Every finding on record at The Pines at Catskill Center for Nursing & Rehab

Based on record review and interviews conducted during recertification and abbreviated (Case # NY00376034) survey, the facility failed to ensure residents were free from neglect for one (1) (Resident #5) of three (3) residents reviewed for neglect. Specifically, on 03/24/2025, Certified Nurse Aide #1 did not use a two-person assist for transfer mobility as required in Resident #5's Comprehensive Care Plan while transferring the resident. Certified Nurse Aide #1 attempted to transfer the resident without assistance from another staff member. Resident #5 fell onto the floor and sustained fractures (bone breaks) to both legs. This resulted in actual harm that was not Immediate Jeopardy.This is evidenced by:The Policy and Procedure titled, Abuse, last revised December 2023, documented that each resident had the right to be free from abuse, neglect and misappropriation of resident property and exploitation. This included but was not limited to freedom from corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's symptoms. It was the philosophy of all the National Health Care Associates facilities to encourage an environment that recognized the special qualities of their residents and provide them with a safe environment. The policy further documented that neglect meant the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish, or emotional distress.Resident #5 was admitted to the facility with diagnoses including heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), osteoarthritis of hip (a condition where the cartilage in joints gradually wears away, leading to pain, stiffness, and reduced mobility), and unspecified glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging the optic nerve). The Minimum Data Set (an assessment tool) dated 03/11/2025, documented the resident was cognitively intact, could be understood, and could understand others. The Care Plan for Daily Living initiated 07/27/2022, documented Resident #5 was dependent on physical assistance from two (2) or more staff to perform transfers.The Facility Investigation dated 03/24/2025, documented Resident #5 required the assistance of two (2) nursing staff to transfer the resident in and out of bed. It further documented that on 03/24/2025 at approximately 7:20 AM, Certified Nurse Aide #1 attempted to transfer the resident from their bed to a chair without the assistance of another staff member. During the transfer attempt, Resident #5 was unable to follow Certified Nurse Aide #1's directions; the resident fell to the floor with slide assistance from Certified Nurse Aide #1. Licensed Practical Nurse #4 assisted Certified Nurse Aide #1 in calling Registered Nurse #2 to come and assess Resident #5. Resident #5 reported pain at the time of the event; the physician was notified as well as the family, and the resident was transferred to the hospital for further evaluation. The facility investigation report documented that hospital records confirmed Resident #5 sustained fractures (bone breaks) in both legs. The facility's investigation report documented that Certified Nurse Aide #1 did not follow Resident #5's care plan. Certified Nurse Aide #1 was suspended immediately and taken out of work during the investigation. Certified Nurse Aide #1 was terminated after choosing to not return to work. Record review of a Facility Incident Report submitted to the New York State Department of Health on 03/24/2025 at 4:08 PM, documented that on 03/24/2025 at 7:20 AM, Resident #5 was being transferred by Certified Nursing Aide #1 from their bed to their chair, the transfer was unsuccessful, and the resident was lowered to the floor. The report further documented that the resident had not been moved due to complaints of back pain and was displaying non-verbal signs of discomfort as well. Emergency Medical Services was called, and the resident was sent to the hospital for evaluation.An Investigation Statement dated 03/24/2025 written by Certified Nurse Aide #1 acknowledged they were aware Resident #5 required two (2) staff for transfer, however, they thought they were capable of providing the care by themself.A Hospital Radiology Report dated 03/24/2025 documented Resident #5 had an intertrochanteric femur fracture (a break in the upper part of the thigh bone) in their right leg, and a distal femoral meta-diaphyseal fracture (a break in the thigh bone) in their left leg.The hospital discharge paperwork dated 04/08/2025 documented Resident #5's plan of care summary listed the diagnoses of closed intertrochanteric fracture of right femur, closed bicondylar fracture of distal end of left femur (break in the lower part of the thigh bone), status post left hip gamma nail and right open reduction internal fixation surgery (hip surgery).A Nursing Note dated 03/24/2025 at 3:28 PM documented Licensed Practical Nurse #5 had called the hospital where Resident #5 was sent in order to give report to the hospital staff regarding what had happened to Resident #5 and was informed that the resident was admitted with a urinary tract infection, and fractures of the right femur and left hip. The note further documented that Family Member #5 was updated.Record review revealed the aforementioned nursing note dated 03/24/2025 at 3:28 PM incorrectly identified the left hip as being fractured. Instead, it was the left leg, per the aforementioned hospital radiology report.A Survey Preparedness Cheat Sheet Inservice dated 03/27/2025, listing topics of oxygen safety, handwashing, documentation, and Accident and Incidents, was provided with 60 employee signatures. There was no documented evidence that the aforementioned completed in-service included reading the Kardex (resident care card used by Certified Nurse Aides to provide care) or of patient transfer and handling safety was completedDuring an interview on 07/02/2025 at 11:41 AM, Resident #5 stated they did not remember the incident at all. Resident #5 stated that they thought they were in the bathroom but was told they were in the bedroom. Resident #5 stated that they might have blacked out because they did not remember any of it and had tried to.During an interview on 07/02/2025 at 11:20 AM, Registered Nurse #1 stated that they were not in the building at the time of the incident. Registered Nurse #1 stated that they expected their staff to check resident's Kardex (resident care card used by Certified Nurse Aides to provide care) every day and consider resident safety when providing care or attempting to move them. They stated that if a resident was physically on the floor, the expectation would be to assure the resident's safety, call for help, and not try to move them until they were assessed. Registered Nurse #1 stated that those were very clear expectations that all their staff should follow. When asked how often the rules were reviewed, Registered Nurse #1 stated that they went over the rules when incidents happened and as needed when problems were seen. They stated that abuse and expectations were also covered in annual staff education training.During an interview on 07/02/2025 at 11:25 AM, Certified Nurse Aide #2 stated they would check the Kardex to see what assistance a resident required prior to providing care. Certified Nurse Aide #2 stated they would not move a resident by themselves if the resident required two (2) person staff assistance. They further stated that if they found a resident on the floor, or if a resident fell while moving them, they would call for a nurse, not move them, and make sure the resident was okay until help arrived.During an interview on 07/03/2025 at 9:19 AM, Medical Director #1 stated that Resident #5 was admitted to the facility with difficulty transferring and was a two (2) person assist for transfers. Medical Director #1 stated that they had to call the unit before the interview to refresh their memory. Medical Director #1 stated that in the incident, one (1) Certified Nurse Aide was helping Resident #5, and the resident fell. Medical Director #1 stated that there was a quick root cause analysis of the incident done and it was determined that the problem was because Certified Nurse Aide #1 did not follow the care plan. They further stated that Resident #5's fall risks were known, and care planned for, preventions were in place to prevent reoccurrences, the incident would continue to be discussed, and the quality assurance committee would continue to discuss how to avoid any repeat issues.During an interview on 07/03/2025 at 9:56 AM, Director of Nursing #1 stated that they were out on medical leave when Resident #5 was injured. When Director of Nursing #1 returned to work, they were informed of what happened. Director of Nursing #1 stated that their understanding was that Certified Nurse Aide #1 was suspended at the time of the incident, and was so upset by what happened, that they never returned to the building. Director of Nursing #1 stated that there was facility-wide education done on abuse, Kardex reading and in following care plans that indicate 2-person assistance for transfers. Director of Nursing #1 stated that it was the facility's expectation that staff would check resident's care card and ensure resident safety when providing care.During an interview on 07/03/2025 at 11:51 AM, Administrator #1 stated the incident happened very quickly, and Registered Nurse #4, the nurse supervisor at the time, called them immediately, and there was no delay in sending the resident to the hospital. Administrator #1 stated they had reported it to the New York State Department of Health as required and believed that the aide had made a bad decision and had never had any issues at the facility prior to this event. Administrator #1 stated that there was a facility-wide education on care planning and looking at a resident's care card before providing care. 10 New York Codes, Rules, and Regulations 415.4(b)

Based on interview and record review conducted during the recertification survey, the facility did not use the services of a Registered Nurse for at least eight (8) consecutive hours a day, seven (7) days a week. Specifically, a review of staffing revealed a Registered Nurse was not scheduled for eight (8) consecutive hours on 1/25/2025.This is evidenced by:The Facility's Policy and Procedure titled Quality of Life - Accommodation of Needs, issued 9/2024, documented, the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed as needed throughout the residents stay in the facility. Staff shall interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity. Resident #7 was admitted to the facility with diagnosis of Parkinson's Disease (a progressive neurological disorder that primarily affects movement, but also involves non-motor symptoms like cognitive and emotional changes); Cerebral Palsy (group of neurological conditions that affect movement and posture); and profound mental retardation (the presence of significantly sub average general intellectual functioning). The Minimum Data Set (an assessment tool) dated 3/05/2025 documented the resident's cognition was unable to be assessed, but they usually were able to be understood and understand others. The Comprehensive Care Plan titled, Communication, dated 4/24/2025, documented Resident #7 has a communication problem. Goal: Resident #7 will maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, writing messages. Problem: Resident has Cerebral Palsy. Goal: The resident will be able to function at the fullest potential possible as outlined by the treatment team.During an observation on 6/26/2025 at 12:20 PM, Resident #7 was observed in their room eating lunch independently with adaptive utensils. Resident with food in lap, clothing and face. Resident did not respond when writer said hello.During an observation on 6/27/2025 at 11:14 AM, resident observed sitting in their room while activities were taking place in the common area. Resident did not respond to greetings, did not respond to queries of how are you? What is your name? do you need anything? Resident #7 made no attempts to speak, but did make eye contact with writer.During an observation on 7/02/2025 at 12:01 PM, Resident #7 was observed in the main dining room on first floor. Resident #7 was sitting at a table alone near window. Activities Director #1 was observed attempting to have conversation with Resident #7. Resident #7's responses were delayed and could not be understood.During an interview on 7/02/2025 at 11:08 AM, Licensed Practical Nurse #6 stated Resident #7 had been a resident for many years; staff were familiar with resident's routine and needs. Resident made some grunts and responds to yes/no questions. Resident did not have a communication board. During an interview on 7/02/2025 at 12:01 PM, Activities Director #1 stated Resident #7 did best with one-to-one activities or engagements. Resident #7 did not like to be around others. When attempt to include Resident #7 in group activities, Resident #7 would push others away. Activities consists of coloring and watching television.During an interview on 7/02/2025 at 12:24 PM, Director of Rehabilitation #1 stated Resident #7 no longer attended speech language therapy. The last time they attended speech language therapy was in 2021 for evaluation and treatment of dysphagia (difficulty swallowing). Director of Rehabilitation #1 stated Resident #7 did not have a communication board or any other adaptive device for commutation. Communication had not been addressed since resident admitted several years ago. Staff communicate using closed ended yes/no questions. During an interview on 07/02/2025 at 12:57 PM, Director of Nursing #1 stated resident was able to make their needs known. The staff were familiar with resident and could understand them. If a new or agency staff were on the unit, they would ask another staff member to assist with communicating with resident. Director of Nursing #1 stated they were not sure whether Resident #7 had a communication board. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

Based on observation, record review, and staff interviews conducted during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the facility did not ensure that two (2) of five (5) trash bins were pest and rodent-proof by having damaged/broken lids. This was evidenced by:During an observation of the trash collection area on 7/02/2025 at 11:05 AM, two trash bins had broken lids and were unable to be fully closed, preventing the disposal of garbage and refuse appropriately, and were pest and rodent-proof.During an interview on 7/02/2025 at 11:30 AM, Director of Maintenance #1 stated that they usually contacted the refuse company to have them replaced periodically because they got broken. They stated that they were unsure of the last time that they had to be replaced. 10 New York Codes of Rules and Regulations 814.14(h)

Based on record reviews and interviews conducted during the recertification survey (NY00376034), the facility did not develop and implemented comprehensive person-centered care plans for each resident that included measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (2) (Resident #'s 5 and 27) of 28 residents reviewed for care plans. Specifically, (a.) Resident #5 was care planned for 2- person assist for when transfer. Certified Nurse Aide #1 did not follow care plan resulting in Resident #5 falling and breaking both legs; (b.) Resident #27 had difficulty hearing and had hearing aids. There was no documented evidence that a comprehensive person-centered care plan was developed and implemented for their hearing impairment. This is evidenced by:A facility policy and procedure titled, Baseline/Comprehensive Person-Centered Care Plan dated 3/2023, documented that the comprehensive care plan would utilize the process to address resident strengths, needs and/or problems as identified on the admission discharge summary, as well as other professional assessments and orders from the healthcare provider, dietary team, therapy, social services and Preadmission Screening and Resident Review (PASARR) and Minimum Data Set. The Person-Centered Care Plan was developed to include information necessary to properly care for the resident and would address the resident's preferences, goals, desired outcomes, and plan for discharge. All clinical department heads were responsible to ensure that there was a system for monitoring implementation of the resident care plans. This was accomplished via quality assurance auditing, observation on rounds, and interview with staff, residents, and families. Corrective action would be carried out when problems with implementation of care plans have been modified. Resident #5:Resident #5 was admitted to the facility with diagnoses of heart failure (a condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), osteoarthritis of hip (a condition where the cartilage in joints gradually wears away, leading to pain, stiffness, and reduced mobility), unspecified glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging the optic nerve). The Minimum Data Set (an assessment tool) dated 3/11/2025, documented the resident was cognitively intact, could be understood and could understand others. The Comprehensive Care Plan for Daily Living, initiated 7/27/2022, documented Resident #5 was dependent on physical assistance from two (2) or more staff to perform transfers. The care plan was updated 4/09/2025 to include that Resident #5 required a mechanical lift for transfers with two (2) staff and was dependent of two (2) staff members for all mobility-based activities of daily living. The Facility Investigation, dated 3/24/2025, documented Resident #5 required the assistance of two (2) nursing staff to transfer the resident in and out of bed. It further documented that on 3/24/2025 at approximately 7:20 AM, Certified Nurse Aide #1 attempted to transfer the resident from their bed to a chair without the assistance of another staff. During the transfer attempt, Resident #5 was unable to follow Certified Nurse Aide #1's directions; the resident fell to the floor with slide assistance from Certified Nurse Aide #1. Licensed Practical Nurse #4 assisted Certified Nurse Aide #1 in calling Registered Nurse #2 to come and assess Resident #5. Resident #5 reported pain at the time of the event; the physician was notified as well as the family, and the resident was transferred to the hospital for further evaluation. The facility investigation report documented that hospital records confirmed Resident #5 sustained fractures (bone breaks) in both legs. The facility's investigation report documented that Certified Nurse Aide #1 did not follow Resident #5's care plan. Certified Nurse Aide #1 was suspended immediately and taken out of work during the investigation. Certified Nurse Aide #1 was terminated after choosing to not return to work. An Investigation Statement dated 3/24/2025 written by Certified Nurse Aide #1 documented that Certified Nurse Aide #1 acknowledged they were aware Resident #5 required two (2) staff for transfer, however, they thought they were capable of providing the care by themself. Resident #27:Resident #27 was admitted with diagnoses of type 2 diabetes (a dysfunction of the endocrine system causing inability to regulate blood sugar), bilateral hearing loss, and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact, could be understood, and understand others.The Minimum Data Set, dated [DATE] also documented that Resident #27 had hearing aids and glasses. The Comprehensive Care Plan initiated 7/02/2025, after the hearing aids were pointed out to the floor staff, documented that Resident #27 had a communication problem, hearing deficit. The goal documented that the resident would be able to communicate needs daily through the review date. The interventions documented refer to ear nose and throat doctor, refer to speech therapy for evaluation and treatment as needed or ordered, and allow adequate time to respond, repeat as necessary and do not rush.There was no documentation regarding the use of hearing aids by Resident #27.During an interview on 7/02/2025 at 11:20 AM, Registered Nurse #1 stated that they were unaware that Resident #27 had hearing aids and if they did, the care plan should have reflected that.During an interview on 7/02/2025 at 12:00 PM, Registered Nurse #1 stated that family had brought in hearing aids but did not tell the staff which was why they did not know. Resident #27 knew how to use them, changed the battery for Registered Nurse #1. Registered Nurse #1 stated they would update the resident's care plan now that they knew.During an interview on 7/02/2025 at 11:25 AM, Certified Nurse Aide #2 stated they would check the Kardex (resident care card used by Certified Nurse Aides to provide care) to see what assistance a resident required prior to providing care. Certified Nurse Aide #2 stated that they did not normally take care of Resident #27. On the occasions where they did need to help care for Resident #27, they did not recall needing to yell to make sure the resident heard them. Certified Nurse Aide #2 stated they did not know if they had a hearing aid.During an interview on 7/03/2025 at 9:19 AM, Medical Director #1 stated that Resident #5 was admitted to the facility with difficulty transferring and was a two (2) person assist for transfers. Medical Director #1 stated that in the incident, one (1) Certified Nurse Aide was helping Resident #5, and the resident fell. Medical Director #1 stated that there was a quick root cause analysis of the incident done, and it was determined that the problem was because the Certified Nurse Aide did not follow the care plan. They further stated that Resident #5's fall risks were known, and care planned for, preventions were in place to prevent reoccurrences, the incident would continue to be discussed, and the quality assurance committee would continue to discuss how to avoid any repeat issues. During an interview on 7/03/2025 at 9:56 AM, Director of Nursing #1 stated that they were not there when Resident #5 was injured. When Director of Nursing #1 returned to work, they were informed of what happened. Director of Nursing #1 stated that their understanding was that Certified Nurse Aide #1 was suspended at the time of the incident, and was so upset by what happened, that they never returned to the building. Director of Nursing #1 stated that there was facility-wide education done on abuse, Kardex (resident care card used by Certified Nurse Aides to provide care) reading and in following care plans that indicate two (2)-person assistance for transfers. Director of Nursing #1 stated that it was the facility's expectation that staff would check resident's care card and ensure resident safety when providing care. Director of Nursing #1 stated that Resident #27's family had brought in hearing aids recently, but did not tell the staff. Director of Nursing #1 could not speak to how long the hearing aids had been being used by the resident. When asked how it could be possible that staff would have been interacting with the resident frequently throughout the day and not notice hearing aids in Resident #27's ears, Director of Nursing #1 stated that they did not understand how it could have been missed. During an interview on 7/03/2025 at 11:51 AM, Administrator #1 stated that they believed that the aide had made a bad decision and had never had any issues at the facility prior to this event. Administrator #1 stated that there was a facility-wide education on care planning and looking at a resident's care card before providing care. 10 New York Codes, Rules, and Regulations 415.11(c)(1)

Based on observation and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) (Passport unit) of three (3) medication carts reviewed. Specifically, (a.) two (2) open multi-dose Humalog (insulin) vials were not labeled with a resident's name and (b.) one (1) open multi-dose bottle of Lantus (insulin) was not clearly marked with an open date. This is evidenced by:During an observation on 6/30/2025 at 9:07 AM, the medication cart on the Passport unit was reviewed. Two opened multi-dose vials of Humalog were found in the first draw of the medication cart. A labeled multi-dose bottle of Lantus was also found with an unclear opened date. During an interview on 6/30/2025 at 9:07 AM, Licensed Practical Nurse #3 stated they were unable to state if the open date on the bottle of Lantus was 6/04/2025 or 6/11/2025. They also stated the two bottles of Humalog were pulled out of the emergency stock because a resident's medication had not yet arrived from pharmacy. They stated a resident name label should have been put on the bottles and stated each resident had a page of adhesive stickers with their names on it in each respective binder.During an interview on 7/02/2025 at 12:07 PM, Registered Nurse #1 stated that when a vial of insulin is taken out of the emergency stock for a resident, it should be immediately labeled. They stated that a vial of insulin, though multi-dose, should only be used for one resident and absolutely should not be shared among residents.During an interview on 7/02/2025 at 1:36 PM, Director of Nursing #1 stated that vials should be labeled with the resident's name when pulled from the emergency stock. They stated that opened dates should be clearly marked on each pen and vial. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation and interviews conducted during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in four (4) of four (4) resident unit nutrition rooms and the central kitchen. Specifically, the area of the main kitchen and resident kitchenettes was not clean. This is evidenced by:During the initial inspection in the central kitchen on 6/26/2025 at 11:20 AM, coffee cups, containers, pots, and trays were put away wet and contained moisture.During an inspection in the central kitchen on 7/02/2025 at 10:45 AM, the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried. Containers, pots, and trays were put away wet and contained moisture.During an observation on 7/02/2025 at 11:00 AM, the 3rd floor west unit nutrition room had a microwave that was unclean with dirt and particles, cabinet doors and handles were broken and unsecured, counters were covered with dirt and debris, dirt and grime were on the edge of cupboards and drawers, and a staff persons orange drink was in a cupboard.During an observation on 7/02/2025 at 11:08 AM, the 3rd floor east unit nutrition room had a microwave that was unclean with dirt and grime.During an observation on 7/02/2025 at 11:13 AM, the 2nd floor east unit nutrition room had a microwave that was unclean with dirt and particles, a refrigerator seal had dirt and grime, and the bottom of the refrigerator was not cleaned and had spilled substance.During an observation on 7/02/2025 at 11:17 AM, the 2nd floor west unit nutrition room had counters that were covered with dirt and debris, and the toaster was uncleaned with dirt and debris.During an interview on 7/02/2025 at 11:45 AM, Director of Food Services #1 stated that their staff was responsible for the overall cleanliness of the nutrition rooms. They stated they would have to have the staff be more diligent in cleaning the equipment and kitchen areas. They stated that the individual who was washing the pots, pans, and containers did not let them dry thoroughly and put them away too soon, as it takes several hours to fully dry. They stated that they have not received any complaints about the cleanliness of the rooms, and the staff were expected to clean the areas within the rooms. They stated that staff should not be placing their personal drinks in the cupboard, as they have an area where they could store those items. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation and staff interviews during a recertification survey, the facility did not ensure a safe, comfortable home-like environment, and effective housekeeping and maintenance services were not maintained for four (4) of four (4) resident units. Specifically, lighting fixtures on all units were unclean and had deceased bugs within covers, and windows on units were unclean and had dirt and debris. During an observations on [DATE] at 9:45 AM, multiple lighting fixtures on the 2nd and 3rd East and [NAME] units, main corridor, and near the nursing supervisor's office had dirt, debris, and deceased bugs within the lighting covers. The windows on either end of the hallways on each unit had dirt, debris, and cobwebs on the window sills and corners of the windows.During an interview on [DATE] at 11:46 AM, Housekeeper #1 stated that the windows were supposed to be cleaned every week. They stated that the night shift sometimes leaves the windows open at night, and the bugs came into the building. They stated that the rooms were cleaned every day with sweeping, mopping, and dusting. They stated that one room a day was scheduled for a deep cleaning as per the supervisor. Housekeeper #1 stated that they had never been asked to clean the lighting fixtures, and they were unsure whether or not they were supposed to.During an interview on [DATE] at 12:15 PM, Director of Maintenance #1 stated that the cleaning of the lighting fixtures was the responsibility of housekeeping. They stated that they did have a contract with a local pest company to come in and fumigate the facility for bugs. They stated that the last time they were at the facility was on [DATE] and were due to come in for service soon.During an interview on [DATE] at 12:30 PM, Director of Housekeeping #1 stated it was the responsibility of all housekeeping aides to perform routine tasks to ensure the cleanliness of assigned areas of the facility. They stated that housekeeping aides' primary responsibility included, but were not limited to, dusting halls, offices, resident rooms, recreation rooms, lounges, washing walls, windows, window frames, tiles, door frames, and other high areas. They stated that it was the responsibility of the maintenance department to ensure that the lighting fixtures were cleaned and free of dirt and debris. During an interview on [DATE] at 12:45 PM, Director of Maintenance #1 stated they would take on the responsibility to ensure that the lighting fixtures were cleaned regularly. Director of Maintenance #1 was shown the lighting fixtures in the main hallway and the ones near the nursing supervisor's office, and they agreed that they should have been cleaned. 10 New York Codes of Rules and Regulations 415.5(h)(2)

Based on record review and interview conducted during a recertification and abbreviated survey (Case # NY00344590), the facility did not ensure each resident was free from misappropriation of resident property and exploitation for one (1) (Resident #136) of three (3) residents reviewed. Specifically, a former Certified Nurse Aide took property from Resident #136 after they had died without permission.This is evidenced by: Resident #136 was admitted with the diagnoses of respiratory failure with hypoxia (occurs when the lungs cannot adequately oxygenate the blood, leading to low blood oxygen levels), chronic congestive heart failure (a long-term condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and congestion in various parts of the body), and chronic kidney disease (a condition where the kidneys are damaged and lose the ability to filter blood effectively, leading to a buildup of waste and excess fluid in the body). The Minimum Data Set (an assessment tool) dated [DATE], documented that the resident had intact cognition, could be understood, and understand others.The Facility's Abuse Policy and Procedure, revised 12/2023, documented that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Misappropriation of property was defined in the policy as: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy further documented that staff would refrain from all actions that could be considered abuse, mistreatment, and/or neglect.The Facility's Investigative Report dated [DATE] documented that Administrator #2 was notified by Director of Housekeeping #1 on [DATE] that they had concerns that Certified Nurse Aide # 3 wanted to retrieve items, a watch and bracelet, from Resident #136's personal belongings before they packed the room up for the resident's family. Administrator #2 and Director of Housekeeping #1 searched the packed belongings on [DATE], and the mentioned items were not present in the box. Administrator #2 met with Certified Nursing Aide #3 and inquired about the items. Certified Nurse Aide #3 stated that they purchased the items for Resident #136 and retrieved them without permission. They stated that they felt they could take them back as they purchased the items for Resident #136but could not provide proof that the purchase was made. Administrator #2 instructed Certified Nurse Aide #3 to return the items immediately, which they did on the evening of [DATE], and were terminated at that point.An attempted interview on [DATE] at 1:15 PM with Administrator #2 was unsuccessful, and no return phone call was made.An attempted interview on [DATE] at 1:20 PM with Certified Nurse Aide #3 was unsuccessful, and no return phone call was made.Past Non-compliance -F602 Based on the following corrective action taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance with this specific regulatory requirement at the time of this survey: A thorough investigation was completed, and it was determined there were no other victims of misappropriation. The misappropriated property was returned and given to the resident's family. The family expressed no other concerns at that time. The alleged perpetrator was terminated and not permitted entrance to the facility to protect the residents from further misappropriation. The incident was reported appropriately to the State Survey Agency. Education was provided on [DATE] to all facility staff on abuse, abuse reporting, misappropriation of property, exploitation, and updated facility policy and procedures. At the time of the survey, there were no additional incidents of misappropriated personal property identified. 10 New York Codes, Rules, and Regulations: 415.4(b)

Based on record review and interview conducted during a recertification and abbreviated survey (Case # NY00344590), the facility did not ensure they reported the results of all investigations to the administrator or their designated representative, and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one (1) (Resident #136) of three (3) residents reviewed. Specifically, a 5-day investigation report was not submitted to the state agency. This is evidenced by: Resident #136 was admitted with the diagnoses of respiratory failure with hypoxia (occurs when the lungs cannot adequately oxygenate the blood, leading to low blood oxygen levels), chronic congestive heart failure (a long-term condition where the heart struggles to pump enough blood to meet the body's needs, leading to fluid buildup and congestion in various parts of the body), and chronic kidney disease (a condition where the kidneys are damaged and lose the ability to filter blood effectively, leading to a buildup of waste and excess fluid in the body). The Minimum Data Set (an assessment tool) dated 3/06/2024, documented that the resident had intact cognition could be understood, and understand others.The facility's Abuse Policy and Procedure, revised 12/2023, documented that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Misappropriation of property was defined in the policy as: the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy further documents that staff will refrain from all actions that could be considered abuse, mistreatment, and/or neglect.The facility's investigative report dated 6/07/2024 documented that the Administrator #2 was notified by Director of Housekeeping #1 on 6/06/2024 that they had concerns that Certified Nursing Aide # 3 wanted to retrieve items (a watch and bracelet) from Resident #136's personal belongings before they packed the room up for the resident's family. Administrator #2 and Director of Housekeeping #1 searched the packed belongings on 6/07/2024, and the mentioned items were not present in the box. Administrator #2 met with Certified Nursing Aide #3 and inquired about the items. Certified Nurse Aide #3 stated that they purchased the items for Resident #136 and retrieved them without permission. They stated that they could take them back as they purchased the items for Resident #136 but could not provide proof that the purchase was made. Administrator #2 instructed Certified Nurse Aide #3 to return the items immediately, which they did on the evening of 6/07/2024, and were terminated at that point.A review of the facilities investigation documents showed that the facility did report the incident on 6/07/2024 at 12:47 PM through the electronic Nursing Home Facility Incident Report program.A review of the facilities investigation documents showed that a thorough investigation and education were completed. The outcome of the investigation was not submitted to New York State through the electronic Nursing Home Facility Incident Report program within 5 days as required.During an interview on 7/02/2025 at 1:00 PM, Administrator #1 stated that if the investigation findings were sent, the report would have been in their investigation file. They stated that they would expect that if it were done, then it would have been in the file. They stated that if the report of submission was not in the folder, then it must not have been done. Administrator #1 stated that the only person who would have known that it was completed was Administrator #2.An attempted interview on 7/02/2025 at 1:15 PM with Administrator #2 was unsuccessful, and no return phone call was made. 10 New York Codes of Rules and Regulations 483.12 (C)(4)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that is in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preference for three (3) (Resident #'s 41, 128, and 245) of six (6) residents reviewed for oxygen administration. Specifically, (a.) for Resident #'s41 and 245, supplemental oxygen tubing was not dated and labeled to reflect when the tubing was changed; and (b.) for Residents #128 and #245, nebulizer equipment was not stored in a proper manner. This is evidenced by: The policy and procedure titled, Oxygen Concentrator Maintenance, revised 4/2023, documented tubing is to be changed weekly. The policy and procedure titled, Nebulizer Treatments, revised 2/2023, documented after the nebulizer treatment was completed, the reservoir was to be disconnected from the compressor, cleaned per manufacturer’s instructions, and placed in a plastic bag. Resident #41: Resident #41 was admitted to the facility with diagnoses of respiratory failure with hypoxia (occurs when the lungs cannot adequately oxygenate the blood, leading to low blood oxygen levels), pulmonary hypertension (high blood pressure specifically within the arteries of the lungs), and chronic obstructive pulmonary disease (a progressive lung disease that makes it hard to breathe). The Minimum Data Set (an assessment tool) dated 5/05/2025, documented that the resident had intact cognition and could be understood and understand by others. During an observation on 6/27/2025 at 11:44 AM, Resident #41 was in their wheelchair receiving oxygen at three (3) liters via a nasal cannula that was connected to an oxygen concentrator (a device that provides a continuous supply of oxygen). The oxygen tubing was labeled and dated for 6/09/2025, the date it was changed. A review of the Medication Administration Record dated June 2025, documented that the oxygen tubing (nasal cannula) was to be changed one time weekly on Sundays, during the 11:00 PM-7:00 AM shift, and was documented as being changed on 6/08/2025, 6/15/2025, and 6/22/2025. During an interview on 6/27/2025 at 12:23 PM, Licensed Practical Nurse #5 stated the oxygen tubing change was usually done weekly. They stated that they were unsure when the residents' oxygen tubing was to be changed. Licensed Practical Nurse #5 reviewed Resident #41's Medication Administration record and stated that it was documented that it was changed on 6/08/2025, 6/15/2025, and 6/22/2025 during the 11:00 PM - 7:00 AM shift. Licensed Practical Nurse #5 showed Resident #41’s oxygen tubing and the date of 6/09/2025 on the tubing. They stated that it should not have the 6/09/2025 date on the tubing, as it was documented that the oxygen tubing was changed on the specific dates in the Medication Administration Record. Licensed Practical Nurse #5 stated that they were unsure of why the tubing was not changed, and it was documented that it was. Resident #128: Resident #128 was admitted to the facility with diagnoses of displaced intertrochanteric fracture of right femur (break in leg and hip bones), hyperlipidemia (high blood cholesterol), and hypertension. The Minimum Data Set (an assessment tool) dated 5/28/2025 documented the resident was understood by others, could understand others, and was moderately cognitively impaired. During an observation on 6/27/2025 at 9:55 AM, the nebulizer mouthpiece was observed to be on the floor. During an observation on 7/01/2025 at 11:20 AM, the nebulizer mouthpiece was observed to be wrapped around and hanging off the flowmeter on the concentrator. During an interview on 7/02/2025 at 12:59 PM, Licensed Practical Nurse #1 stated that nebulizers should be stored in a bag after using. Resident #245: Resident #245 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease, supraventricular tachycardia (a faster than normal heart rate beginning above the heart’s two lower chambers), and gastro-esophageal reflux disease (a digestive disease in which stomach acid or bile irritates the lining of the esophagus). The Minimum Data Set, dated [DATE] documented the resident was understood by others, could understand others, and was cognitively intact. During an observation on 6/26/2025 at 12:05 PM, the oxygen tubing was not dated, and the nebulizer mask was on the floor. During an observation on 6/27/2025 at 10:43 AM, the oxygen tubing was not dated, and the nebulizer mask was not stored in a bag. A Physician’s Order dated 6/17/2025 documented oxygen tubing change every night shift every Sunday for prophylaxis. During an interview on 7/02/2025 at 12:59 PM, Licensed Practical Nurse #1 stated that nebulizers should be stored in a bag after using. They stated oxygen tubing should be changed and labeled every week, usually on the night shift. During an interview on 7/03/2025 at 11:00 AM, Director of Nursing #1 stated oxygen tubing should be changed weekly as ordered and labeled with the date it was changed. Nebulizers should be rinsed out and stored in a plastic bag. If a nebulizer was on the floor, it should be discarded. 10 New York Codes, Rules, and Regulations 415.12(k)(6)

Based on record review and interviews conducted during a recertification survey, the facility did not ensure it developed and implemented a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident within 48 hours of a resident's admission for one (1) resident (Resident #248) of 28 residents reviewed for baseline care plans. Specifically, Resident #248's baseline care plan did not address resident's dialysis.This is evidenced by:The policy and procedure titled, Baseline/Comprehensive Person -Centered Care Plan, revised 3/2023, documented the baseline care plan must include the minimum of healthcare information necessary to provide the proper care for the resident, establish goals (include the resident's goals and preferences), and orders from the Healthcare Provider, dietary, therapy, social services, and Preadmission Screening and Resident Review (PASARR) (if applicable). Resident #248 was admitted to the facility with the diagnoses of acquired absence of right leg above the knee (surgical removal), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids).The Baseline Care Plan dated 6/18/2025 did not have documented evidence of care plan for dialysis.During an interview on 7/3/2025 at 11:16 AM, Director of Nursing #1 stated the resident's baseline care plan should have included dialysis.10 New York Codes, Rules and Regulations 415.11

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for one (1) (Resident #120) of the 28 residents reviewed. Specifically, for Resident #120, the medical record contained documentation of wound vacuum (a wound management device that uses negative pressure that draws out excess fluid and promoting blood flow to the area) monitoring when there was no wound vacuum present. This is evidenced by:Resident #120Resident #120 was admitted to the facility with the diagnoses of morbid obesity (a serious health condition characterized by a very high body mass index), infection (when microorganisms like bacteria, viruses, or fungi invade and multiply within the body, potentially causing harm)), and asthma (a chronic respiratory disease characterized by inflamed and narrowed airways, leading to breathing difficulties). The Minimum Data Set (an assessment tool) dated 4/03/2025 documented the resident was understood, could understand others, and was cognitively intact. During an observation on 6/26/2025 at 11:27 AM, Resident #120 had a dry dressing on the left knee. A Physician's Order dated 6/16/2025 documented Prevena drain (a wound management system that applies negative pressure to a closed incision to promote wound healing), monitor placement and function every shift for wound care. Needs to be charged overnight.The Medication Administration Record for June 2025 documented nursing staff monitored the Prevena drain that was not present on 6/25/2025 10:00 PM - 6:00 AM shift, 6/26/2025 all shifts, 6/27/2025 all shifts, 6/28/2025 all shifts, 6/29/2025 10:00 PM - 6:00 AM shift, 6/30/2025 2:00 PM - 10:00 PM shift and 10:00 PM - 6:00 AM shift.The Medication Administration Record for July 2025 documented nursing staff monitored the Prevena drain that was not present on 7/01/2025 10:00 PM - 6:00 AM shift and 7/02/2025 6:00 AM - 2:00 PM shift.During an interview on 6/26/2027 at 11:27 AM, Resident #120 stated they had recently had a left knee replacement and did have a wound vacuum, but it was removed on 6/25/2025.During an interview on 7/03/2025 at 10:24 AM, Licensed Practical Nurse #2 stated the resident did not have a wound vacuum to monitor and they marked accordingly on the Medication Administration Record.During an interview on 7/03/2025 at 10:27 AM, Nurse Practitioner #1 stated the resident did not have a wound vac. They were not aware the order was still active.During an interview on 7/3/2025 at 11:00 AM, Director of Nursing #1 stated the nurses should not have been signing for treatments/medications that were not done. They stated if a medical appliance like a wound vacuum had been discontinued, they should not sign that they were monitoring the placement and drainage.10 New York Codes, Rules, and Regulations 415.22 (a)(1)(2)

Based on observations, record review, interviews conducted during the recertification survey, the facility did not ensure dependent residents were provided with appropriate treatment and services to maintain or improve their language and communication for one (1) (Resident #7) of two (2) residents reviewed. Specifically, (a.) for Resident #7, nursing staff did not ensure there was consistent access to their communication dry/erase board so resident could use it to write down what they wanted to express as Resident #7 had difficulty speaking secondary to cerebral palsy (group of neurological conditions that affect movement and posture). This is evidenced by:The Facility's Policy and Procedure titled Quality of Life - Accommodation of Needs, issued 9/2024, documented, the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed as needed throughout the residents stay in the facility. Staff shall interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity.Resident #7 was admitted to the facility with diagnosis of Parkinson's Disease (a progressive neurological disorder that primarily affects movement, but also involves non-motor symptoms like cognitive and emotional changes); Cerebral Palsy (group of neurological conditions that affect movement and posture); and profound mental retardation (the presence of significantly sub average general intellectual functioning). The Minimum Data Set (an assessment tool) dated 3/05/2025 documented the resident's cognition was unable to be assessed, but they usually were able to be understood and understand others. The Comprehensive Care Plan titled, Communication, dated 4/24/2025, documented Resident #7 has a communication problem. Goal: Resident #7 will maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions appropriately, using communication board, writing messages. Problem: Resident has Cerebral Palsy. Goal: The resident will be able to function at the fullest potential possible as outlined by the treatment team.During an observation on 6/26/2025 at 12:20 PM, Resident #7 was observed in their room eating lunch independently with adaptive utensils. Resident with food in lap, clothing and face. Resident did not respond when writer said hello.During an observation on 6/27/2025 at 11:14 AM, resident observed sitting in their room while activities were taking place in the common area. Resident did not respond to greetings, did not respond to queries of how are you? What is your name? do you need anything? Resident #7 made no attempts to speak, but did make eye contact with writer.During an observation on 7/02/2025 at 12:01 PM, Resident #7 was observed in the main dining room on first floor. Resident #7 was sitting at a table alone near window. Activities Director #1 was observed attempting to have conversation with Resident #7. Resident #7's responses were delayed and could not be understood.During an interview on 7/02/2025 at 11:08 AM, Licensed Practical Nurse #6 stated Resident #7 had been a resident for many years; staff were familiar with resident's routine and needs. Resident made some grunts and responds to yes/no questions. Resident did not have a communication board. During an interview on 7/02/2025 at 12:01 PM, Activities Director #1 stated Resident #7 did best with one-to-one activities or engagements. Resident #7 did not like to be around others. When attempt to include Resident #7 in group activities, Resident #7 would push others away. Activities consists of coloring and watching television.During an interview on 7/02/2025 at 12:24 PM, Director of Rehabilitation #1 stated Resident #7 no longer attended speech language therapy. The last time they attended speech language therapy was in 2021 for evaluation and treatment of dysphagia (difficulty swallowing). Director of Rehabilitation #1 stated Resident #7 did not have a communication board or any other adaptive device for commutation. Communication had not been addressed since resident admitted several years ago. Staff communicate using closed ended yes/no questions. During an interview on 07/02/2025 at 12:57 PM, Director of Nursing #1 stated resident was able to make their needs known. The staff were familiar with resident and could understand them. If a new or agency staff were on the unit, they would ask another staff member to assist with communicating with resident. Director of Nursing #1 stated they were not sure whether Resident #7 had a communication board. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

Based on observation, record review, and interviews during a recertification survey and abbreviated survey (Case #NY 370) dated 3/14/2022 through 3/18/2022, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 10 (Resident #'s 34, 43, 68, 82, 89, 101, 104, 108, 119, and #127) of 26 residents reviewed. Specifically, for Resident #34, the facility did not ensure the Activities of Daily Living (ADL) Comprehensive Care Plan (CCP) intervention to check and change the resident every 2 hours was implemented, and ensure the resident received supervision while eating in bed was implemented; for Resident #43 the facility did not ensure the Respiratory CCP intervention for oxygen administration at two liters per minute via nasal cannula was implemented; for Resident 68, did not ensure a behavior management program was implemented as documented on the [CONDITION(S)] medication care plan; for Resident #82, did not ensure a CCP was developed for the resident's ongoing complaints of and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] #108, did not ensure a CCP was developed for a rash to the resident's bilateral upper and lower extremities; for Resident #104, did not ensure the resident was provided with bi-weekly showers as documented on the ADL care plan; for Resident #119, did not ensure a care plan was developed to address small circular areas covered with fresh blood and dried blood on the resident's right and left arms; and for Resident #127, did not ensure the intervention for monthly weights was consistently implemented as documented on the CCP for the resident's potential for nutritional problem. This was evidenced by: The facility Policy & Procedure (P&P) titled Comprehensive Care Plan dated 2/2015, documented the CCP was developed to provide individualized plans of care that addressed the resident's identified needs and assisted the resident to achieve their highest practicable quality of life. The interdisciplinary team would be responsible to maintain the CCP current at all times and to update the care plan when a new problem/goal/intervention was identified that required a team member to intervene. The P&P documented all clinical department heads were responsible to ensure that there was a system for monitoring the implementation of the resident care plans. Resident #82: Resident #82 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 2/6/2022 documented the resident was without cognitive impairment and could understand and be understood. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A document titled, Documentation Survey Report (a form used to document Certified Nurse Assistant (CNA) care provided) dated March 2022 documented the resident had a bowel movement with loose/diarrhea consistency on: Day Shift: 3/1/2022, 3/2/2022, 3/3/2022, 3/6/2022, 3/7/2022, 3/8/2022, 3/9/2022, 3/10/2022, 3/12/2022, 3/13/2022, 3/14/2022, 3/15/2022, 3/16/2022 and 3/17/2022 Evening Shift: 3/1/2022, 3/2/2022, 3/7/2022, and 3/13/2022 Night Shift: 3/8/2022 During an interview on 3/15/22 at 9:46 AM, Resident #82 stated they do not get out of bed often or attend activities at the facility secondary to frequent loose stools. During an interview on 3/18/2022 at 9:44 AM, CNA #4, stated they have worked with the resident for the previous six months, and the resident regularly has loose stools. The CNA stated the nurse was made aware with each loose stool the resident had. During an interview on 3/18/22, Licensed Practical Nurse Unit Manager (LPNUM) #7, stated they were aware the resident continued to have loose bowel movements for several months, and the resident would refuse to get out of bed or attend activities at the facility due to loose stools. LPNUM #7 stated the resident should have a CCP in place for loose stools. LPNUM #7 stated Unit Managers were expected to ensure the resident's care plan accurately reflected the care and services needed to care for the resident. During an interview on 3/18/2022 at 12:01 PM, the Director of Nursing (DON) stated the Unit Manager was responsible for ensuring the CCPs were updated and accurate and the Unit Manager should contact an RN (Registered Nurse) in the facility to develop a care plan when needed. Resident #108: Resident #108 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 3/14/2022 at 2:01 PM, the resident was observed scratching both their arms. During an observation on 3/15/2022 at 12:12 PM, the resident was observed in the dining room with their right pant leg raised, and their right leg was red. During an observation on 3/16/2022 at 3:07 PM, the resident's arms appeared bright red with raised skin and had scratch marks with dried blood. During an observation on 3/17/2022 at 12:38 PM, both of the resident's arms were bright red with slightly raised skin. Nursing Progress Notes documented the resident had a rash present on: 2/2/2022 to bilateral arms and right ankle; 2/4/2022 to bilateral arms and legs; 2/8/2022 to bilateral arms and legs; 2/11/2022 to arms and back; 2/14/2022 to bilateral arms and legs; and on 2/19/2022 a full body rash was noted that the resident was digging at angrily. A Nursing Progress Note dated 2/23/2022 documented the resident was readmitted to the facility and a rash was noted to the resident's entire body. Nursing progress notes dated 2/25/2022 and 2/27/2022 documented the resident had a rash on their body and the resident was scratching and picking at their skin. During an interview on 3/18/2022 at 10:06 AM, LPNUM #1 stated the resident has had a rash on their body for several weeks. LPNUM #1 stated the resident should have a care plan in place for the rash on their body and they requested the DON to develop a CCP for the resident's rash. During an interview on 3/18/2022 at 12:19 PM, the Director of Nursing (DON) stated the Unit Manager was responsible for ensuring the CCPs were updated and accurate and the Unit Manager should contact an RN in the facility to develop a care plan when needed. Resident #119: Resident #119 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 3/3/2022 documented the resident had moderately impaired cognition, could understand others and could make self understood. During an observation on 3/14/2022 at 10:30 AM, the resident's right arm was visible and there were multiple small circular areas covered in fresh red blood and some covered with dried blood (scabbed over) on their forearm. There were drops of dried blood on the resident's yellow blanket that covered their lap and on the right sleeve of their short-sleeved white t-shirt. During an observation on 3/15/2022 at 12:21 PM, the resident's right and left arms were visible. Both arms had multiple small circular areas that were either covered with fresh red blood or dried blood. The resident stated their arms itched but they did not know why their arms itched. The resident stated the staff would sometimes put lotion on the resident's arms but stated they did not receive a regularly scheduled treatment to their arms. The Comprehensive Care Plan (CCP) did not include a care plan to address the small circular areas covered with fresh and dried blood on the resident's right and left arms. During an interview on 3/17/2022 at 3:21 PM, the DON stated the resident was very anxious and noncompliant with care. The DON stated they did not know about the resident's arms. The DON stated the resident had a renal condition and chronic kidney disease so it would make sense if the resident scratched their skin. The DON stated that to the best of their knowledge the open areas on the resident's arms was not a known condition or a known behavior. The DON stated open areas on the resident's arms would be picked up on the weekly skin evaluations and it would not necessarily be on the care plan. The DON stated they would have to go look at the resident's arms. During an interview on 3/18/2022 at 9:05 AM, Licensed Practical Nurse (LPN) #6 stated Resident #119 was admitted to the facility with those areas on their arms. LPN #6 stated the resident was a scratcher and the LPN would sometimes use lotion on the resident's arms because the resident would say their arms itched. The LPN stated they had seen blood on the resident's shirt from the open areas on the resident's arms. The LPN stated the resident had a lot of health issues and anxiety that contributed to the resident's scratching. The LPN stated those areas should be on a skin check and everyone should be aware of them because the resident has had them on their arms since they came into the facility. The LPN stated the areas on the resident's arms should be on the resident's care plan because it was an ongoing issue. The LPN stated the areas would close over but the resident would scratch again re-opening the areas and they would bleed. During an interview on 3/18/2022 at 9:55 AM, LPNUM #2 stated the areas on the resident's arms had not been reported to them. Prior to becoming Unit Manager earlier this week, LPNUM #2 stated they worked as an LPN on the opposite end of the hallway and did not provide direct care to Resident #119. LPNUM #2 was not aware of the open areas on the resident's arms. The LPNUM stated if the skin condition was new for the resident, it would be on the care plan and any condition that was ongoing would be care planned. LPNUM #2 stated LPNs could not initiate care plans, but LPNs could add to the existing care plan. 10NYCRR 415.11(c)(1)

Based on observation, record review and interviews during the recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure each resident was free from accident hazards for 2 (Resident #'s 34 & #101) of 5 residents reviewed. Specifically, for Resident #34, who had difficulty swallowing, the facility did not ensure the resident was supervised during eating and was evaluated for the ability to chew after their dentures were broken and for Resident #101, the facility did not ensure the resident was not self-administering inhalers in their room after being assessed not to be a potential candidate for self-medication administration. This is evidenced by: Resident #34: The resident was admitted to the facility on with the diagnosis of [CONDITION(S)], heart failure and dysphagia. The Minimum Data Set (MDS-an assessment tool) dated 3/8/2022, documented the resident had moderate cognitive impairment. The resident could understand and be understood. The resident required the supervision of 1 person while eating. During an observation on 3/16/2022 at 9:02 AM, the resident was in their room with the door closed. Upon entering Resident #34's room at 9:07 AM, the resident was observed in bed eating cereal. Staff were not present during this encounter and the door remained closed until 9:11 AM, when a staff member opened the door to the resident's room to retrieve the breakfast tray. The Comprehensive Care Plan (CCP) titled, Behavior problem, revised on 9/6/2020, documented the resident refused to meet dietary safety recommendations for safety and refused to get out of bed for meals and constant supervision. Resident #34 would accept intermittent supervision with the door open during mealtimes. The CCP titled ADL (Activities of Daily Living) revised on 12/21/2021, documented: Eating -encourage resident to get out of bed or keep bed at ninety degrees while eating; resident wears dentures and the resident required set up and supervision. The Certified Nurse Aide (CNA) Kardex (resident specific care instructions) documented: Resident #34 refused (to be) out of bed for meals and constant supervision - however would accept intermittent supervision during meals with the door open during mealtimes. Additionally, it documented, for Eating and Nutrition, the resident wore dentures and the bed set at ninety degrees while eating. - Resident is safe to have meals in bed and needs to be fully upright in bed for meals; Preferred dining location - Cluster or bedroom. If in room eating, ensure door is left open to visualize resident while eating. A Speech Therapy evaluation completed on 1/14/2022 documented the resident was evaluated for oral and pharyngeal swallow function. The reason for the referral was the resident was experiencing difficulty swallowing. An untitled document provided by the facility that included the meals Resident #34 was served, documented the resident received a burger on a bun five (5) times for either lunch or dinner during the time period from 3/8/2022 through 3/15/2022, . A Therapy Progress Note dated 3/17/2022 at 1:50 PM, documented Resident #34 was screened by a speech language pathologist (SLP) and their diet was downgraded to mechanical soft as their dentures were broken and sent out for repair. During an interview on 3/14/2022 at 11:29 AM, Resident #34 reported their dentures broke about a month ago and they had difficulty chewing several items, especially burgers. The resident reported to staff their difficulty chewing burger since their dentures were broken. During an interview on 3/16/2022 at 10:07 AM, Certified Nurse Assistant #5 stated the resident regularly ate in their room alone with the door closed. CNA #5 stated the resident complained to them about always getting burgers for dinner and reported difficulty chewing them since the resident's dentures were broken. CNA #5 stated it was difficult to supervise the resident during meals as they had to feed a resident across the hall. CNA #5 stated they tried to check on the resident during eating, but often did not have time to do this. During an interview on 3/16/2022 at 10:14 AM, SLP #1 stated when a resident had a history of dysphagia and reported difficulty chewing foods, or there was a change in the resident's ability to chew, such as when dentures were being repaired, a request for a swallowing evaluation would be placed. During an interview on 3/17/22 at 8:23 AM, Licensed Practical Nurse Unit Manager (LPNUM) #7 stated the resident's dentures were broken prior to 2/2/2022. LPNUM #7 stated a swallowing evaluation was not placed, as the LPNUM was not aware the resident reported difficulty chewing foods. LPNUM #7 stated they were aware the resident complained of receiving too many burgers but were not informed this was due to chewing difficulties. LPNUM #7 stated they were aware the resident refused to get out of bed for meals and required supervision with the door to their room open, however they were not aware staff were not completing this task. During an interview on 3/17/2022 at 12:16 PM, the Director of Nursing (DON) stated they would expect the resident to be supervised for meals as per the CCP. The DON stated they would only expect a swallowing evaluation to be completed when a resident was observed to have difficulty swallowing and the nurses aides should observe the resident for any difficulties chewing or swallowing. The DON stated they thought the resident had a swallowing evaluation completed after Resident #43's dentures were broken. Resident #101: Resident #101 was admitted with diagnoses of [CONDITION(S)] ([CONDITION(S)]), [CONDITION(S)], and hypertension. The Minimum Data Set (MDS-an assessment tool) dated 2/27/2022 documented the resident was cognitively intact, could understand others and could make self understood. The undated facility Policy and Procedure titled Self Medication documented to maximize and promote resident independence, self-administration of medication was encouraged for all residents capable of performing this function. The interdisciplinary care team used various factors in determining a resident's capacity to self-medicate. The resident must desire to participate in the self medication program and agree to adhere to safety rules and open communication with nursing staff as they monitored compliance and effectiveness of the medication program. During an observation and interview on 3/14/2022 at 11:15 AM, the resident was sitting in their wheelchair and had 2 inhalers on the over bed table in front of them. The resident stated the blue inhaler was [MEDICATION(S)] and was full. The resident stated the orange inhaler was [MEDICATION(S)] and was empty. The resident stated the [MEDICATION(S)] was supposed to be refilled by the facility. The resident stated they self-administered the [MEDICATION(S)] inhaler 3 times a day and as needed in between. The resident stated they self-administered the [MEDICATION(S)] inhaler as needed when they felt short of breath. The resident stated they were on these inhalers at home and self-administered the inhalers in the facility. The resident stated they always had the inhalers in their room and staff were aware they had them and used them. The resident stated they had difficulty breathing and was on oxygen at 3 liters at all times and used the inhalers when they needed it. During a subsequent observation on 3/14/2022 at 12:28 PM, the resident was sitting in their wheelchair and had 2 inhalers on the over bed table in front of them. During an observation and interview on 3/15/2022 at 12:13 PM, the resident had the 2 inhalers (blue and orange) on the over bed table in front of them. The resident stated the [MEDICATION(S)] inhaler still had some left and the [MEDICATION(S)] was empty. The resident stated they were being discharged and the facility was supposed to refill the [MEDICATION(S)]. The resident stated nursing may have the [MEDICATION(S)] in the medication cart. The Nursing Admission Evaluation dated 2/23/2022, documented the resident was not a potential candidate for self-medication administration. The Comprehensive Care Plan (CCP) for [CONDITION(S)] dated 2/25/2022, documented to give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness. The CCP did not include a care plan for the resident to self- administer medications. The physician orders documented: -2/23/2022, [MEDICATION(S)] HFA Aerosol Solution (an inhaled medicine used to treat or prevent bronchospasm; when the airways go into spasm and contract) 108 (90 Base) MCG/ACT (Microgram/Actuation)- 2 inhalation inhale orally every 6 hours as needed for wheezing. -2/23/2022, [MEDICATION(S)] Respimat Aerosol Solution (an inhaled medicine used to treat [CONDITION(S)]) 20-100 MCG/ACT- 1 inhalation inhale orally four times a day for [CONDITION(S)]. Review of the physician orders did not include an order that the resident was able self-administer medications. Review of the Medication Administration Record (MAR) from 3/1/2022 to 3/14/2022, did not include documentation that [MEDICATION(S)] PRN was administered. The MAR documented the resident was administered the [MEDICATION(S)] inhaler 4 times as day. During an interview on 3/17/2022 at 8:47 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated when they were on the medication cart they would give the resident their inhalers from the medication cart and the resident did not keep the inhalers in their room. LPNUM #2 stated they never had to administer the [MEDICATION(S)] inhaler to the resident. The LPNUM stated there would have to be an order for the resident to self-administer their inhalers. During an interview on 3/17/2022 at 8:57 AM, LPN #3 stated Resident #101 did not keep the inhalers in their room regularly. The LPN would keep the inhalers in the medication cart. The LPN stated there would have to be an order for the resident to self-administer the inhalers. During an interview on 3/17/2022 at 9:10 AM, Certified Nursing Assistant (CNA) #1 stated Resident #101 always had 2 inhalers on their over bed table. CNA #1 stated one inhaler was blue and one was orange. CNA #1 stated they remembered watching the resident take the orange inhaler in their room by themselves. CNA #1 stated in addition to the 2 inhalers on the over bed table, the resident also kept 1 inhaler in their purse. CNA #1 stated they frequently saw the resident self-administer the orange inhaler. CNA #1 stated the resident would usually self-administer the orange inhaler after the CNA helped the resident to the bathroom. CNA #1 had not seen the resident use the blue inhaler but stated that did not mean they resident did not use it. It was on the resident's over bed table. CNA #1 stated they had also seen inhalers in other resident's rooms on occasion. CNA #1 stated they would not know if a resident was supposed to have inhalers in their room, but the nurses knew Resident #101 had inhalers in their room. The CNA stated Resident #101 had 2 inhalers in their room every day on the over bed table. During an interview on 3/17/2022 at 9:32 AM, Physical Therapy Assistant #1 stated they had seen 1 inhaler in the resident's room when they treated the resident for therapy at the beginning of the resident's rehab stay. PTA #1 stated they saw the resident had an orange inhaler and saw the resident self-administer the inhaler. The PTA stated they saw the resident use the inhaler occasionally when the resident was anxious. The PTA stated they would not necessarily know if the resident was supposed to have the inhaler in their room and did not know if the nurses knew the inhaler was in the resident's room. During an interview on 3/17/2022 at 3:06 PM, the Director of Nursing (DON) stated they did not know of any residents who self-administered medications in the facility. The DON stated Resident #101 did not ask to self-administer medications and if a resident said they wanted to self-administer medication, the facility had a process to follow for resident's who wanted to self-administer medication and they would have an evaluation completed. The DON stated if staff saw the inhalers in the resident's room, they should ask the nurse if the resident should have them. The DON stated medications should not be hanging out in the room. The DON stated they did not recall ever seeing anything on the resident's bed side table and it was never reported to the DON that the resident had the inhalers in their room. The DON stated they should not have been in the resident's room and the nurses should have noticed. The DON stated they did not think the resident would be able to properly administer the inhalers. The DON stated the resident was alert and oriented and their roommate was alert and oriented and no one wandered on the unit near their room so the DON would not consider the inhalers being in the resident's room an accident hazard. The DON stated it was concerning if the resident was self-administering because the nurses would not know what the resident was taking. The DON was made aware of the Surveyor's observations on 3/14/2022 and 3/15/2022. The DON stated the resident was very anxious and they could see the resident wanting to hang on to the inhalers because the resident was very anxious about their breathing. The DON stated it would make sense if the resident wanted to keep the inhalers in their room. 10NYCRR415.12(h)(2)

Based on record review and interviews during a recertification survey dated 3/14/2022 through 3/18/2022, the facility did not develop and implement baseline care plans that included instructions needed to provide effective and person-centered care for 9 (Residents #'s 10, 13, 17, 68, 77, 83, 86, 89, and #104) of 18 residents reviewed. Specifically, for Resident #'s 68, 83, 86, 89 and #104, the facility did not ensure the baseline care plans included the required minimum healthcare information necessary to properly care for each resident immediately upon their admission and did not address resident-specific health and safety concerns by identifying needs for supervision, behavioral interventions, and assistance with activities of daily living and for Resident #'s 10, 13, 17, and #77, the facility did not ensure that baseline care plans were developed with 48 hours of the resident's admission. This is evidenced by: The Policy and Procedure titled Baseline/Comprehensive Person Centered Care Plan revised 10/2017, documented the baseline care plan must be developed within 48 hours of admission. The baseline care included at least a minimum of healthcare information necessary to provide the proper care for the resident, establish initial goals and orders from the physician, dietary, therapy, social services and PASARR (Preadmission Screening and Resident Review). Resident #13: Resident #13 was admitted to the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- an assessment tool) dated 12/18/2021, documented the resident was cognitively intact, could understand others and could make self-understood. Review of the resident's medical record on 3/17/2022 at 2:41 PM, did not include documentation of a baseline care plan. During an interview on 3/17/2022 at 3:04 PM, Licensed Practical Nurse Unit Manager (LPNUM) #7 stated baseline care plans should be completed within 48 hours of admission. LPNUM #7 stated the baseline care plan should be developed by the registered nurse who completed the admission within 48 hours and a copy should be documented in the medical record. LPNUM #7 reviewed the medical record for Resident #13 and stated the record did not include the baseline care plan. During an interview on 3/18/2022 at 12:25 PM, the Director of Nursing (DON) stated baseline care plans should have been developed by the admitting nurse soon after admission and filed in the paper chart. The DON did not give a time frame for the development of the baseline care plans after new admissions were admitted to the facility. Resident #68: Resident #68 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 2/12/2022, documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The Hospital Discharge Summary dated 2/4/2022, documented the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [MEDICATION(S)] (antipsychotic medication) 2.5 mg by mouth at bedtime. The Baseline Care Plan, dated 2/5/2022, did not address the use of antipsychotic medication, the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/17/2022 at 3:06 PM, the Director of Nursing (DON) stated the Admissions Nurse or the registered nurse completing the new admission was responsible for completing the baseline care plan and reviewing it with the resident or family. The DON stated the baseline care plan was a 1-page form that was filled out and kept in the resident's chart on the unit. The DON stated a copy of the baseline care plan, the 1-page form, was provided to the resident or family as the summary. During an interview on 3/18/2022 at 10:30 AM, Registered Nurse (RN) #1 stated they were the Admissions Nurse and completed the baseline care plan for the residents they admitted . RN#1 stated the baseline care plan was very basic. RN#1 used documents from the hospital to complete the the baseline care plan, including the transfer summary and the Patient Review Instrument (PRI) as well as interviews with the resident and family. RN#1 stated an antipsychotic medication and diagnoses, such as dementia, would not be documented on the baseline care plan but would be on the initial care plan in the computer. RN#1 stated the 1-page baseline care plan was reviewed and provided to the resident or family. The physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN#1 stated the form they used for the baseline care plan was what the facility provided to them to use with each new admission. Resident #83: Resident #83 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 2/17/2022 documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The MDS dated [DATE], documented the presence of a urinary catheter on admission. The Hospital Discharge Summary dated 3/22/2021 documented the resident had an indwelling urinary catheter. The undated Baseline Care Plan (BCP) did not address resident-specific health and safety concerns including the presence of a urinary catheter, supervision needs and the resident's specific needs related to the care of the urinary catheter, and assistance with activities of daily living. The Progress Note dated 3/22/2021 documented the presence of a urinary catheter on admission. During an interview on 3/18/2022 at 10:30 AM, Registered Nurse (RN) #1 stated they were the Admissions Nurse and completed the baseline care plan for the residents they admitted . RN#1 stated the baseline care plan was very basic. RN#1 used documents from the hospital to complete the the baseline care plan, including the transfer summary and the Patient Review Instrument (PRI) as well as interviews with the resident and family. RN#1 stated the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN#1 stated the form they used for the baseline care plan was what the facility provided to them to use with each new admission. During an interview on 3/18/22 at 10:41 AM, LPNUM #3 stated they could not start a care plan on their own but could update a care plan. LPNUM #3 stated the Admissions Nurse was the one who completed the admission paperwork for new admissions including a baseline care plan. 10NYCRR 415.11

Based on observation, record review and interviews during the recertification survey and an abbreviated survey (Case #NY 370) dated 3/14/2022 through 3/18/2022, the facility did not ensure each resident maintained acceptable parameters of nutritional status for 3 (Resident #'s 17, 89, and #126) of 5 residents reviewed for nutrition. Specifically, for Resident #17, the facility did not ensure the resident was weighed upon admission and re-admission in accordance with professional standards, for Resident #89, did not ensure the resident was weighed in accordance with professional standards as documented in the Nutritional Evaluation dated 2/21/2022, the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: The Policy and Procedure (P&P) titled Weight Policy & Procedure dated 11/24/2021, documented each residents weight will be obtained and documented upon admission to the facility. New admission: Initial weight will be obtained and recorded within 24 hours of admission. Re-admissions: Weight will be obtained and recorded upon return to facility. New admissions will be weighed weekly for four (4) weeks. Subsequent weights will be monthly, unless physicians' orders or the resident's condition warrants more frequent as determined by the Interdisciplinary Team (IDT). Monthly weights are to be obtained and recorded in the beginning of each month. Resident #17: Resident #17 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 12/28/2021, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The Comprehensive Care Plan (CCP) for Unplanned/Unexpected Weight Loss related to acute illness and poor food intake updated on 1/18/2022, documented to monitor and evaluate any weight loss, weigh weekly and record. During a record review on 3/16/2022 at 9:14 AM, the medical record did not document a weight within 24 hours of the resident's admission on 12/21/2021. The resident was weighed 8 days later on 12/29/2021 at 167.5 #s. During a record review on 3/16/2022 at 9:14 AM, the medical record did not document a weight within 24 hours of the resident's re-admission on 2/1/2022. The resident was weighed 5 days later on 2/6/2022 at 145.8 #s. During an interview on 3/17/2022 at 11:21 AM, Certified Nursing Assistant (CNA) #1 stated residents admitted in the afternoon were usually weighed the next morning. CNA #1 also stated, honestly weights were very important and the staff lacked in getting the weights timely. During an interview on 3/17/2022 at 10:31 AM, Registered Dietician (RD) #1 stated admission and re-admission weights should be obtained and documented in the computer within 24 hours of admission. RD #1 stated the admission weights were often not documented in the computer and they would use the weights documented in the hospital transfer packet to complete the initial nutritional evaluation or assessment by day 7 of the resident's admission. The RD would ask the CNAs to get the admission weight. During an interview on 3/18/2022 at 12:09 PM, the Director of Nursing (DON) stated residents should be weighed shortly after admission, within 24 hours. The DON stated they were aware that obtaining admission and weekly weights was an ongoing struggle for the facility and currently had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #89: Resident #89 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 2/21/2022 documented the resident had moderately impaired cognition, could understand others and could make self understood. The Comprehensive Care Plan for Nutrition related to severe malnutrition, last revised 3/16/2022, documented the goal was for the resident to have a weight gain towards >105# (pounds). An intervention dated 2/21/2022, documented to weigh the resident weekly x 4 weeks then monthly and record. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nutritional Evaluation dated 2/21/2022, documented to weigh the resident weekly x 4 weeks. The medical record documented the following weights: 2/21/2022- 83.0# 3/5/2022- 82.8# The medical record did not include weekly weights for 4 weeks after admission and did not include documentation that the resident refused to be weighed. During an interview on 3/17/2022 at 8:51 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated residents were typically weighed as soon as possible on admission, then weekly 4x weeks, and then monthly. The LPNUM stated if there was a concern with a resident's weight, the Registered Dietitian (RD) would also ask nursing to weigh the resident. The LPNUM stated the Certified Nursing Assistants (CNAs) obtained the weights for each resident, but nurses would get weights too. The nurses knew a weight was needed when it popped up on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD was responsible for reviewing the weights to make sure they were being done. During an interview on 3/17/2022 at 9:10 AM, CNA #1 stated it was the CNAs responsibility to obtain the weights for the residents. The CNAs would know a weight was due because it would show up in the computer to let them know. The CNA stated monthly weights would show up in the computer on the 1st of every month and weekly weights would show up every Monday. The CNAs or LPNs would document the weights in the medical record. The CNA stated the CNAs did not have access to compare a resident's current weight with their previous weight. During an interview on 3/17/2022 at 2:03 PM, RD #1 stated facility policy and best practice was to obtain an admission weight within 24 hours, then weigh the resident weekly for 4 weeks, then monthly after that. It was the responsibility of the RD to monitor weights and to ensure weights were being done. The RD stated they were aware weights were missing and the facility was trying to improve that by putting an order in for weights so it would show up on the MAR for LPNs to sign off. This was a way for more staff to keep an eye on the weights and ensure they were being done and documented. The RD stated the frequency of the weights for a resident was also on their care plan because not all residents needed to be weighed at the same frequency. The RD stated ultimately, it should be the LPN documenting the weights in the medical record because it was on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The RD stated the care plan should match physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 3/18/2022 at 1:09 PM, the Director of Nursing (DON) stated the residents were weighed upon admission, weekly for 4 weeks, and then monthly. The CNAs were responsible for obtaining the weights and the nurses were responsible to see that the weights were obtained. The RD monitored the residents' weights. The DON stated the care plan and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #127 Resident #127 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) for Potential Nutritional Problem, created on 8/14/2019, documented an intervention dated 9/13/2019 for monthly weights. A facility document titled, Weights and Vital Signs documented Resident #127's weight on: 1/06/2020 at 138.6# 2/10/2020 at 132.6# 4/15/2020 at 133.6# 5/18/2020 at 130.6# 7/18/2020 at 105.0# A review of the Medical Record did not include weights for March 2020 or June 2020. Additionally, it did not document that Resident #127 refused weights. A Dietary/ Nutrition Note dated 2/17/2020 documented a quarterly review was completed and the resident had a weight loss of 8.2 pounds, the resident was at high risk due to variable oral intake. A Dietary/Nutrition Note dated 7/17/2020 documented the resident had a 28.6-pound weight loss. It documented Resident #127 was at risk for weight loss due to dementia, very particular food likes and multiple stated food allergies. During an interview on 3/17/2022 at 2:03 PM, the Dietician stated all residents should be weighed upon admission, weekly for 4 weeks and then monthly. The Dietician stated it was their responsibility to ensure weights were completed and monitor the resident for weight loss. They stated the facility was aware weight monitoring was not being completed per professional standards of practice and the facility recently implemented new measures to improve consistent weight monitoring. 10NYCRR415.12(i)(1)

Based on observation, record review and interview conducted during a recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure that residents in need of respiratory care, received such care consistent with professional standards for one (1) (Resident #43) of two (2) residents reviewed. Specifically, for Resident #43, the facility did not ensure a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This is evidenced by: Resident #43: Resident #43 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 3/4/2022, documented the resident was cognitively intact, could understand others and could make self-understood. The undated Policy and Procedure titled Oxygen Therapy- Mask and Nasal Cannula, documented oxygen was administered by licensed staff under a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's (MD) order dated 5/15/2020, documented the resident was to receive oxygen at two liters per minute continuous via nasal canula every shift. During observations Resident #43 received oxygen via nasal cannula at three liters per minute on: 3/14/2022 at 2:47 PM at three liters per minute. 3/15/2022 at 9:54 AM at three liters per minute. 3/15/2022 at 12:13 PM at three liters per minute. 3/15/2022 at 12:26 PM at three liters per minute. 3/16/2022 at 9:15 AM at three liters per minute. 3/16/2022 at 10:18 AM at three liters per minute. 3/16/2022 at 11:00 AM at three liters per minute. During an interview on 3/16/2022 at 11:00 AM, Licensed Practical Nurse Unit Manager (LPNUM) #7 stated residents should receive oxygen per Medical Doctor (MD) orders. LPNUM #7 stated licensed staff should change a resident between an oxygen concentrator and an oxygen tank. LPNUM #7 confirmed Resident #43 was receiving oxygen at three liters per minute via nasal canula during the interview and then confirmed the MD orders indicated the resident was to receive two liters per minute of oxygen. During an interview on 3/17/2022 at 11:47 AM, the Director of Nursing (DON) stated the licensed nurse was responsible for ensuring the resident received oxygen per MD orders. The Unit Manager was responsible for ensuring all staff were following MD orders. 10NYCRR415.12(k)(6)

Based on record review and interviews during the recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure residents diagnosed with dementia, received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for 1 (Resident #68) of 4 residents reviewed for dementia care. Specifically, for Resident #68, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the facility did not ensure the Comprehensive Care Plan (CCP) for Cognition included person-centered interventions related to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #68: Resident #68 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 2/12/2022 documented the resident had severely impaired cognition, could usually understand others and could usually make self understood. The undated facility Policy and Procedure (P&P) titled Dementia and Behaviors (Alzheimer's/ Dementia Type Illnesses), documented residents with behaviors that were problematic and or/dangerous for themselves, or others would be identified. A Behavior Management Plan would be developed based on the residents with Alzheimer's Disease/Dementia and other related illnesses and the resident's individual needs and would be implemented. Ongoing education and training on managing residents with aggressive or catastrophic behaviors would be provided upon hire and then at least annually. The facility P&P titled Dementia Training Hand in Hand dated 3/2020, documented the mission of the Hand in Hand training was to provide nursing home staff with a high-quality training program that emphasizes person-centered care in the care of persons with dementia and the prevention of abuse. The CCP for Cognition, last revised 2/22/2022, documented the resident had impaired cognitive function or impaired thought processes related to dementia. The care plan interventions documented to encourage the resident to make choices/decisions regarding daily Activities of Daily Living (ADLs) and to administer medications as ordered and monitor/document for side effects and effectiveness. The CCP for Cognition did not include person-centered interventions related to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The CCP for Behaviors, last revised 2/22/2022, documented the resident had the potential to be physically and verbally aggressive related to dementia and poor impulse control. The care plan interventions included: a CD player was available to play a specific singer and Gospel music, to monitor and document observed behavior and attempted interventions in behavior log, to modify the environment: adjust room temperature to comfortable level, reduce noise, dim lights, and place familiar objects in room. The CCP for Activities, last revised 2/7/2022, documented the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to the resident's cognition. The CCP documented the resident stated it was not very important to do their favorite activities. The care plan interventions included: The resident needed 1:1 bedside/in-room visits and activities if unable to attend out of room events. A CD played was placed in the room with Gospel music for use during periods of agitation and the resident played cards in the past, liked country music and enjoyed going to church. The Care Card (caregiving instructions), as of 3/16/2022, documented to offer the resident a nap after lunch, to monitor and document observed behavior and attempted interventions in behavior log, to modify the environment: adjust room temperature to comfortable level, reduce noise, dim lights, and place familiar objects in room, a CD player was available to play a specific singer and Gospel music for use during periods of agitation and the resident played cards in the past, liked country music and enjoyed going to church, ensure resident has access to thin liquids whenever possible, toilet after meals, offer the resident a Geri-chair by the nurses' station when out of bed as tolerated. During an observation on 3/15/2022 at 2:24 PM, Resident #68 was sitting in the hallway in their wheelchair near the nurses' station next to room [ROOM NUMBER]. Resident #68 was calling out Will someone give me a hand. The staff that were behind the nursing station did not come to assist the resident. -At 2:28 PM, the resident wheeled their wheelchair over to the handrail and used the handrail to stand up. The chair alarm went off. The resident took 3 steps away from their wheelchair and stood in the doorway of room [ROOM NUMBER]. Licensed Practical Nurses (LPNs) #8 and #9 came from the nurses' station to assist the resident when the alarm sounded. The LPNs asked the resident to sit back down their wheelchair. -At 2:30 PM, Certified Nursing Assistant (CNA) #3 was walking past the resident and LPN #8 and #9. The CNA asked what the LPNs were doing. LPN #8 stated Just trying to get (the resident) to relax, and as CNA #3 continued to walk by toward to the housekeeping closet, CNA #3 stated, that's not in (the resident's) blood. The LPNs had the resident sit back in their wheelchair. The resident was not offered meaningful activities or diversional activities. -At 2:39 PM, the resident stood up from their wheelchair, the alarm sounded, and LPN #8 and #9 assisted the resident to sit back down. The LPNs did not offer the resident meaningful activities or diversional activities. -At 2:49 PM, the resident stood up from their wheelchair, the alarm sounded, and the resident walked 2 steps inside room [ROOM NUMBER]. CNA #4 attended to the resident and asked where the resident was going? Did the resident need something? Did the resident need help? The resident stated no. CNA #4 asked the resident to stay out of other residents' rooms. The CNA assisted the resident back into the wheelchair and moved the wheelchair to the other side of the hall across from room [ROOM NUMBER]. The CNA did not offer the resident meaningful activities or diversional activities. -At 2:56 PM, the resident was calling out for their family member. CNA #4 and another CNA walked past the resident as the resident called out for their family member. Staff did not engage with the resident while they were calling out for their family member. During an observation on 3/17/2022 at 8:55 AM, the resident was brought out of the dining room after having breakfast and was sitting in the hallway in their wheelchair near the nurses' station next to room [ROOM NUMBER]. The resident fell asleep and was snoring in the hallway. At 9:49 AM, the resident continued to sleep in their wheelchair in hallway. At 11:36 AM, the resident remained sleeping in their wheelchair in the hallway. The resident was not offered meaningful activities, to sit in a Geri chair (reclining chair on wheels), or to go back to bed. At 12:00 PM, the resident was brought to the dining room for lunch. During an observation on 3/18/2022 at 9:06 AM, the resident was in their wheelchair and placed next to room [ROOM NUMBER] near the nurses' station. The resident remained sleeping until the observation ended at 10:35 AM. The resident was not offered meaningful activities, to sit in a Geri chair, or to go back to bed. A review of Resident-Specific Activity documentation from 3/2/2022 to 3/15/2022 included: -Social Programs: 2 entries on 3/5/2022 at 11:56 AM, a group movie and on 3/6/2022 at 11:49 AM, a 1:1 interaction; -Spiritual Programs: 1 entry on 3/9/2022 at 1:59 PM, attended church; -Room Visits: 14 entries (10 room visits were in the 8:00 AM hour; 3 room visits were in the 9:00 AM hour; 1 room visit was in the 10:00 AM hour.) All 1:1 daily room visits occurred in the morning before lunch. A review of progress notes from 2/22/2022 - 3/15/2022 related to meaningful activities: -3/2/2022 at 2:38 PM, documented the resident attended religious services this afternoon for Ash Wednesday service. The resident was pleasant and calm and happy to be there. The resident was actively engaged. The resident was a Sunday School teacher at their church and was very happy to see the Pastor -3/10/22 at 10:37 AM, documented the resident attended Lutheran Chapel yesterday. The resident was engaged actively and was calm and happy to be there. During an interview on 3/17/2022 at 9:04 AM, Licensed Practical Nurse (LPN) #3 stated the staff re-directed Resident #68 when needed and the resident attended activities. The LPN stated the resident had more behaviors on the evening and nights shifts and less on the day shift. During an interview on 3/17/2022 at 9:17 AM, CNA #1 stated the resident was not on a behavior management program. The CNA stated the resident did well with religious services. On the unit, the staff would try to walk the resident and give the resident a snack when they were agitated. The CNA stated a lot of times there was very little that could be done to contain the resident safely when the resident was agitated. The CNA stated the resident was kept in the hallway with a clip alarm so the resident could be seen and heard if the resident got up from the wheelchair. The CNA stated the night shift would have the resident in the Geri-chair and on the day shift, the staff tried to leave the resident in their wheelchair as much as possible. The CNA stated they had not received dementia care training and had been told to walk away when a resident was having behaviors. The CNA stated they could not just walk away and risk the resident falling when they were having behaviors. The CNA stated the resident was on the Rehab Unit and was not a Rehab candidate. During an interview on 3/17/2022 at 3:48 PM, CNA #3 stated the resident could be very confused, combative and could become agitated. The CNA stated they would talk to the resident and offer the resident something to drink. The CNA stated the CNAs told the nurses when a resident had behaviors and the nurses documented, or should document, resident behaviors in the medical record. The care card had interventions on it that the CNAs could use with the resident, but the interventions did not always work. CNA #3 stated they worked on the Rehab Unit on 3/15/2022, and although they did not recall specifically saying that's not in (the resident's) blood, the CNA stated they just meant that the resident was not going calm down because the staff kept telling the resident to sit down when the resident kept standing up. The CNA stated when there was enough staff, one staff would sit with the resident, but when there was not enough staff, they kept the resident close to the nurses' station or by the nurse passing medications. The CNA stated the resident mostly stayed in their wheelchair. CNA #3 stated they received dementia care training because they worked on the dementia unit. The CNA did not recognize the name Hand in Hand for dementia training and did not know how often they received dementia care training. During an interview on 3/18/2022 at 9:10 AM, LPN #6 stated the resident was a sundowner and around 1:30 PM the resident's behavior would escalate, and the resident would start saying they wanted to go home or wanted their family. The LPN stated they tried to orient the resident, but the resident could be physically aggressive with staff. The LPN stated the resident was not a good sleeper at night and the staff usually put the resident in the Geri chair. The LPN stated the resident was content in the Geri chair. During an interview on 3/18/2022 at 9:28 AM, CNA #4 the resident was confused and would look for their significant other. The resident was always trying to stand up and the staff just tried to get the resident to sit back down. The CNA stated sometimes they offered the resident a walk, but the resident was mostly in their wheelchair with an alarm. The CNA stated they received dementia care training upon hire and yearly. During an interview on 3/18/2022 at 10:07 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated the resident never really had any behaviors on day shift and the resident slept in their wheelchair by the nursing station. The LPNUM stated the resident was sitting right there and gestured where the resident was sleeping in their wheelchair near the nurses' station. The LPNUM stated right there might not be the best for the resident, but the resident was calm right now. The staff did not bother the resident if the resident was quiet and sleeping. The LPNUM stated the resident was physical with staff and constantly up and down from their wheelchair. The LPNUM stated the resident's behaviors started around 4:00 PM and continued on the night shift. The LPNUM stated the resident was on the Rehab Unit and the Rehab Unit was not the right place for the resident. The resident would be better upstairs on the dementia unit. The LPNUM stated the staff tried non-pharmacological interventions including music, calling the resident's significant other, and snacks. The resident was not on a behavior management program and the resident did not have a behavior log. The LPNUM stated they had not received dementia care training as they had always been a Rehab Nurse and never worked a dementia unit. The LPNUM stated since they had not had dementia training, they would talk to the psychiatrist about dementia and the progression of dementia. During an interview on 3/18/2022 at 12:46 PM, Director of Nursing (DON) stated they had not observed Resident #68's behavior firsthand. The DON had seen the resident in their wheelchair and wandering on the unit in their wheelchair. The DON stated Nurse Managers or the Registered Nurses in the facility assisted with dementia care planning. The DON stated Resident #68's care plan documented to play music for the resident and staff could bring the music out of the resident's room to where the resident was sitting on the unit. Sometimes it helped, sometimes it did not. The DON stated it was not on the care plan, but staff could offer the resident food. The DON stated the staff knew what interventions to do based on the resident's care card. The DON was made aware of the observation on 3/15/2022 with the resident standing up from their wheelchair and setting off the alarm. The DON stated the resident was pretty wabbly when they stood and staff could stand with the resident and depending on how many times the resident was standing up, the staff could figure out something else that worked, like putting the resident back to bed. The DON stated the resident had their nights and days mixed up and the staff could offer to put the resident in a Geri chair. The DON did not like the use of the Geri chair because the DON did not want the resident to climb out of it. The DON stated the Geri chair had worked to some extent when it was tried. The DON stated the resident was on their Rehab Unit, but the DON wanted the resident to go to a quieter unit. The Rehab Unit might get the resident going but moving to another unit would be another adjustment for the resident. When asked about making the resident's care plan for dementia person-centered as it included 2 interventions, the DON stated they were still trying to figure the resident out. The DON stated staff were provided with dementia care training annually and during orientation. 10NYCRR 415.12

Based on record review and interviews during a recertification survey dated 3/14/2022 through 3/18/2022, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #'s 24, 77 and #104) of 4 residents reviewed for ADL's. Specifically, for Resident #34,who required extensive assistance of staff for ADL care, the facility did not ensure incontinence care was provided as documented in the resident's care plan; for Resident #77, who was dependent on staff for ADL care, did not ensure the resident was shaved daily in accordance with the resident's preference and as documented on the resident's care plan, and for Resident #104, who was dependent on staff for ADL care, the facility did not ensure the resident was bathed or showered as documented on the resident's care plan. This is evidenced by: The facility did not provide a Policy and Procedure for Activities of Living (ADL) related to resident showers, incontinence care, personal hygiene and grooming. A document titled CNA (Certified Nursing Assistant) Standard of Care/Information Sheet dated 2/2019 documented Daily Morning Care: 1. Toilet as needed 2. Wash hands and face 3. Peri care 4. Dress in day clothes and non-skid footwear 5. Oral hygiene 6. Shave as needed 7. Make-up as requested 8. Nail care daily prn except diabetics. It documented to report all resident complaints and concerns regarding care, meals, activities and general expressions of unhappiness to the charge nurse. Resident #34: Resident #34 was admitted to the facility with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 3/8/2022, documented the resident had moderate cognitive impairment, could understand others and could make themselves understood. The MDS documented the resident required extensive assistance for toileting and toileting hygiene. The Comprehensive Care Plan (CCP) titled, Overactive Bladder incontinence/ [CONDITION(S)] bladder revised on 9/9/2019 documented the resident would be checked and changed every 2 hours. The CCP titled, ADL self-care performance deficit revised on 12/21/2021, documented the resident required extensive assistance of two staff for toileting use. The CNA Kardex (caregiving instructions) dated 3/16/2022 documented the resident required extensive assistance by two staff members for bed mobility and toileting. Additionally, for bowel/bladder care it documented the resident would be checked and changed every two hours. During an interview on 3/14/2022 at 11:22 AM, Resident #34 stated they did not receive incontinence care from before dinner on 3/13/2022 until after 6:30 AM on 3/14/2022. The resident stated this was reported to the day shift CNA and the CNA brought the nurse into the room to show the nurse how wet I was. During an observation and interview on 3/15/2022 at 9:25 AM, the resident was eating breakfast in bed and stated they received incontinence care by the night shift around 5:00 AM. Resident #34 stated they had not been checked or changed since that time. During an interview on 3/15/2022 at 2:19 PM, Resident #34 stated they were provided incontinence care today by the night shift CNA around 5:00 AM and by the day shift CNA around 11:00 AM when they received wound care by the nurse. The resident stated they did not refuse care today; it was not offered. During an observation and interview on 3/16/2022 at 9:54 AM, CNA #5 exited Resident #34's room with a bag of soiled linen in their hand. CNA #5 stated that was the first time since the start of their shift at 6:00 AM today that the resident was checked and changed and provided incontinence care. CNA #5 stated they regularly worked the day shift and were assigned to care for Resident #34. CNA #5 stated they regularly provided care to Resident #34 twice between 6:00 AM and 2:00 PM, once around 10:00 AM or 10:30 AM and again after lunch around 1:00 PM. CNA #5 stated they were unsure how frequently the resident was care planned for incontinence care. CNA #5 reviewed the resident's CNA Kardex during the interview and identified the resident was supposed to be checked and changed every two hours and stated they did not do that. During an interview on 3/16/2022 at 1:55 PM, Licensed Practical Nurse (LPN) #12 stated they were assigned to the resident on 3/14/2022 until 9:30 AM and was not made aware that Resident #34 had not been provided incontinence care on the overnight shift on 3/13/2022. During an interview on 3/17/2022 at 8:12 AM, LPNUM #7 stated they were unaware of the resident's allegations that they did not receive incontinence care from before dinner on 3/13/2022 until after 6:30 AM on 3/14/2022. The staff had not reported it to the LPN on 3/14/2022. LPNUM #7 stated CNA #6 and LPN #11 were assigned to the resident. The contact information for CNA #6 and LPN #11 was requested but was not provided to the survey team. Additionally, LPNUM #7 stated they began interviewing staff yesterday following the surveyor's interview with LPN #12 and identified at that time staff were not following the resident's CCP for incontinence care. During an interview on 3/17/2022 at 12:02 PM, the Director of Nursing (DON) stated they would expect staff to follow the resident's CCP to check and change the resident every two hours. The DON stated the LPNUM and LPN should ensure all care and services were being provided to the resident as per the CCP. Resident #77: Resident #77 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 2/4/2022 documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The CCP for ADL self-care performance deficit, last updated on 11/17/2021, documented the resident required limited assist of 1 staff for personal hygiene. The CNA Kardex dated 3/17/2022 documented the resident required extensive assist of 1 staff for personal hygiene. The Kardex did not document the resident preferred to have a beard. The Kardex also did not document the resident's preference was not to be shaved daily. A Documentation Survey Report dated 3/1/2022 - 3/16/2022, documented Resident #77 was provided personal hygiene, including shaving daily with an extensive assist of 1 staff. During an observation and interview on 3/14/2022 at 12:05 PM, Resident #77 was lying in bed and had a moderate amount of facial hair. The resident rubbed both sides of their face and chin and stated their beard was driving them crazy. The resident stated they preferred to be shave every day but was not longer able to shave independently. The resident stated the staff only shaved them once or twice a month, not daily. During an observation and interview on 3/15/2022 at 1:11 PM, Resident #77 was lying in bed and had a moderate amount of facial hair. The resident stated morning care was provided at 5:30 AM and staff did not shave them. During an observation and interview on 3/16/2022 at 11:02 AM, Resident #77 was sitting up in bed and a moderate amount of facial hair. The resident stated they had received morning care but had not been shaved. During an interview on 3/16/2022 at 11:11 AM, Licensed Practical Nurse (LPN) #10 stated residents should be offered to be shaved daily with morning care. The LPN stated the CNA Kardex would document when a resident's preference was not to be shaved. All other residents would be offered to be shaved. During an interview on 3/16/2022 at 11:30 AM, CNA #4 stated Resident #77 preferred to be shaved daily. The CNA stated the resident would explain this to new caregivers who may not be aware of their preferences. During an interview on 3/16/2022 at 12:46 PM, LPNUM #7 stated a resident's preference to maintain a beard and/or facial hair would be documented in the care plan, and if it was not specified on the care plan, then the resident should be shaved with morning care. LPNUM #7 stated they were not aware that Resident #77 was receiving assistance to shave during morning care. The LPNUM stated they would expect to have been notified if care was not provided, or when the staff were unable to complete a task for any reason. During an interview on 3/18/2022 at 11:38 AM, the Director of Nursing (DON) stated shaving was a resident preference and should be offered with morning care. Resident #104: Resident #104 was admitted with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 3/1/2022 documented the resident had moderately impaired cognition, could understand others and could make themselves understood. During an observation and interview on 3/14/2022 at 11:08 AM, the resident's hair was greasy (oily), and the resident stated they were supposed to get a shower 2x a week but had not had a shower since they were admitted to the facility. The resident stated they could use a shower and their hair was dirty. During an observation and interview on 3/15/2022 at 12:15 PM, the resident's hair was greasy (oily), and the resident stated they were offered a shower last evening, but the resident declined because they were not feeling well. The resident stated that was the first time they had been offered a shower and the first time they had declined. The resident stated they were not re-offered a shower last evening or this morning. The resident stated they wanted to shower, and their hair needed to be washed. The CCP for ADLs, last revised 3/2/2022, documented: Bathing/Showering- the resident required extensive assistance of 1 staff and was scheduled on Monday and Thursday evenings. A review of the CNA Documentation for Showers dated 2/22/2022 - 3/15/2022 documented: 2/28/2022- n/a (not applicable); 3/7/2022- no; 3/14/2022- n/a A review of Progress Notes dated 2/22/2022 - 3/15/2022 did not include documentation the resident refused to be bathed or showered and did not include documentation the resident was re-offered a shower from last evening (3/14/2022) after the resident reported they declined their shower due to not feeling well. During an interview on 3/17/2022 at 9:06 AM, CNA #1 stated the residents were supposed to be showered 2x a week. CNA #1 stated all of the showers did not get done and honestly, showers were missed. CNA #1 stated it was possible that both showers scheduled in the same week could be missed and not provided to the resident. The CNA stated they would re-offer the shower or communicate to the next shift to let them know when a shower was missed or refused. The shower would sometimes get picked up by the next shift and sometimes it did not. CNA #1 stated Resident #104 did not necessarily refuse care but dictated when they wanted care done. The CNA stated CNAs documented showers in the computer and documented the following for showers: Yes, No, Refused or N/A. During an interview on 3/17/2022 at 11:37 AM, CNA #2 stated when a CNA was unable to get a shower done on their shift, the shower would be given on the next shift or the next day. If a resident refused a shower, the CNA would let the charge nurse know and then the nurse and CNA would document the resident refused their shower. During an interview on 3/18/2022 at 9:59 AM, Licensed Practical Nurse Unit Manager (LPNUM) #2 stated Resident #104 was forgetful and noncompliant. The resident was particular when they wanted things done for them. The LPNUM stated staff had not reported to them that Resident #104 had refused to shower. The LPNUM stated if Resident #104 refused, then they would get a good bed bath with a shampoo shower cap or get a shower at another time. LPNUM stated if the resident's hair was greasy hair, the staff could have given the resident a bed bath and used a shampoo shower cap to wash the resident's hair. The LPNUM stated it had not been reported to them by staff that showers were not getting done. The LPNUM stated they would document in the resident's medical record if a shower was declined. During an interview on 3/18/2022 at 1:11 PM, the Director of Nursing (DON) stated prior to survey it had not been brought to their attention that Resident #104 had not received their showers. The DON stated the residents were showered 2x a week. The DON stated showers were specified on the care plan and the care plan was what the CNAs should go by when providing care. The DON stated if a CNA was busy, they would let nurse know, and the nurse would talk to the resident to see when the shower could be done. If the resident refused the shower, it should be re-offered. If the resident did not want to take a shower, the staff would give a bed bath and shampoo shower caps were offered to wash their hair. 10NYCRR415.12(a)(3)

Based on observation, medical record review and staff interviews during an abbreviated survey (Case #NY 082) it was determined for one (Resident #1) of four residents reviewed, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, Resident #1 sustained a second degree burn to his knee when receiving a hot pack treatment to his left knee. The facility did not have a policy for administration of hot packs. The facility did not assess the resident when the burn was identified. The area still required treatment 3 months after the accident occurred. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident #1: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident has no cognitive impairment. The Minimum (MDS) data set [DATE] assessed the resident was able to understand and was understood The resident had no cognitive impairment. Physician orders [REDACTED]. Hot pack to right knee as needed. Nurse's notes dated 1/1/14 on the 10:00 pm to 6:00 am shift, documented the resident was complaining of left knee pain. Hot pack applied to knee. Relief noted. An additional note dated 1/2/14 at 12:20 am documented the resident was noted to have a heart shaped red area on his left knee with the center partially fluid filled blister, measuring 1.5 by 1.0 cm; the surrounding area noted to measure 2.2 by 1.5 cm. Physician orders [REDACTED]. The facility was unable to provide any policy or procedure for application of a "hot pack." A facility form titled "Accident/Incident Report dated 1/2/14 (untimed) documented in the section "describe what happened", it documented the Registered Nurse Supervisor (RNS) retrieved a hot pack from the therapy department to be placed on the resident's knee. The hot pack was then applied by the agency nurse. Additional documentation included training to the RNS that was provided, regarding the application of hot packs for resident, that they are applied by the rehabilitation department only. A facility form titled "Summary of Investigation Report dated 1/2/14 (untimed), documented that a blister was noted to the resident's left knee with surrounding redness measuring 2.25 by 1.5 cm. (centimeters). The reddened area measured 1.5 by 1.0 cm. The resident had been receiving hot packs from physicial therapy (PT). The resident had requested a hot pack to his knee, which was discussed with the therapy program manager and the physician, and the hot pack was ordered for the resident. During the off hours, the resident requested a hot pack, the RNS retrieved hot packs from the therapy department for the resident. The hot pack was placed on the resident and the resident developed [DIAGNOSES REDACTED] and blistering to the left knee. The hot pack was removed and discontinued. The resident sustained [REDACTED]. physician progress notes [REDACTED]. Continue with Silvadine cream and Bactracin (antibiotic) every twelve hours for ten days. 1/16/14 continued to complain of pain in the left knee. Left patella second degree burn healing slowly, [DIAGNOSES REDACTED] present but improved, along with [MEDICAL CONDITION] and pain. On 3/19/14 the Weekly Wound Report documented the area was assessed as 2 cm by 1 cm and still required treatment with Santyl. During an interview on 3/19/14 at 3:15 pm the resident stated he had the hot pack applied and it felt warm and it burst or leaked. He then had a blister and the facility started a treatment. Sometimes the treatment is not completed, usually on the evening shift. During an interview on 3/20/14 at approximately 2:00 pm the PT program manager stated he was never contacted about an evaluation for the resident, and if he had, would never recommend hot moist treatment because ofthe residents underlying diagnosies. The PT manager stated those [DIAGNOSES REDACTED]. They tend to decrease the resident's sensorium. During a second interview 3/21/14 at approximately 11:00 am, the PT program manager stated and documented that there had been a conversation with him regarding the use of moist heat. He stated "he remembered a conversation" after the surveyor left the facility. He "had discussed the use of moist heat" for the resident, but did not think it would be benefical and that modality of therapy should not have been performed. During an interview on 3/20/14 at approximately 2:00pm the Director of Nursing stated she was unable to provide any documentation that a RN assessment was done when the resident was found to have a second degree burn to his left knee. During interview on 3/31/14 at 1:50 pm the resident's physician stated he was not aware that they facility did not have a policy/procedure use for hot pack application, and he would expect the facility to have a policy/procedure for use of hot packs. The physician stated he discussed the use of a hot pack with the physical therapist because the resident had pain in his knee which wasn't being relieved with medication. Normally with [DIAGNOSES REDACTED]. In this case the resident was not monitored and was burned. 10 NYCRR 415.12

Based on record review and staff interview, the facility failed to ensure that newly admitted and readmitted residents received the care and services required to ensure their optimal health and well being. Specifically, 6 (Resident #s 1, 2, 3, 4, 5, 6, ) of 14 residents admitted or readmitted to the facility failed to: receive all necessary physician ordered medications in a safe and timely manner, ensure that a Registered Nurse (RN) completed a thorough assessment for newly admitted and readmitted residents, ensure that medication omissions were investigated and action was taken to prevent recurrence. The facility failed to ensure that physician ordered medications were transcribed timely and clinical nursing staff identified and prevented avoidable medication omissions. Additionally, the facility failed to have systems in place to ensure that all physician orders [REDACTED]. This had the potential to affect all newly admitted and readmitted residents to the facility. This resulted in no actual harm that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care. This is evidenced by the following: The Policy and Procedure (P&P) for medication pass dated 10/2008 documented it is the policy of the facility that medications are administered safely and timely per physicians orders. The procedures included; acceptable medication pass time was one hour before and one hour after the scheduled time, document medications withheld, refused or given at a time other than scheduled. The P&P for Accident & Incident (A&I) reporting dated 09/2001 documented that it was the responsibility of all staff to report all A&Is that occur at the facility. All occurrences are investigated in a timely manner and preventive measures initiated. The purpose documented was to provide a mechanism for quality assurance and risk management, to ensure that all occurrences were reported and were thoroughly investigated and to ensure that residents involved received immediate assessment and treatment as appropriate. The P&P further documented the A&I report must be completed on the shift that the event occurred or was discovered and the Director of Nursing (DNS) reviews all A&I reports to ensure accurate and complete documentation of the incident. The P&P for abuse dated 08/2012 documented each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of funds. Mistreatment shall be defined as any covert omission of care such as medication omissions or treatment omissions. Listed under Identification it is documented that any complaint, observation or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. The facility will monitor trends and/or patterns of occurrence via the Quality Performance Committee in order to identify and suspicions of abuse as well as to rule out abuses. The P&P for Unavailable Medications dated 07/2010 documented; in the event that medication is unavailable, for any reason, the facility shall act promptly to notify the pharmacy and appropriate practitioners to obtain new medication supply. The P&P included: upon identification that a medication is unavailable for administration as per physician order, the nurse is to notify the Registered Nurse Supervisor (RNS) immediately. For any medication held or not given for any reason the nurse is to place an "H" in the box on the the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] All medications not administered are to be documented on the back of the MAR indicated [REDACTED]. Medication is to be administered as per physician order [REDACTED]. If the medication arrives after the indicated administration window, administer and adjust the timing of the next doses accordingly. Once determined a medication is unavailable; contact pharmacy and document, request STAT (immediate response), if needed pharmacy will contact alternate pharmacy for delivery, notify physician and document, document all medications held on 24 hour report (communication tool used to share resident information to RNS from shift to shift), complete medication error report and report errors to the DNS. There was no P&P for new admissions/ readmission's in place for the facility. The emergency box (EBOX, a box that is provided by the pharmacy and contained those medications that a facility deemed most likely to have an emergency need for) documented the contents which included [MEDICATION NAME] Regular Insulin. Position description which is not dated and is entitled Registered Nurse Supervisor documented: responsible for the general overseeing of the facility's operations and management including providing optimal care, communicating the facility's policies and ensuring the general order, safety and cleanliness of the facility. Follows all health, sanitary and infection control policies and maintains established standards of practice set forth by the facility's administration and nursing policies and procedures. The primary functions included are: makes house rounds and consults with charge nurse concerning new admissions and acutely/seriously ill residents, ensures availability of supplies and that all equipment is in proper working order, supervises to ensure the proper completion of accident/incident documentation and notification. Position description which is not dated and is entitled Charge Nurse-Licensed Practical Nurse (LPN) documented, responsible for the overall operation and optimal quality of care for the residents on the assigned unit. Follows all health, sanitary and infection controls policies and maintains established standards of practice. Primary functions include: makes rounds on assigned resident at least once every two hours, administers medication and treatments according to the physician's orders [REDACTED]. Other duties include: transcribes, documents and implements physician's orders [REDACTED]. Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Assessment, undated, documented the resident was alert and oriented. There was no Minimum Data Set (MDS)available. The Comprehensive Care Plan (CCP) dated 12/08/2012 entitled diabetes mellitus listed the problem as insulin dependent diabetes. Interventions included; monitor the fingerstick blood sugar( FSBS) per physician order, observe for signs and symptoms (s/s) of [DIAGNOSES REDACTED] (condition that occurs when your blood sugar is too low), observe for s/s of [MEDICAL CONDITION] (condition that occurs when your blood sugar is too high), and medications per physician order. The CCP dated 12/08/2012 entitled alteration in comfort listed the problem as Pain less than daily, with a medication order for Tylenol included the interventions of pain assessment every shift and as needed, [MEDICATION NAME] medications as ordered. The CCP dated 12/08/2012 entitled gastrointestinal problems with [DIAGNOSES REDACTED]. The Physician orders [REDACTED]. [MEDICATION NAME] N (NPH is an insulin with an intermediate duration of action. It has an onset of action starting about 2 hours following injection. It has a peak effect 4-12 hours) insulin 16 units subcutaneously (sc) before breakfast; [MEDICATION NAME] N insulin 13 units sc every evening at 9:00 pm; FSBS twice a day at 7:00 am and 4:00 pm with [MEDICATION NAME](a fast-acting mealtime insulin that may help control high blood sugar) sliding scale coverage as follows: 151-200 give 2 units sc 201-250 give 4 units sc 251-300 give 6 units sc 301-350 give 8 units sc Above 450 or below 60 call the physician Regular insulin (Regular insulin has an onset of action which begins to reduce blood sugar within 30 minutes of injection) 4 units sc every morning; Regular insulin 6 units sc at 5:00 pm. [MEDICATION NAME] 6.25 mg ( used to treat heart failure and hypertension ) two times a day. [MEDICATION NAME] 20 mg ( used to treat [MEDICAL CONDITION] reflux disease (GERD) and other conditions caused by excess stomach acid) two times a day. Tylenol 650 mg ( a pain reliever and a fever reducer) every four hours. The MAR indicated [REDACTED] [MEDICATION NAME] N (NPH) insulin 13 units sc at 9:00 pm, had a line through the signature box. This indicated the medication was not given on 12/08/12 at 9:00 pm. [MEDICATION NAME]coverage for sliding scale at 4:00 pm, had an X in the signature box. This indicated the fingerstick was not done and insulin coverage was not given on 12/08/12 at 4:00 pm. Regular insulin 6 units at 4:00 pm, had a line through the signature box indicating the medication was not given on 12/08/12 at 4:00 pm. [MEDICATION NAME] 6.25 mg two times a day, had a line through the signature box indicating the medication wasn't given on 12/08/12 at 7:00 pm. [MEDICATION NAME] 20 mg two times a day, had a line through the signature box indicating the medication was not given given on 12/08/12 at 7:00 pm. Tylenol 650 mg every four hours, had a line through the signature box indicating not given on 12/08/12 at 3:00 pm, 7:00 pm and 11:00 pm. The Nursing 24 hour Report sheet dated 12/08/2012 contained no documentation of Resident #1 on the report sheet. Nurse notes dated 12/08/2012 at 1:30 pm by a registered nurse had no documented information regarding the residents' medication. Physician history and physical (H&P) dated 12/10/2012 contained no reference to the resident not receiving her insulin and other medications on 12/08/2012. physician progress notes [REDACTED]. During an interview on 12/18/2012 at 2:00 pm Resident # 1 stated that her admission day was really bad. The resident stated she did not receive any of her medications that day. She stated she kept asking the nurse and certified nurse aides (CNA) for her insulin and nobody brought them. She stated she gets her insulin around dinner time and again at night and she also has her blood sugar checked in the evening and gets insulin coverage if needed. She further stated she did not remember seeing a supervising nurse after she was admitted to her room. During an interview on 12/18/2012 at 3:00 pm Licensed Practical Nurse (LPN) #1 stated on 12/08/2012 she worked the 2:00 pm till 10:00 pm shift (evening shift) and was floated (term used for assigning a staff member to a unit different from their usual) to two east. LPN#1 stated she was not used to working on that unit but she did state that she was familiar with the admission process and knew how to complete an admission. She stated she received report from the 6:00 am to 2:00 pm (day shift) nurse and was made aware of the new admission and that the medication list had to be done. She was very busy that night and called the supervisor on many occasions to ask for assistance, and the RNS#3 would not help her. When she reported off to the RNS#3 at 10:00 pm she stated that she told the supervisor that Resident #1 did not receive her medications or insulin and that he took the medication cart keys and said it would have to wait for the next shift. She stated she did not call the physician to make him aware of the insulin and other medications not given to Resident #1 but she should have. LPN#1 also stated she did not do a FSBS on Resident #1 and that she should have. She stated she did not know of any way to contact an administrative person above the supervisor when such a situation occurred. During an interview on 12/19/2012 at 9:20 am the physician stated he did not remember when he was made aware of the insulin and other medication omissions with Resident #1, that he thought it was the next day. He further stated that someone was not performing their duties that day and if he was made aware of any resident not receiving their insulin he would have ordered a fingerstick blood sugar and coverage for the resident. He stated that he thought there was other insulin in the facility that they could have used for the resident. During an interview on 12/18/2012 at 12:15 pm the DNS stated the admission process started with the RNS who would complete the skin check and the LPN would be responsible for the remainder of the admission process. The orders would be taken from the discharge summary from the hospital and sometimes they would received the discharge summary before the new resident arrived and could do the work before and if not it would be done after the resident arrived. He stated medications for new admissions should be available to be administered within four hours of admission or the pharmacy should be called and medications should be received from the local back-up pharmacy. He stated the RNS should follow up with the LPN to ensure completion of an admission. Documentation for an admission would be the admission packet and then the nurses should document in nurses notes as well. During an interview on 12/19/2012 at 11:15 am the DNS stated an A&I was not completed, but he did give a disciplinary counseling to the LPN for not completing the admission. The DNS stated he did not speak of the incident with Resident #1 to the RNS #3 and he did not look to see if there were similar problems with other new admissions. The DNS stated that RNS#3 should have gone in to see the new resident and that they are responsible to oversee the admission process. RNS#3 should have intervened to ensure the resident received the care she should have received. The orientation of Supervisors included the DNS speaking with them in regards to the admission process, he did not have documentation of this process. The DNS stated that when he started as the DNS two years ago he became aware of a problem with new admissions receiving their medications in a timely manner. He stated that he reinforced the P&P on unavailable medications at that time but did not follow up to ensure their were no further issues. The disciplinary notice dated 12/10/ given to LPN#1 for not completing admission orders [REDACTED]. The RN is responsible for the skin assessment and the LPN charge nurse completes the remainder of the admission process. This document was signed by the DNS and the Administrator. During an interview on 12/19/2012 at 12:00 pm the Administrator stated he had been at the facility since August 2012. He became aware of the medication error on Resident #1 last week from the DNS. He reviewed the disciplinary action written for the LPN with the DNS and viewed the incident as isolated. He did not think to look at other newly admitted residents for similar situations. He stated he was unaware that a medication error report was not done and he would expect that a medication error report would be done to determine root cause. He was unaware that the Nursing Supervisor or staff members were not interviewed or statements were not obtained related to the error. He stated he just found out on this day that a medication error report was not done. He further stated that he was unaware that 24 hour report sheets did not have documentation of new admissions. During an interview on 12/19/2012 at 1:30 pm RNS # 3 stated that on 12/08/2012 there was a tremendous amount of confusion due to the many call-ins. He stated that he spoke with the resident and introduced himself and checked to see that her needs were met. He further stated the RNS was responsible for the skin checks, vital signs on new admissions and readmission's and it ended there. The LPNs were responsible for the remainder of the admission which included the paperwork, calling the physician and pharmacy. He stated the medications are a priority and the LPNs are aware of that. RNS#3 stated that he is very busy when he supervises because he is in charge of the resident units as well as the first floor and the dietary personnel. The RNS stated he helped in the dining room that evening and no one ever told him there was a problem with the admission. Resident # 2: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no MDS available. The Physician orders [REDACTED]. [MEDICATION NAME] N insulin (an intermediate-acting insulin with a slower onset of action and a longer duration of activity, up to 24 hours) 22 units sc with breakfast. [MEDICATION NAME] N insulin 18 units sc with dinner. [MEDICATION NAME]12 units sc three times a day before meals. FSBS three times a day and HS (bedtime), with [MEDICATION NAME]sliding scale coverage as follows: 201-250 give 2 units sc 251-300 give 4 units sc 301-350 give 6 units sc 351-400 give 8 units sc 401-450 give 10 units If above 450 or below 60 call physician The MAR indicated [REDACTED] [MEDICATION NAME] N insulin 18 units sc with dinner at 5:30 pm. This had an X in the signature box which indicated the insulin not given on 12/14/12 at 5:30 pm. [MEDICATION NAME]12 units sc three times a day before meals at 7:30 am, 12:00 pm and 5:30 pm, had an X in the signature box which indicated insulin was not given on 12/14/12 at 5:30 pm. FSBS three times a day and HS (bedtime), with [MEDICATION NAME]sliding scale coverage, had an X in the signature box which indicated the FSBS was not done and insulin coverage not given on 12/14/12 at 5:30 pm. The Nursing 24 hour report sheet dated 12/14/2012 contained no documentation of Resident #2 not receiving her insulin as ordered by physician. Nursing Admission assessment dated [DATE] documented the resident was admitted on [DATE] with no time of day documented. The assessment was signed by an RN and LPN. There was no documentation regarding the medication not administered. There was no nurses note written on 12/14/2012. On 12/19/2012 there was no Comprehensive Care Plan (CCP) completed by the nursing staff. There was a dietary CCP dated 12/17/2012 which documented the problem of diabetes mellitus. The Physician H&P was signed by the physician on 12/17/2012. There was no documentation regarding the omission of the residents' insulin on 12/14/2012. During an interview on 12/18/2012 at 2:15 pm LPN #5 stated that she was working on two east on 12/14/2012 and it was a very busy day with three admissions and she has only been an LPN for four months. LPN #5 stated she was not sure of the time of admission but that it was on the 2:00 pm to 10:00 pm shift and around dinner time. She stated that the supervisor did the skin check and she saw the resident on admission. She stated that she reviewed the discharge medication list and called the physician and told him all the medications, she did not remember the time but that it was late. She stated she did not give the resident her insulin that evening and was not sure if she told the physician that the resident did not receive any of her insulin. LPN #5 further stated she did not document in the nurses notes about Resident # 2. She stated when she reported off to the 10:00 pm to 6:00 am shift nurse she does not remember what she told them but thought she mentioned that Resident # 2 was a diabetic. She stated that she did tell the supervisor but that she was busy also that night, that they were short a nurse. During an interview on 12/19/2012 at 9:20 am the physician stated he did not remember being told that Resident # 2 did not receive her insulin. He stated he would never allow an insulin to wait until it arrived. The physician stated he would have ordered a FSBS and would have given orders based on the result. He stated that he thought there was other insulin in the facility that they could have used for the resident. During an interview on 12/19/2012 at 11:15 am the DNS stated he was not aware of an A&I report. He stated he was not aware of Resident #2 not receiving her insulin. He further stated he did not know the time of her arrival to the facility. The DNS stated the orientation of supervisors included the DNS speaking with them in regards to the admission process. The DNS stated he did not have documentation of this process. The DNS stated that when he started as the DNS two years ago he became aware of a problem with new admissions receiving their medications in a timely manner. He stated that he reinforced the P&P on unavailable medications at that time but did not follow up to ensure their were no further issues. Resident # 3 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission Assessment documented the resident was alert and oriented. There was no MDS available. The CCP dated 12/13/2012 entitled diabetes mellitus listed as interventions to monitor finger sticks per physician order, observe for signs and symptoms of [DIAGNOSES REDACTED], observe for s/s of [MEDICAL CONDITION], medications per physician order. CCP dated 12/13/2012 entitled cardiovascular with hypertension (high blood pressure) listed the interventions to monitor pulse oximetry (a medical device that indirectly measures the amount of oxygen in a patient's blood) every shift, oxygen @ 4 liters per minute, medications as per physician's orders [REDACTED]. CCP dated 12/13/2012 entitled gastrointestinal problems with [DIAGNOSES REDACTED]. CCP dated 12/13/2012 entitled Respiratory with [DIAGNOSES REDACTED].@ 4 liters per minute, medicate per physician order, and medication nebulizer treatments as ordered. CCP dated 12/13/2012 entitled Constipation/fecal impaction with risks listed as use of pain medications and decreased mobility, included the interventions of observe for signs of constipation. Physician order [REDACTED]. FSBS three times a day and at hs with [MEDICATION NAME]sliding scale coverage as follows: 70-200 give 0 units sc 201-250 give 2 units sc 251-300 give 4 units sc 301-350 give 6 units sc 351-400 give 8 units sc 401-450 give 10 units sc Above 450 or below 60 call physician Acidophilus capsules (Acidophilus supports a favorable environment for the absorption of nutrients, encourages intestinal microflora balance, and promotes the healthy functioning of intestinal system), which is house stock only, give two capsules two times a day. [MEDICATION NAME] diskus 250/50 (inhalation medication for treatment of [REDACTED]. [MEDICATION NAME] 0.083%/milliliter (ml), one unit dose ([MEDICATION NAME] is a [MEDICATION NAME][MEDICATION NAME] that relaxes muscles in the airways and increases air flow to the lungs) via nebulizer (a device used to administer medication in the form of a mist inhaled into the lungs) four times a day. [MEDICATION NAME] ([MEDICATION NAME] treats fluid retention in people with [MEDICAL CONDITION], liver disease, or a kidney disorder) 40 mg three times a day "for systolic blood pressure less than 100 or heart rate less than 60 hold medication". [MEDICATION NAME] (used to treat high blood pressure)100 mg two times a day "for systolic blood pressure less than 100 or heart rate less than 60 hold medication". [MEDICATION NAME] 600 mg ([MEDICATION NAME] is used to treat [MEDICAL CONDITION] and nerve pain) three times a day. [MEDICATION NAME] 1000 mg two times a day ([MEDICATION NAME] is a medication used to treat adults with chronic [MEDICAL CONDITION]). [MEDICATION NAME] 20 mg/30 ml, 30 ml two times a day. . The MAR indicated [REDACTED] FSBS three times a day and at hs with [MEDICATION NAME]sliding scale coverage was documented as given at 5:00pm and 8:00pm. Acidophilus capsules, in house stock, give two capsules two times a day, had an X in the signature box indicating medication was not given on 12/13/12 at 3:00 pm. [MEDICATION NAME] diskus 250/50 one puff/inhalation two times a day, had an X in the signature box which indicated the medication was not given on 12/13/12 at 3:00 pm. [MEDICATION NAME] 0.083%/milliliter (ml), one unit dose via nebulizer four times a day, had an X in the signature box indicating medication not given on 12/13/12 at 3:00 pm. The 7:00 dose was initialed as given. [MEDICATION NAME] 40 mg three times a day "for systolic blood pressure less than 100 or heart rate less than 60 hold medication", had an X in the signature box indicating the medication not given on 12/13/12 at 3:00 pm. The 7:00 dose was initialed as given. [MEDICATION NAME] 100 mg two times a day "for systolic blood pressure less than 100 or heart rate less than 60 hold medication", had an X in the signature box indicating medication not given on 12/13/12 at 3:00 pm. [MEDICATION NAME] 600 mg three times a day. had an X in the signature box indicating medication not given on 12/13/12 at 3:00 pm. The 7:00 dose was initialed as given. [MEDICATION NAME] 1000 mg two times a day, had an X in the signature box indicating medication not given on 12/13/12 at 3:00 pm. [MEDICATION NAME] 20 mg/30 ml, 30 ml two times a day, had an X in the signature box indicating medication not given on 12/13/12 at 3:00 pm. The Pharmacy Delivery invoice documented that Resident #3's medications arrived at 1:30 am on 12/14/2012. Nursing 24 hour report sheet dated 12/13/2012 had no documentation of Resident #3 not receiving his medications as ordered by physician. Nurse notes for 12/13/2012 at 9:00 pm revealed a note written by an LPN fin regards to the resident being admitted and does not document the medications not given during the evening shift. The next nurses note was documented on 12/14/2012 at 2:00 pm. Physician history and physical (H&P) dated 12/14/2012 contained no reference to resident not receiving his medications on 12/13/2012. During an interview on 12/18/2012 at 2:15 pm LPN #5 stated that she was working on two east on 12/13/2012. She stated that the resident was admitted at 2:30 pm and she stated that she reviewed the discharge medication list and called the physician and told him all the medications. LPN#5 stated she was not able to get the medications in the computer until after 6:00 pm. She stated she did not call the physician to make him aware of the medications that were not available. She stated that the supervisor did the skin check and she did the remainder of the admission. She stated she did not think to give the 3:00 pm doses of twice a day medications. She stated the medications did not arrive on her shift and that those she signed for she probably borrowed but did not really remember. She stated she did not notify the RNS of any issues with Resident #3 medications. During an interview on 12/19/2012 at 9:20 am with the physician he stated he was not made aware of the medication omissions with Resident #3. He stated the resident's inhaler, BP medication and [MEDICATION NAME] should not have been omitted and he would have told them to get the medication from the back up pharmacy. During an interview on 12/19/2012 at 11:15 am the DNS stated he was not aware of the resident not receiving his medications. Resident # 4: The resident was admitted to the facility on [DATE], was hosptalized on [DATE] and readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident had no cognitive impairment. The CCP dated 11/13/2012 entitled diabetes mellitus listed interventions that included; monitor finger sticks per physician order, observe for signs and symptoms of [DIAGNOSES REDACTED], observe for s/s of [MEDICAL CONDITION], medications per physician order. The Physician orders [REDACTED]. FSBS three times a day and HS, with Humalog insulin sliding scale coverage as follows: 151-200 give 2 units sc 201-250 give 4 units sc 251-300 give 6 units sc 301-350 give 8 units sc 351-400 give 10 units sc If above 400 or below 60 call physician The MAR indicated [REDACTED] FSBS three times a day and HS, with Humalog insulin sliding scale coverage, at 7:30 am, 11:30 am, 5:00 pm, and 8:00 pm. The MAR indicated [REDACTED]. Nursing 24 hour report sheet dated 12/17/2012 documented that resident was readmitted on the 6:00 am to 2:00 pm shift. There was no documentation of Resident # 4 not having her FSBS done and insulin coverage not given as ordered by physician at 5:00 pm. Nurses notes were reviewed on 12/19/2012 and there was no nurse notes that documented the residents readmission on 12/17/2012. physician progress notes [REDACTED]. During an interview on 12/18/2012 at 11:30 am LPN #2 stated that the admission process for medications was to put them in the computer system, then call the physician and review the medications and receive an order. Then the medications would be sent to the pharmacy via the computer. If medications did not come in at the time they were to be administered the physician should be called for an order to give when the medications arrived. She stated the medication delivery times were 11:30 am, 8:00 pm and 11:00 pm. She stated she was not aware of the delivery of medications as a problem. During an interview on 12/18/2012 at 2:15 pm LPN #2 stated that she was working on two east on 12/17/2012 and Resident # 4 was readmitted on the 6:00 am shift to 2:00 pm shift and her orders were completed around 4:00 pm. She stated she did not do the 5:00 pm FSBS because the hospital nurse told her during a phone call that the resident received her daily insulin at the hospital and she did not think the fingerstick needed to be done. LPN#2 stated she did not document this in the nurse notes and she did not communicate this to the physician. During an interview on 12/19/2012 at 9:20 am the physician stated that the FSBS should have been done as ordered and the nurse should not have made the decision not to do it without speaking to him. Resident # 5: The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident was alert and oriented to person and place according to the Nursing Admission Assessment. There was no MDS available. CCP dated 12/12/2012 entitled cardiovascular with hypertension included the interventions, monitor vital signs per physician order, medications as per physician's orders [REDACTED]. CCP dated 12/12/2012 entitled anticoagulant therapy with potential for untoward affects due to anticoagulant therapy, history of [MEDICAL CONDITIONS] and surgical [MEDICATION NAME] had interventions that included anticoagulant therapy as ordered, labs as per physicians order. CCP dated 12/12/2012 entitled [MEDICAL CONDITION] medication with [MEDICATION NAME] and used as an appetite stimulant included the interventions, medications per physician order, observe for effectivenes

Based on record review, and staff interviews, the Administration 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. Findings rising to the level of Immediate Jeopardy were identified on 12/19/2012. Concerns rising to the level of immediate risk to resident health and safety included the facility failure to ensure 6 of 14 residents reviewed during an abbreviated survey ( NY 857) were provided routine and emergency medication in a timely manner as ordered by the physician, failed to ensure that a Registered Nurse (RN) completed a thorough assessment of newly admitted and readmitted residents, the facility failed to ensure that medication omissions were investigated and action was taken to prevent recurrence. The facility failed to ensure that physician ordered medications are transcribed timely and clinical nursing staff identified and prevented avoidable medication omissions. This resulted in no actual harm but had the potential to affect all newly admitted and readmitted residents that is Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Residents . Interviews revealed staff failed to complete the admission or readmission process for newly admitted and readmitted residents in a timely manner resulting in residents not receiving medications as ordered by the physician. Investigation further revealed that the staff were not following the facility policy by notifying the physician, pharmacy and supervisor when medications were not available for administration. Investigation further revealed that the omission of medications were not investigated to determine the root cause of the medication omissions and to prevent further incidence. This resulted in IMMEDIATE JEOPARDY to resident health and safety and Substandard Quality of Care and had the potential to affect all newly admitted and readmitted residents in the facility. This was evidenced by: Refer to F 309 scope and severity- K- Quality of Care During an interview on 12/19/2012 the Director of Nurses (DNS) stated he did not complete a medication error report or investigation on Resident # 1 but he did give a disciplinary counseling to the LPN for not completing the admission. He stated he did not speak of the incident with Resident # 1 or the nursing supervisor and he did not look to see if there were similar problems with other new admissions. He further stated he was not aware of any other medication omissions from prior or subsequent admissions. He did state that when he started in the facility as DNS two years ago he became aware of a problem with new admissions receiving their medications in a timely manner. He stated he reinforced the Policy & Procedure (P&P) on unavailable medications at that time but did not follow up to ensure their were no further issues. During an interview on 12/19/2012 with the Administrator he stated he had been at the facility since August 2012. He became aware of the medication error on Resident # 1 last week from the DNS. He reviewed the disciplinary action written for the Licensed Practical Nurse (LPN) with the DNS and he viewed the incident as isolated. He did not think to look at other newly admitted residents for similar situations. He stated he was unaware that a medication error report was not done and he would expect that a medication error report would be done to determine root cause. He was unaware that the Nursing Supervisor or staff members were not interviewed or statements were not obtained related to the error. He stated he just found out on this day that a medication error report was not done. He further stated that he was unaware that 24 hour report sheets did not have documentation of newly admitted residents care or treatments. 10NYCRR 415.26