needed. The CNA Care Card documented that the resident was not at risk for aspiration (inhale food or fluids into the respiratory tract). This was contrary to the current physician's orders [REDACTED]. Review of the Activities of Daily Living Flow Sheets from ,[DATE] through ,[DATE] provides documentation by the CNAs that describes varying levels of assistance required by the resident from independent to total dependence for all three meals. During an interview on [DATE] at 4:00pm the RN Unit Manager was asked if she had requested a speech evaluation prior to upgrading the resident's level of assistance. She replied "no". Further review of the medical record revealed no documentation about the Annual Care Plan meeting regarding the change made in the resident's level of assistance for feeding. It did not address the decision made by the attendees that the resident was now able to feed herself despite a physician's orders [REDACTED]. 415.11(c)(3)(i)

Based on observations, interviews and record review during an abbreviated and partial extended survey, the facility failed to have systems in place to adequately monitor and supervise residents who are at risk for choking. The facility failed to: ensure that policies and procedures were implemented to prevent accidents and injuries to residents who required supervision during meals due to known swallowing problems and to provide the proper food consistency for residents on mechanically altered diets. The facility failed 1)to follow a physician' s order to feed Resident #1 at all meals and 2) to follow the care plan requiring supervision of Resident #2 at all meals. Specifically, Resident #1 was on a mechanically altered diet due to dysphagia (difficulty swallowing) and a history of choking, and had a physician's orders [REDACTED]. This resident expired due to aspiration of a whole, peeled hard-boiled egg when she was left alone to feed herself during a breakfast meal that did not contain food items with the proper consistency. This resulted in actual harm for Resident # 1, and no actual harm with the potential for more than minimal harm for Resident #2, and the potential for serious harm for 94 residents who had swallowing difficulties and mechanically altered diets. This resulted in Immediate Jeopardy for residents' health and safety and Substandard Quality of Care. Complaint ID Number: NY 716 The findings are: 1. Resident #1 is a [AGE] year-old female with [DIAGNOSES REDACTED]. A review of the Swallowing Screen performed by the facility ' s Speech Language Pathologist (SLP) on [DATE] indicated that this resident was to be supervised and assisted at all meals, to continue the Ground Diet with extra gravy and to notify the Speech Therapist of any changes. This evaluation was ordered immediately after this resident had a severe choking episode on [DATE] that required the Heimlich maneuver after choking on a large amount of "magic cup" ( a thick ice cream-like substance). A physician's orders [REDACTED]. A review of the resident ' s Minimum Data Set (MDS)(an evaluation tool) dated [DATE] revealed that this resident was independent with decision making. The MDS further revealed that this resident required guided maneuvering of her limbs and other assistance by staff. A review of the Comprehensive Care Plan (CCP) for Nutrition dated [DATE] documents that the resident is a nutritional risk related to her [DIAGNOSES REDACTED]. The interventions included providing the resident with a Ground Diet with extra gravy and assist with meals as needed. Goals for the resident were that she will have a good food and fluid intake, maintain her weight and will not aspirate (inhale food into her lungs). The facility ' s Policy and Procedure regarding Aspiration Precautions for the residents at risk states: " POLICY: Precautions are taken to minimize the possibility of aspiration for residents that are high risk. PROCEDURE: 1. Identify residents at risk for aspiration. These include, but are not limited to the types of residents: a. without adequate gag reflux. b. with history of choking. c. with difficulty swallowing. d. receiving thickened liquids. 2. Keep the head of the bed elevated at least 45 degrees after meals. 3. Feed residents with the head of the bed elevated 90 degrees and preferably out of bed. 4. Thicken all liquids to appropriate consistency as recommended by speech therapy and ordered by the Physician. " According to the facility investigation of the incident the resident was found unresponsive by staff on [DATE] at 8:50AM. Cardio-Pulmonary Resuscitation was started and 911 Emergency was called. Attempts to revive the resident were unsuccessful as well as attempts to clear her airway. Paramedics arrived and attempted to clear her airway. They used long tongs to remove the blockage, a hardboiled egg. The resident was pronounced dead by the hospital emergency room Physician-via telephone at 9:23AM. During an interview with the assigned C.N.A on [DATE] at 1:00PM she stated she brought the breakfast tray to the resident on [DATE] and it contained a whole, peeled boiled egg and 2 pieces of toast. The C.N.A. further revealed she was not aware that Resident #1 had a swallowing problem. During a telephone interview with the attending Physician on [DATE] at 12:30 P.M. regarding Resident #1, he stated that "due to her tremors the resident was to be fed by staff." A review of the physician's order [REDACTED]. The Certified Nurse Aide (CNA #1) assigned to Resident #1 on [DATE] was interviewed on [DATE] at 1:00 P.M. She stated that she brought the resident her breakfast tray on the morning of [DATE]. The breakfast consisted of 2 pieces of toast and a whole, peeled, hard-boiled egg. The CNA added that she was not aware that Resident #1 had a swallowing problem and that the resident was to be fed. This CNA also added that this resident was a fast eater. The CNA stated she was aware that this resident had an order for [REDACTED]. A review of the Nurses Notes dated [DATE] at 8:50 A.M. revealed that a Certified Nurse Aide (CNA #2) summoned the Licensed Practical Nurse (LPN#1) to the resident ' s room after the CNA found the resident unresponsive. LPN #1 indicated in her note that " resident ' s skin was blue and skin clammy, she was without a pulse and respirations. " This note continues to document that Cardio-Pulmonary Resuscitation (CPR) was initiated and 911-Emergency was called. Paramedics arrived at 8:58 A.M. and they continued CPR until 9:23AM. The resident remained unresponsive with no cardiac rhythm or spontaneous respirations. The resident was pronounced dead at 9:23AM. by the Hospital emergency room Physician via telephone to the Paramedics. An interview was conducted with the facility ' s Medical Director on [DATE] at 11:30 A.M. The Medical Director stated that the EMT's (Emergency Medical Technicians) removed a hard-boiled egg from Resident #1 ' s airway with long tongs, as they were unable to pass an ET tube (endo-tracheal tube- artificial airway) as the airway was obstructed. The Medical Director further stated that the Medical Examiner ' s preliminary findings from an autopsy of the resident determined that Resident #1 died from "Asphyxiation by Food Bolus in Airway." The Director of Nursing (DON) was interviewed on [DATE] at 3:30 P.M. During the interview the DON stated that the facility had already identified five (5) "problems" with respect to Resident #1. This included: (1) a monthly physician's order [REDACTED].;" (4) the Activities of Daily Living Care Plan did not document that the resident was to be "fed by staff;" and (5) after the annual Comprehensive Care Plan Meeting on [DATE] with the Registered Nurse (RN) Unit Manager and the Social Worker, the original physician's order [REDACTED].#1 to be more independent with eating. The Registered Nurse (RN) Unit Manager was interviewed on [DATE] at 4:00 P.M. The RN stated that on [DATE] she attended the Annual Care Plan Meeting with the facility Social Worker. The RN explained that at this meeting they discussed the resident's improved level of assistance with feeding and the decision was made (between the RN and Social Worker) to upgrade the resident. The RN and the Social Worker determined that the resident was able to feed herself with physical assistance by staff as needed. When the RN was asked if the Physician was notified of this resident's progress and whether a Swallowing Screen was ordered, the RN replied " no. " Review of the C.N.A. Care Guide dated [DATE] revealed the resident was now able to feed herself, was independent with tray set-up and was not at risk for aspiration. The Director of Rehabilitation was interviewed on [DATE] at 9:40 A.M. She stated that if staff want to "upgrade" a resident (make a change in the resident's level of assistance with feeding where less supervision is required) they must first have a Swallowing Evaluation performed for that resident. The DON was re-interviewed on [DATE] at 10:15 A.M. regarding the upgrading of residents ' assistance with feeding. The DON stated anyone on staff can " downgrade " a resident (requiring more assistance with feeding) but only the Physician or the Speech Language Pathologist (SLP) can upgrade a resident per the facility Policy and Procedure on Diets. Review of this Policy and Procedure includes but not limited to:"1.Nursing, Dietary, Occupational and Physical Therapy/Speech therapy may make recommendations about diets, but all diets must be ordered by the attending Physician and recorded in the resident's record. 2. Nursing is responsible for forwarding resident information by way of a "Dining Services and Nutrition Communication Form". An interview was conducted with the Dietary Technician (DT) on [DATE] at 9:50 A.M. The DT stated that the resident had a good appetite, her weight was stable and she saw the resident in the dining room feeding herself. She added that the resident frequently went to the facility ' s Cafe for snacks. When asked if the resident was supervised while eating at the Cafe, the DT replied "no." The DT further revealed she was unaware that the resident was supposed to be fed by staff. The Administrator was interviewed on [DATE] at 4:00 P.M. He stated " there were things we could have done better. " In a further interview on [DATE] at 3:00PM, the Administrator revealed that he was of the opinion that a " hard boiled egg is a finger food." 2.Resident #2 has [DIAGNOSES REDACTED]. A Swallowing Evaluation was performed for this resident on [DATE] by the SLP. The SLP made the following recommendations regarding this resident: (1) needs cues and supervision at all times during all meals; (2) diet is Ground Moist with no bread and Nectar Thick Liquids; (3) resident is to be up in a chair for all meals; (4) resident is an Aspiration Risk; and (5) during consumption of meals this resident is to follow the SLP ' s instructions which are to " put the spoon down and swallow before the next bite of food, take small sips of liquids, tuck chin and double swallow fluids and staff to check the resident ' s Left Cheek for pocketing" The Physician concurred with these recommendations. Resident #2 ' s Dietary Care Plan and CNA Care Card documented that the resident is to be supervised at all times for meals, requires cues during eating and swallowing, on aspiration precautions and diet is Ground moist, no bread, and with nectar thick liquids. The resident is to be out of bed for all meals and the SLP directions to be followed. The Physician concurred by his initials on the Swallow Evaluation recommendations form. During observation of the facility ' s dinner meal on [DATE] at 5:45 P.M. Resident # 2 was observed in his room. The resident was sitting in a chair eating his meal, which was in front of him on a table. No staff members were present as he ate his food. Immediately after this observation, the Charge Nurse was asked if Resident # 2 required supervision and assistance during meals. The Charge Nurse replied " Yes he should. " 415.12(h)(1)

Based on record review and staff interviews, the facility failed to ensure that residents received food in the appropriate form as ordered by the physician. This was evident for 1 of 5 residents reviewed during an abbreviated survey. (Resident #1). Specifically, Resident #1 did not receive food in the ground form as ordered by the physician. The resident received a whole, peeled, boiled egg on her breakfast tray and aspirated ( inhale food or fluid into the respiratory tract). Paramedics were able to remove the egg with tongs. The resident never regained consciousness and subsequently expired. This resulted in actual harm for Resident #1 with the potential for serious harm for 94 residents with swallowing difficulties, mechanically altered diets that is Immediate Jeopardy for residents' health and safety and Substandard Quality of Care. Findings are: Complaint # NY 716 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0(MDS- a resident assessment tool) dated 11/5/10 documented the resident was on a mechanically altered diet. Review of the Comprehensive Care Plan (CCP) for Nutrition Risk dated 8/10/10 documented the "resident is to be fed by staff at times" based on chewing and swallowing issues. The goal for this resident was that she will not aspirate. Review of the Nutrition Care Progress Notes written by the Dietary Technician (DT) dated 11/11/10 reveal the resident feeds herself with supervision and physical assist of staff at times. It further documents she saw the resident eating snacks at the facility's cafe. During an interview with the DT on 12/31/10 at 9:50 AM she revealed she was not aware the resident was to be fed by staff but she stated she observed Resident #1 eating candy and pretzels in the cafe. Review of the most recent Physician's orders revealed the resident was on a ground diet with extra gravy. It further documented the resident was to be fed by staff for meals. This order was consistently renewed on the monthly orders from 12/2009 through 12/2010. Review of the facility policy entitled " Dietary Consistencies and Descriptions" for the Ground diet revealed all egg items must be ground. Review of the Certified Nursing Assistant (C.N.A.) Care Card documents the resident "feeds herself especially when eating finger foods" and is not at risk for aspiration. The diet consistency listed on the CNA care card states "ground with extra gravy". The Incident/Accident report states the resident was found unresponsive by staff on 12/29/10 at 8:50AM. Cardio-Pulmonary Resuscitation was started and 911 Emergency was called. Attempts to revive the resident were unsuccessful as well as attempts to clear her airway. Paramedics arrived and attempted to clear her airway. They used long tongs to remove the blockage, a hardboiled egg. The resident was pronounced dead by the hospital emergency room Physician-via telephone at 9:23AM. During an interview with the assigned C.N.A on 12/31/10 at 1:00PM she stated she brought the breakfast tray to the resident on 12/29/10 and it contained a whole, peeled boiled egg and 2 pieces of toast. The C.N.A. further revealed she was not aware that Resident #1 had a swallowing problem. During an interview with the Medical Director on 12/30/10 at 11:30AM he stated that the Medical Examiner performed an autopsy and the cause of death was "asphyxiation by food [MEDICATION NAME]". According to review of the "American Dietetic Association, Food lists for Dysphagia- Mechanically Altered Diet", copyright 2002, hard-boiled eggs are to be avoided. It further documents that foods are to be moist, with small pieces to make them easy to chew and easy to swallow. 415.14(d)(3)

The Administrator failed to ensure that the facility was administered in a manner that enables the facility to use it resources effectively and efficiently to attain or maintain the highest practicable physical , mental, and psychosocial well-being of each resident. This resulted in actual harm for Resident #1 with the potential for serious harm for 94 residents with swallowing difficulties, mechanically altered diets that is Immediate Jeopardy for residents' health and safety . Findings are : The Administrator failed to ensure that the facility operates in a manner that enables it to effectively use it resources to maintain the highest practicable well-being and safety of each resident. Specifically, the facility Administrator failed to ensure adequate supervision was provided for Resident #1 identified as an Aspiration Risk and for 94 other residents with swallowing difficulties and with mechanically altered diets.. The Facility Administrator failed to ensure that the Nursing Staff , Certified Nursing Aides and Dietary Staff were knowledgeable of their job duties and performed monitoring responsibilities in a manner that ensured that residents requiring varying degrees of supervision, received the appropriate level of supervision .The facility Administrator failed to ensure that the Nursing Staff ,Certified Nursing Aides and Dietary Staff verified meal consistency for residents and that the residents received the correct meal consistency. During an interview with the Administrator on 12/30/2010 at 3:30pm he stated " we could have done things better". 415.26