Every finding on record at Trustees of Eastern Star Hall & Home of the N Y S

Based on observations, record review, and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for 2 of 2 medication carts ([NAME] and [NAME] Unit's medication carts); 1 of 2 medication rooms ([NAME] Unit); and 1 of 2 treatment carts ([NAME] unit). Specifically, the [NAME] and [NAME] Units medication carts had expired stock medications and insulin; the [NAME] medication room had expired stock medications and biologicals; and the [NAME] treatment cart was unlocked and unattended. Findings include: The undated facility policy, Storage and Maintenance of Medication, documented all drugs and biologicals were stored in the locked designated cabinets and stored under proper temperature controls. All medications, except those requiring refrigeration, were kept in locked medication carts and cabinets. Medications must be checked regularly for expiration dates and deterioration. Expired medications were removed from use and returned to the pharmacy. Bottles of eye drops, insulin, inhalers etc., were dated when opened and a sticker placed for 30 days to discard. A list of treatment cart contents received from the facility included: -medicated creams and ointments -urinary catheter bag covers -wound cleanser -adhesive bandages -hearing aids -hearing aid batteries -personal shavers -medicated shampoos -dressing supplies During an observation and interview on 11/6/2024 at 11:53 AM, the treatment cart on [NAME] unit was unlocked. The treatment cart contained individual trays with resident names. The items in the trays included diclofenac sodium cream (nonsteroidal anti-inflammatory) and clotrimazole betamethasone dipropionate (a topical antifungal). Licensed Practical Nurse #13 stated they did not lock the treatment cart after removing hearing aid batteries earlier that day. They stated the cart should be locked because it contained medicated creams. During an interview on 11/6/2024 at 11:58 AM, Registered Nurse Supervisor #10 stated the treatment cart should be locked. On 11/6/2024 at 1:09 PM, the [NAME] Unit medication room was observed with Licensed Practical Nurse #11. A shelf contained an opened bottle of Vitamin B-12 1000 micrograms with a manufacturer's expiration date of 9/2024. The medication refrigerator contained 2 boxes (17 syringes total) of single dose Afluria (influenza vaccine) 0.5 milliliter syringes with manufacturer's expiration date of 5/31/2024. Licensed Practical Nurse #11 stated those medications were expired and should have been disposed of. They stated all nurses were responsible for checking the medication carts and rooms for expired medications prior to giving any medication. They were unsure if someone was assigned to perform medication room and cart checks on a scheduled basis. On 11/6/2024 at 1:15 PM the [NAME] Unit medication cart was observed with Licensed Practical Nurse #12. The middle drawer of the cart contained an opened bottle of antacid tablets with a manufacturer's expiration date of 7/2024. On the side of the bottle was a handwritten opened date of 9/8/2024. Licensed Practical Nurse #12 stated they were unaware of any resident who received the antacid. Any nurse opening a bottle and/or administering a medication should check the expiration date prior to opening the bottle or giving the medication. On 11/6/2024 at 1:25 PM the [NAME] Unit medication cart was observed with Licensed Practical Nurse #13. The top drawer of the cart contained an opened bottle of multivitamins with iron with a manufacturer's expiration date of 4/2024; an opened bottle of aspirin 81 milligrams with no legible manufacturer's expiration or opened date; an opened bottle of aspirin 325 milligrams with a manufacturer's expiration date of 7/2024; and a Glargine (insulin) pen with no opened date on the pen and no plastic bag for the pen. Licensed Practical Nurse #13 stated they gave the resident insulin from the pen that morning and gave another resident an 81 milligram aspirin from that bottle this morning. They expiration dates were checked every night shift. All nurses should check the expiration dates prior to administration of medications. They did not check the expiration dates prior to administration as they trusted the night shift nurse removed all expired medications. During an interview on 11/8/2024 at 9:13 AM, Licensed Practical Nurse Manager #14 stated stock medications were kept in the medication rooms on each unit. All medications should be checked for expiration dates when unit staff were ordering par levels for the unit. All medications should be checked in the medication rooms, the medication carts, and the medication refrigerators when checking monthly stock inventory. Any expired medication was to be disposed of. Each nurse should check the expiration date prior to administering a medication. If an expiration date was not readable, it was deemed expired. Insulin was only good for 30 days past the open date, therefore, if there was no opened date, it was considered expired. It could be harmful for a resident to receive an expired medication depending on the medication's purpose. The treatment cart contained supplies and prescribed treatments like creams which could harm a resident if they were ingested. The treatment cart should have been locked. During an interview on 11/8/2024 at 12:20 PM, the Director of Nursing stated all day shift nurses should check the medication carts and rooms for expired medications. All medications should be labeled with an opened date. No opened date on insulin meant the medication was expired as the insulin was only good for 30 days once opened. Any stock medication without a legible expiration date was considered expired. Any expired medication bottle past the expiration date should not be opened and the medication not given to a resident. All treatment carts should be locked if unattended as they contained medicated creams which could be harmful if a resident got into them. 10NYCRR 415.18(d) 48446

Based on observations and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure the results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members, and legal representatives of residents for 1 of 1 Federal Health Recertification survey. Specifically, the results of the most recent Federal health recertification survey conducted 2/23/20223 were located behind the reception desk on a high shelf and was not accessible to all without having to ask for assistance. Findings include: During a Resident Council meeting on 11/6/2024 at 1:56 PM, eight anonymous residents in attendance stated they did not know they could view the previous survey results and did not know where the results were located. During an observation on 11/7/2024 at 3:45 PM, the State Survey binder was on a shelf on a table behind the reception desk in the main entrance to the building. The area was not accessible to residents or visitors. During an interview on 11/7/2024 at 4:46 PM, Receptionist #4 stated if a resident or family wanted to see the State Survey binder for the previous survey, they would have to ask them for it. They stated residents or visitors did not go behind the reception desk and the survey results were too high for residents to reach especially from a wheelchair. During an interview on 11/8/24 at 8:19 AM, Social Worker #3 stated it was a resident right to view the previous survey results. The results were located at the reception area and in Administration. They were not sure if residents could access them without asking. The results used to be posted in a living room, but they were moved when the living room was no longer being used. During an interview on 11/8/2024 at 9:38 AM, the Administrator stated it was a resident right to have survey results available and accessible without asking for them. They were not aware the results were not accessible without asking staff for assistance as they were new to the role as the facility Administrator. 10NYCRR 415.3(c)(v)

Based on record review and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries for 1 of 3 residents (Resident #276) reviewed. Specifically, Resident #276 remained in the facility after discontinuation of Medicare Part A services and the facility did not provide the resident with timely Notice of Medicare Non-Coverage (Centers for Medicare and Medicaid Services-10123) when Medicare Part A coverage was ending and a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (Centers for Medicare and Medicaid Services-10055) for Medicare Part A as required. Findings include: The Center for Medicare and Medicaid Services form instructions for the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage Center for Medicare and Medicaid Services-10055, expiration date 1/31/26, documented a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (form 10055) must be issued by providers to beneficiaries in situations where Medicare payment was expected to be denied. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage must be delivered far enough in advance that the beneficiary or representative had time to consider the options and make an informed choice prior to services ending. Resident #276 had diagnoses including cerebral vascular accident (stroke), aphasia (difficulty speaking), and anxiety. The 8/5/2024 Minimum Data Set assessment documented it was a Skilled Nursing Facility Part A Prospective Payment System (a method of reimbursement used by Medicare that pays a predetermined amount for a service) discharge assessment and the resident had a Medicare-covered stay with a start date of 5/7/2024 and an end date of 5/23/2024. The resident had moderately impaired cognitive skills for daily decision making. The Notice of Medicare Non-Coverage for Centers for Medicare and Medicaid Services-10123 letter documented Resident #276's effective end date of services was 5/23/2024. The handwritten note on the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage documented the Notice of Non-coverage Center for Medicare and Medicaid Services-10055 was not provided because the resident resumed Medicaid coverage. The facility policy regarding Beneficiary Notification was requested on 11/7/2028 and on 11/8/2024 at 3:16 PM, Administrative Assistant # 7 stated the facility did not have a policy regarding notice of Medicare non-coverage. During an interview on 11/8/2024 at 11:23 AM, Accounts Receivable Coordinator #19 stated they determined who received an Advanced Beneficiary Notification if the resident remained in the facility and had no other payor resource. They did not give the form to residents with Medicaid because Medicaid would pick up coverage for the residents stay. During an interview on 11/8/2024 at 12:59 PM, the Administrator stated they were familiar with the Notice of Medicare Non-coverage and Advanced Beneficiary Notices, however, was not involved in the process. They stated residents who remained in the facility that came off Medicare Part A needed an Advanced Beneficiary Notification. They were not aware accounts receivable was not issuing them to residents who had Medicaid and should have been. 10 NYCRR 483.10 (g) (18)

Based on record review, and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for 1 of 1 resident (Resident #218) reviewed. Specifically, Resident #218 did not have their ordered blood sugars documented in the medical record and were not available for the medical provider's review. Findings include: The undated facility policy, Protocols for Diabetic Residents, documented if a resident on insulin had a blood sugar over 240 (milligrams/deciliter) the provider was notified the following day. If the resident had a blood sugar of 420 and was symptomatic the provider was informed. If the residents blood sugar was 420 and the resident was not symptomatic the provider was informed the following day. Residents with blood sugars less than 60 were given glucagon (a hormone that raises blood sugar levels) 1 milligram injection in the muscle under nursing supervision with a blood sugar repeated every 30 minutes until the blood sugar was over 90. Resident #218 had diagnoses including diabetes. The Minimum Data Set assessment had not been completed as the resident was a new admission. Physician orders documented: - on 11/4/2024 Lantus Solostar (long-acting insulin) U-100 Insulin 100 unit/milliliter (3 milliliter) subcutaneous (under the skin) pen; inject 25 units by subcutaneous route once daily. - on 11/5/2024 morning blood sugar at AM before breakfast and at bedtime at 7:00 AM and 8:00 PM. The 11/5/2024 provider admission progress note documented Resident #218 was admitted with Type 2 Diabetes Mellitus with unspecified complications. They were on a diabetic diet. Medications were ordered for Tradjenta 5 milligrams daily, Jardiance 10 milligrams daily, and [NAME] insulin 25 units twice daily. The resident's blood sugars were to be monitored and medication would be adjusted as needed. The 11/2024 Treatment Administration Record documented monitor blood sugars before breakfast and at bedtime at 7:00 AM and 8:00 PM. - on 11/5/2024 the 7:00 AM blood sugar was marked with a dash and no nurse initials. The 8:00 PM blood sugar was marked as completed by Licensed Practical Nurse #21. Neither time had a documented blood sugar result. - on 11/6/2024 the 7:00 AM blood sugar was marked as completed with no documented blood sugar result. The 8:00 PM blood sugar was documented as completed by Licensed Practical Nurse #21 with no documented blood sugar result. There were no documented blood sugar results in the 11/5/2024 or 11/6/2024 nursing progress notes. During an interview on 11/8/2024 at 10:32 AM, Licensed Practical Nurse #21 stated they cared for Resident #218 the last few nights and the resident had an order for blood sugars to be completed every evening at 8:00 PM. They stated they did not think there was a place in the electronic record to document the blood sugar results. They stated they obtained the resident's blood sugar, thought they had recorded it, but could not remember where. They stated If a blood sugar was not documented in the electronic medical record, it was not completed. On 11/8/2024 at 11:32 AM a telephone interview was attempted with Physician #15. A voicemail message was left with no return call prior to survey exit. During an interview on 11/8/2024 at 11:55 AM, the Director of Nursing stated testing blood sugars required an order from the provider. All blood sugars should be recorded in the electronic chart or on a paper Medication Administration Records. If blood sugars were not documented, it was a medication error and if a blood sugar was too low and the resident received insulin it could cause a diabetic reaction. 10NYCRR 415.12

Based on observations, record review, and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 1 of 1 resident (Resident #37) reviewed. Specifically, Resident #37 did not have their pressure ulcer wound vacuum dressing (a vacuum assisted wound closure device that uses suction to help heal wounds) changed every three days as ordered. Findings include: The undated facility policy, Pressure Ulcer Prevention Treatment Plan, documented a skin care plan would be initiated on admission and carried forth through discharge to assure prevention, early detection, and treatment of any pressure ulcer. Interdisciplinary wound care observations were made on residents with Stage 2 to Stage 4 pressure areas per the treatment plan of care at least weekly by the Nurse Manager and the nutritional services personnel. The facility policy, Care Planning, dated 11/2017, documented an individualized comprehensive care plan that included measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs was developed for each resident upon admission. Resident #37 had diagnoses including pressure ulcer to the sacral region (low back, buttocks area), sepsis (system wide infection), and Parkinson's Disease (a progressive neurological disorder). The 8/3/2024 Minimum Data Set assessment documented the resident was cognitively intact, required substantial assistance for most activities of daily living, had an unstageable (full thickness tissue loss in which the base of the ulcer cannot be visualized) pressure ulcer that was not present on admission, and received application of nonsurgical dressings. The Comprehensive Care Plan revised 8/16/2024 documented the resident had skin breakdown from pressure to their sacral area. Interventions included turning and positioning every 2 hours, wound care rounds weekly, and pressure relieving devices as appropriate. The care plan did not include the use of a wound vacuum. A 10/10/2024 outside Wound Care Physician progress note documented the resident had a sacral pressure wound which had improved. The wound was debrided (removal of dead tissue) and was a Stage 3 (full thickness tissue loss). The plan was to begin wound vacuum assisted closure at 125 millimeters of mercury (pressure reading) with black foam, 3 times per week. The dressing to be used until the vacuum was started and daily back up dressing if the vacuum needed to be removed for any reason was skin prep to the peri ulcer, collagenase (an enzyme used to remove dead tissue), Mesalt (a dressing used to manage heavily draining wounds), ABD pad (a thick bandage), and secure with tape. Physician #15 medical order renewals documented: - 10/25/2024 if wound vacuum loses suction for more than 2 hours clean wound with normal saline, pat dry, cut Mesalt sodium chloride to size, place on wound bed, and cover with super absorbent foam dressing as needed. - 10/28/2024 skin prep (skin protectant) to peri wound (area surrounding the wound). Wound VAC (vacuum assisted closure, a device that uses suction to help heal wounds). Apply predrape (keeps a seal and eliminates leaks), fill wound with black foam, apply track pad (tubing used for suctioning) to appropriate side. Wound vac set to 125 millimeters of mercury (pressure). Change every three days on the day shift. The 11/2024 Treatment Administration Record documented: - skin prep to peri wound, apply predrape, fill wound with black foam, apply track pad to appropriate side. Wound vacuum set at 125 millimeters of mercury, change dressing 3 times weekly with a start date of 10/29/2024 at 12:30 PM. Administer during 7:00 AM-3:00 PM shift and as needed. The treatment scheduled for 11/4/2024 was not documented as administered and had a - in the corresponding box. Licensed Practical Nurse #16 signed for Resident #37's other treatments administered on 11/4/2024 during the 7:00 AM-3:00 PM shift. There were no documented nursing notes addressing the resident's wound vacuum dressing change for 11/4/2024. During an observation and interview on 11/7/2024 at 9:43 AM, Registered Nurse Supervisor #10 stated the wound vacuum dressing was ordered to be changed every three days. The dressing was observed and dated 11/1/2024. They removed the old dressing dated 11/1/2024 and stated the dressing was ordered to be changed 11/4/2024 and was not changed. They stated because the dressing was not changed as ordered the foam was really stuck to the wound bed. In an effort not to remove new tissue, they had to soak off the old dressing. They used two bottles of normal saline and waited several minutes to remove the old dressing. The wound had a foul odor. They stated when dressings were not changed as ordered the resident's wound could worsen and become infected. During an interview on 11/8/2024 at 10:43 AM, Licensed Practical Nurse #16 stated the wound vacuum dressing for Resident #37 was changed every three days. They stated when the treatment was scheduled on their day, they notified the Nurse Manager as they were not trained on how to care for a wound vacuum and were not going to change the dressing. They stated the Unit Manager was going to educate them on how to care for the wound vacuum dressing but had been too busy and had not completed the education yet. They stated they did not document the dressing was changed on 11/4/2024 because they did not change it and was not trained on it. If the dressing was not changed as ordered the resident can get an infection in the wound. During an interview on 11/8/2024 at 11:55 AM, the Director of Nursing stated 10 nurses, including Unit Managers and licensed practical nurses received training on wound vacuums from the company that manufactured the wound vacuums. They did not believe Licensed Practical Nurse #16 attended the training. If staff was not trained on the wound vac, they should notify the Registered Nurse Supervisor and document in the electronic record who was notified. If the dressing was not done as ordered the resident could get an infection, become septic, and the wound could worsen. If the dressing was dated 11/1/2024 when changed 11/7/2024 the dressing was not done as ordered. 10NYCRR 415.12(c)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00353222) surveys conducted 11/5/2024-11/8/2024 the facility did not ensure the resident environment remained as free of accident hazards as is possible for 1 of 3 residents (Resident #26) reviewed. Specifically, the facility did not ensure egress doors were secure and Resident #26 was able to exit through the doors and was found in the stairwell, scooting down the steps on their bottom. Findings include: Resident #26 had diagnoses including dementia, difficulty walking, and history of falling. The 6/7/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not exhibit wandering behaviors, did not walk, required substantial/maximal assistance for transfers, used a manual wheelchair, was dependent for wheelchair mobility, and did not use a wander/elopement alarm. The comprehensive care plan initiated 10/24/2022 documented Resident #26 had cognitive impairment. Interventions included increasing cognitive levels for activities of daily living, safety, and quality of life. The resident had an alteration in functional status with interventions including extensive assistance of one for transferring. The resident was at risk to fall, and interventions included appropriate footwear, request assistance with transferring, engage in activities, keep the environment free from clutter, bed in the lowest position, call bell in reach, and respond to the call light promptly. The updated 9/6/2024 care plan documented the resident was at risk for elopement and interventions included redirecting negative behaviors, regularly assessing for elopement risk, social services evaluation, and monitoring ankle alert. The 8/31/2024 Nursing Elopement Risk Assessment documented Resident #26 was not at risk for elopement. The 9/3/2024 at 5:15 AM incident report completed by Licensed Practical Nurse #24 documented Resident #26 was not in their room and they began searching for the resident in the hallway and rooms. The resident was found in the stairwell by a dietary aide. The resident was scooting down the stairwell steps on their buttocks when found. Contributing factors included increased confusion, the resident was awake earlier than usual that morning. The investigation summary documented the resident was able to self-propel in their wheelchair. A reenactment was completed using video footage. The resident was observed pushing open the door and was able to get through the door with a lot of difficulty but was able to do so. A wander alert device was applied. The incident was reviewed by the Director of Nursing on 9/7/2024. There was no documented evidence how the resident was able to exit through a door without being noticed or without the door alarming. The 9/3/0243 at 5:22 PM Social Worker #3 progress note documented Resident #26 was found sitting on the bottom of the stairs in the stairwell. The resident was evaluated by nursing staff with no noted injury. The resident was alert however cognitively impaired related to diagnosis of dementia. As a rule, does not engage in conversations and it takes a lot of encouragement to get them to respond with one or two words. In light of this, a wander guard has been placed on her person as well as her wheelchair. During an observation and interview on 11/8/2024 at 8:49 AM, Licensed Practical Nurse #14 stated the door to the stairwell to the right when looking at the receptionist desk alarmed and was able to be turned off. They stated this was the stairwell Resident #26 was found in on 9/3/2024. When attempting to open the door, the bar moved however did not unlock. Licensed Practical Nurse #14 stated to release the door, you had to hold the bar for 45 seconds. After 45 seconds the door still did not release. Licensed Practical Nurse #14 stated you can put in a code and the door would alarm until the code was entered a second time. During an interview on 11/8/2024 at 9:11 AM, Maintenance Director #7 stated they checked the doors annually and visually on a weekly basis. After putting in a code there was 15 seconds to get through the door before it alarmed. The door would not open without a code. They were aware Resident #26 got into the stairwell on 9/3/2024. They did not believe they were questioned about the doorways during the investigation. After the incident they checked all the doors, and they were functioning. They were not sure how the resident got through the doors if they were locked and functioning. They did not believe the door was ever unlocked as it was an entrance for staff and the door had always alarmed after being opened for more than 15 seconds. During an interview on 11/8/2024 at 1:20 PM, Licensed Practical Nurse #24 stated on 9/3/2024 while a certified nurse aide was changing Resident #26, they went to another unit to administer medications. When they returned Resident #26 was missing so they called a code for a missing resident. They located the resident in the stairwell on the middle of the stairs. The door to the stairwell was not locked and did not alarm after 15 seconds. They were unsure how long the door was unlocked prior to the incident or why it was unlocked. During an interview on 11/8/2024 at 11:55 AM, the Director of Nursing stated they arrived at the facility after getting a call about Resident #26 getting into the stairwell on 9/3/2024. The resident was located at approximately 5:30 AM when dietary staff came through the staff entrance and saw the resident 1-2 steps from the bottom stair scooting down the stairs on their buttocks. After the incident part of the plan of correction was putting a keypad on the door. There was not a keypad on the door at the time and the door was not locked as it was an employee entrance. The door was not a fire door with a delayed egress for as long as they had been employed. During an interview on 11/8/2024 at 12:59 PM, the Administrator stated at the time of the 9/3/2024 incident with Resident #26 the door was an employee entrance and exit. The fire doors in the hallways were usually closed at night to deter wanderers from going across the center. After the incident the door was secured. 10 NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted [DATE]-[DATE], the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen had unclean, scratched, and dented ceiling tiles, unclean ovens, pans with baked on debris, and expired cannisters of 3 bay sink sanitizer test strips. Findings include: The facility policy, Cleaning Procedure Conventional Ovens, updated ,d+[DATE], documented conventional ovens interiors and exteriors were cleaned daily. The interior was cleaned with detergent solution with special attention to the corners. The exterior was cleaned with stainless steel cleaning solution. The following observations were made in the main kitchen: - on [DATE] at 6:31 PM the dish machine area ceiling tiles were not cleanable, and were scratched, dented, and damaged. - on [DATE] at 6:35 PM two ovens were unclean on the inside and outside. - on [DATE] at 9:00 AM four pans on a clean pot rack had baked on debris and were not clean. - on [DATE] at 9:20 AM two cannisters of sanitizer test strips for the 3 bay sink had an expiration date of [DATE]. -on [DATE] between 9:00 AM and 9:20 AM, the ceiling tiles were not cleanable, and were scratched, dented, and damaged. During an interview on [DATE] at 9:17 AM, Interim Food Service Director #5 stated they were aware the ceiling tiles in the kitchen that were unclean, scratched, damaged, and dented and were not cleanable. They stated the outside of the two ovens were unclean and not acceptable. They were not able to locate a specific cleaning schedule for outside of the ovens. They stated the 4 pans on the pot rack were old and should have been taken out of service. They verified the two canisters of sanitizer strips located near the three bay sink were expired [DATE] and they were responsible for checking the sanitizer strip dates. It was important the main kitchen was kept clean manner, so residents and staff did not get sick. During an interview on [DATE] at 10:00 AM, Kitchen Supervisor #6 stated there were damaged, dented, and chipped ceiling tiles, that were not cleanable. Once the tiles were dented or chipped those regular tiles could not be cleaned and needed to be replaced. It was the cook's responsibility to clean inside and outside the two ovens. They stated the ovens were cleaned twice a week by the night cooks. They verified 4 pans had baked on debris and should have been discarded. They were not aware the sanitizer test strips were expired. The Food Service Director was responsible for ensuring strips were not expired. The previous Food Service Director left 2 weeks ago. They stated it was important to keep a clean kitchen to avoid pests and for the safety of residents. 10NYCRR 415.14(h)

Based on observations and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure there was an effective pest control program for the main kitchen and the [NAME] Unit. Specifically, fruit flies and drain flies were observed in the main kitchen and on the [NAME] Unit. Findings include: The facility pest control policy was requested on 11/7/2024 and was not received. The following observations were made: - on 11/5/2024 at 6:18 PM approximately 5 drain flies and 5 fruit flies were in the main kitchen dish machine room. - on 11/6/2024, between 9:00 AM and 9:20 AM 2 drain flies and 5 fruit flies were in the main kitchen dish machine room. - on 11/6/2024 at 10:08 AM there were ten fruit flies in the [NAME] Unit Kitchenette. - on 11/6/2024 at 10:10 AM there was one fruit fly on the ceiling near the housekeeping closet on the [NAME] Unit. - on 11/8/2024 at 8:45 AM 2 live drain flies and 10 live fruit flies were in the main kitchen dish machine room. During an interview on 11/8/2024 at 9:17 AM, Interim Food Service Director #5 stated pest control service came every three weeks and was last at the facility two weeks ago. They were not aware of fruit flies or drain flies in the kitchen as staff did not report them. They had only been covering the facility for two weeks and stated it was important to maintain a pest control program for the safety of residents, so they do not get sick. During an interview on 11/8/2024 at 10:00 AM, Kitchen Supervisor #6 stated a pest control service came monthly. They were aware of the fruit flies and drain flies and stated fruit flies could come in by bringing in outside food. They had not seen a lot of fruit flies since being hired and because there was no odor in the dish machine area, they were not sure where the drain flies were coming from. They had not reviewed or maintained the monthly pest control log and was not given any directions to eliminate pests. It was important to review and maintain the pest control logs for food safety and the safety of the residents. They were not aware of fruit flies in the [NAME] unit kitchenette or hallway. During an interview on 11/8/2024 at 11:25 AM, Director of Environmental Services #7 stated they could not find any monthly pest control logs from 3/2023 through 10/2024. On 10/17/2024, immediately after the previous Food Service Director left the facility, they had secured a new vendor agreement to complete pest control. During an interview on 11/8/2024 at 11:15 AM the Administrator stated they expected the facility to be free from pests. The Food Service Director oversaw the kitchen. They stated they had only been the Administrator since August and when they realized there was not a pest control program, they reached out to different vendors and signed with a pest control vendor in October 2024. They stated if there were pests in the facility, it was not homelike for residents. 10 NYCRR: 415.29(j)(5)

Based on record review and interviews during the recertification survey conducted 11/5/2024-11/8/2024, the facility did not ensure they assessed residents using the quarterly review instrument specified by the State and approved by the Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 3 of 70 residents (Residents #14, #16, and #50) reviewed. Specifically, Residents #14's, #16's, and #50's Minimum Data Set assessments were completed later than 14 days after the Assessment Reference Date (the final day of the observation period to gather information about a resident's condition when completing the assessment). Findings include: 1) Resident #14 had diagnoses including lymphedema (disrupted flow of lymph fluid), heart failure, and hypertension. The quarterly Minimum Data Set assessment documented an Assessment Reference Date of 9/18/2024 and was completed on 10/28/2024. 2) Resident #16 had diagnoses including lung cancer, peripheral vascular disease, and arthritis. The quarterly Minimum Data Set assessment documented an Assessment Reference Date of 12/26/2023 and was completed on 2/2/2024. 3) Resident #50 had diagnoses including Alzheimer's disease, renal failure, and depression. The quarterly Minimum Data Set assessment documented an Assessment Reference Date of 9/7/2024 and was completed on 10/24/2024. During an interview on 11/8/2024 at 8:19 AM, Social Worker #3 stated the Minimum Data Set Assessments were done by Minimum Data Set Coordinator #18. They were done upon admission, annually, quarterly, and with any significant change. They were used to get a picture of the residents' needs and to develop the plan of care. They were also required to receive reimbursement from Medicare and Medicaid. They were unaware of resident assessments not being current. During an interview on 11/8/2024 at 3:16 PM Administrative Assistant #17 stated the facility did not have a policy regarding Minimum Data Set Completion. During an interview on 11/8/2024 at 8:26 AM, Minimum Data Set Coordinator #18 stated they were the only person completing Minimum Data Set Assessments on a 92 day rotation which allowed for wiggle room if they needed it. They stated the facility recently had an influx of admissions and they were behind. When they started in this position the process was completed by the interdisciplinary team and when staff from the interdisciplinary team decreased, they were asked to complete more sections until they were completing the entire assessment. Resident #14 should have had their assessment done by 10/14/2024 and submitted by 10/16/2024. It was not completed until 10/28/2024. Resident #16's assessment should have been completed by 1/9/2024 and submitted by 1/23/2024 and was not completed until 2/2/2024. Resident #50's assessment should have been completed 9/21/2024 and submitted by 10/6/2024 and was submitted 10/24/2024. They stated the assessments were late because they were behind. During an interview on 11/8/2024 at 11:15 AM, the Administrator stated Minimum Data Set Assessments were the responsibility of Minimum Data Set Coordinator #18. They were completed upon admission, quarterly, and with any significant change. If they were not done timely the resident could have a decline and the care plan would not be current. 10NYCRR 415.11(a)(4)

Based on observation, interview, and record review during the recertification survey conducted 2/21/23-2/23/23, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 14 windows on the [NAME] unit (1 window at the nursing station, 2 windows in the dining room, 1 window in the soiled utility room, 1 window in the kitchenette, 2 windows in resident room [ROOM NUMBER], 2 windows in resident room [ROOM NUMBER], 2 windows in resident room [ROOM NUMBER], 2 windows in resident room [ROOM NUMBER], and 1 window in the shower room). Specifically, windows on the [NAME] unit were able to fully open without restriction. Findings included: There was no documented facility policy addressing window restrictors or routine window inspections. During observations on 2/21/23, the following windows in the [NAME] unit had no restrictors and/or could be fully opened: - At 6:15 AM, the nursing station window could be fully opened; - At 7:55 AM and 3:20 PM, both dining room windows (2) opened to 20 inches. These windows had built-in window restrictors that were not set. - At 8:03 AM and 3:22 PM, the soiled utility room window opened to 27 inches. - At 8:05 AM and 3:35 PM, the kitchenette window opened to 27 inches. There was a sign on the door that documented Keep locked, keep closed, and the door was opened during both observations. - At 8:15 AM, both windows (2) in resident room [ROOM NUMBER] could be fully opened; - At 8:25 AM, both windows (2) in resident room [ROOM NUMBER] could be fully opened; - At 3:30 PM, the shower room window opened to 27 inches. There was a sign on the door that stated, keep closed, and the door was opened. During observations on 2/22/23, the following windows in the [NAME] unit had no restrictors and/or could be fully opened: - At 2:30 PM, both windows (2) in resident room [ROOM NUMBER] opened to 27 inches. - At 2:35 PM, both windows (2) in resident room [ROOM NUMBER] windows opened to 27 inches. During an interview on 2/21/23 at 2:35 PM, certified nurse aide (CNA) #1 stated that they had never noticed any of the residents on the [NAME] unit trying to tamper with or attempting to open the windows. The CNA stated they had never opened windows on the unit more than 5 inches when allowing airflow. There were 3 residents on the unit who could open windows and there were no current residents on the unit that were an elopement risk. They stated that if a window could open over 12 inches, there could be a potential safety risk for residents. During an interview on 2/21/23 at 3:00 PM, licensed practical nurse (LPN) #2 stated they had not noticed any of the residents on the [NAME] unit trying to tamper with or open the windows. No residents had attempted to elope from the unit via the windows. LPN #2 stated they thought the regulation for window openings was 6 inches or less. It was not acceptable for the windows on the [NAME] unit to open to 27 inches, especially in resident rooms where there was less supervision. During an interview on 2/21/23 at 3:57 PM, CNA #3 stated that they had never seen any residents trying to elope through the windows on the [NAME] unit, and they did not believe that any of the current residents on the unit could open the windows. The CNA stated they had never been told of the maximum amount the windows were allowed to be opened to ensure resident' safety. A 27 inch window opening would be large enough for a resident to get through. During an interview on 2/22/23 at 1:55 PM, registered nurse (RN) #4 stated they had never been told about an appropriate window gap for air flow and safety purposes, and they were not aware the windows on the [NAME] unit opened fully. They stated that it could be a potential elopement risk if the windows in resident rooms opened to 27 inches. RN #4 stated there were no residents at risk of elopement on the [NAME] unit. During an interview on 2/22/23 at 4:14 PM, the Director of Nursing (DON) stated that windows on ground level could open fully and the windows not on ground level had limiters (restrictors) on them to only open enough for air flow. The DON stated there were no current residents at risk for elopement. They stated there had been no elopements within the last month since they were hired. During an interview on 2/22/23 at 4:39 PM, the Administrator stated that windows not at ground level had security devices that would allow them to be opened to 6 inches, and those at ground level were allowed to be fully opened. They stated a resident could potentially elope out of the [NAME] unit via the ground floor windows that opened 27 inches. The windows opening to this amount was perceived as acceptable as it had not been an issue in the past. The Administrator stated that there had been no elopements in the last 3 years and since they had been at this facility there had never been a window elopement. During an interview on 2/23/23 at 10:43 AM, the Maintenance Director stated they were not aware that the windows on the [NAME] unit could fully open. At one time the maintenance department had installed window stoppers on all the windows, and over time the stoppers must have been removed by staff. They stated that the window stoppers had been installed three years ago and they had tried to install the stoppers so the windows could open 6 inches to 8 inches. 10 NYCRR 415.12(h)(1)

Based on observation, interview and record review during the recertification survey conducted 2/21/23-2/23/23, the facility failed to ensure that residents maintained acceptable parameters of nutritional status for 1 of 2 residents (Resident #23) reviewed. Specifically, Resident #23 had a significant weight loss, weights were not obtained as ordered, and the medical provider was not notified of the significant weight loss. Findings include: The undated facility policy, Standards of Nutritional Status and Assessment, documented within 7 -14 days of admission a comprehensive nutritional assessment would be completed to evaluate parameters of nutritional status and included. Height and weight would be evaluated to establish a desirable weight range or recommended weight range for each resident. Therapeutic diets would be provided to manage problematic health conditions. A nutritional plan of care would be developed for each resident and would be documented on the interdisciplinary plan of care. The plan of care would be updated/modified with subsequent nutritional evaluation. It was the responsibility of the dietitian to see that the policy was implemented and maintained. The undated facility Weight Policy, documented each new admission/readmission would be weighed within 24 hours of arrival to the facility. All new admissions/readmissions to the facility would be weighed every 2 weeks by the nursing staff for one month unless otherwise directed by the physician. Residents recording a weight gain/loss of 5 pounds (lbs) or more from the previously recorded weight must be re-weighed the next day (same shift) for verification of gain/loss. Weight/re-weight would be recorded on the 24-hour report for nutritional services notification and to monitor the section of the electronic health record (EHR) for clinical intervention as needed. The facility policy, Medical Nutritional Therapy Intervention Program, revised 2/22/23, documented significant weight loss was defined as a weight loss of 5% in 30 days, 7.5% in 90 days and 10% in 180 days. Dietary staff would maintain an ongoing review to monitor the progress of the resident. Resident #23 had diagnoses including hemiplegia (paralysis on one side of the body) and Alzheimer's disease. The 10/13/22 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance of 2 for bed mobility and transfers, extensive assistance of one for eating, weighed 183 pounds, and did not have a significant weight change. Physician orders documented: - On 10/7/22 weekly weights Fridays on the 3:00 PM-11:00 PM shift. - On 10/8/22 no concentrated sweets (NCS) diet, chopped (cut-up meat), and thin liquids. - On 11/7/22 180 cubic centimeters (cc) extra fluids three times a day with medication passes. The comprehensive care plan (CCP) for nutrition, initiated 10/10/22, documented the resident required assistance with meals and had a NCS diet with modified consistency (chopped meat). The undated care instructions documented the resident was totally dependent for transfers and used a mechanical lift. The instructions did not include when the resident was scheduled to be weighed or the method used to weigh the resident. Resident #23's record documented weekly weights as follows: - On 10/7/22 183.1 pounds. - On 10/15/22 181.9 pounds. - On 10/21/22 179.6 pounds. - On 10/28/22 177.1 pounds - On 11/4/22 163.5 pounds (10.7% decrease or 19.6 pound loss in 1 month), no reweight recorded. - On 11/11/22 no weekly weight recorded. - On 11/18/22 165.1 pounds Progress notes by registered dietitian (RD) #7 documented: - on 11/9/22 at 11:23 AM the resident had a Stage 2 (partial thickness skin loss) pressure ulcer, and the plan was to continue with current nutritional interventions. The progress note did not include documentation of the resident's weight of 163.5 pounds on 11/4/22 and lack of a reweight. - on 11/16/22 at 12:39 PM the resident weighed 164 pounds on 11/4/22 and a request was made to the Unit Manager for a reweight. The plan was to increase Ensure (nutritional supplement) from 4 ounces to 8 ounces at breakfast and supper. - on 11/18/22 at 2:00 PM continue with current nutritional interventions. There was no documented evidence of a reweigh or a missing weekly weight on 11/11/22. - on 11/19/22 at 3:16 PM the resident weighed 165 pounds on 11/18/22 a 17 pound weight loss and 9.3% significant weight loss in 1 month. The resident had their nutritional supplements increased for improving caloric and protein intake. The plan was to continue to monitor weight trends. Nursing progress notes from 11/4/22-11/18/22 did include documentation of the resident's weights or significant weight loss. There was no documented evidence the medical provider was informed of the resident's significant weight loss. On 11/17/22 the CCP was updated and documented to monitor and record meal consumptions, supplements as ordered, and weigh resident as ordered. On 11/18/22 the CCP was updated and documented a significant weight loss, 9.3% x one month. Interventions included the resident would consume 75% of meals and was to maintain the highest level of consistency as possible for a stable weight. The resident was observed: - on 2/21/23 at 8:44 AM with a breakfast tray which included toast, cold cereal, coffee, orange juice, milk, and sausage. The resident was assisted with breakfast by an unidentified staff and at 9:03 AM the resident had consumed 100% of their fluids, 100% of the cold cereal, and 100% of the sausage. -on 2/21/23 at 12:19 PM seated at a tray table in the TV lounge during the lunch meal. The resident's meal included Oreo pie, a chopped turkey sandwich, water, and milk. At 12:38 PM the resident's family member was seated next to the resident. The resident ate 100% of the pie, all of their drinks, and 25% of the sandwich. During an interview with certified nurse aide (CNA) #8 on 2/22/23 at 2:00 PM they stated the care plan indicated how to weigh a resident using a standing scale or the mechanical lift scale. The licensed practical nurse (LPN) or the Unit Manager would put required weights on the assignment sheets. Once the weights were taken, usually by a CNA, the LPN or Unit Manager would record the weights in the resident's record. If a weight was not done, they would tell the nurse. It was important to obtain weights to monitor the resident's nutritional and fluid status. The CNA stated they were familiar with the resident, but evening staff weighed the resident on Fridays. The CNA stated they could not tell if the resident gained or lost any weight. During an interview on 2/22/23 at 2:46 PM with registered nurse (RN) Unit Manager #9 they stated weights were listed on the treatment administration record (TAR) and the assignment sheet. They stated weights were typically done on shower/bath days and all residents were weighed weekly or monthly per physician orders. The LPN or Unit Manager recorded weights. If a resident refused to be weighed, they expected staff to tell them and educate the resident, or re-approach. The nurse should document the refusal. Resident #23 should be weighed weekly on Fridays during the 3:00 PM-11:00 PM shift. The RN stated they thought the resident received supplements on their meal trays such as Ensure at breakfast and lunch and a milk shake at dinner. They were not aware of any significant weight changes. If a resident had a significant weight loss the Unit Manager would write in the medical book and the diet tech would let them know if a reweight needed to be done. During an interview on 2/22/23 at 4:29 PM with diet technician #10 they stated obtaing weights was based on the physician order. The nursing staff was responsible for obtaining weights and the LPN or Unit Manager would enter weights in the computer. A reweight was needed if there was a 5 pound difference since the last weight. The need for a reweight should be picked up on when the weight was obtained but they would let staff know if it was needed. They stated they usually sigma messaged (electronic message) the Unit Manager. A significant weight change was 5% in 30 days and 10% in 6 months. If a resident refused weights, they should be reapproached, and the refusal should be documented. When a resident had a significant weight change, they discussed it with the RD to review interventions. The RD completed all the nutritional assessments including if a resident had a significant weight loss. They stated it was important to reassess to determine nutritional status. Nutritional services would let the Unit Manager and MDS coordinator know of significant weight changes and nursing should notify medical. Nursing would check to see if the weights were completed as ordered. During an interview on 2/22/23 at 4:34 PM RD #7 stated nursing staff should obtain weights as ordered. The diet technician reviewed weights and would let them know if there was a 5 pound difference. The diet technician would message nursing about reweights. If a resident refused a weight, they should be reapproached, and the refusal should be documented. Resident #23 did have a weight loss and had stabilized. Previously in November 2022 the resident was 177 pounds then 164 pounds, so the RD increased the 4 ounce milk shake to 8 ounces at breakfast and dinner. There was no weekly weight recorded for 11/11/22 and no reweight. If there was a trigger of 5 pounds or more difference, nursing should have reweighed the resident. If there was a significant change of 5 pounds nursing should let the RD and diet technician know. The RD stated they did not recall being told about the resident's weight loss, but they saw the weight loss and added the supplements on 11/8/22. Nursing should notify medical about significant weight changes. During an interview on 2/23/23 at 9:48 AM with physician #11 they stated nursing should inform them of significant weight changes. Residents should be weighed per medical orders. Nursing should document if weights could not be obtained and try to weigh the resident again. They stated they were out in November and was not sure who covered for them. If the covering physician was made aware of the weight loss, they should document and assess the resident. During an interview on 2/23/23 at 2:56 PM with the DON they stated nursing should obtain resident weights as ordered and should document any refusals. They stated nutrition staff should track weights and assess needs, add supplements, and update preferences. Once nutrition identified significant weight changes, they should notify nursing. Nursing would notify medical and medical should document significant weight changes in their progress notes. 10NYCRR415.12(i)(1)

Based on observation, record review and interview during the recertification survey, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident (Resident #35) reviewed for respiratory care. Specifically, a staff member was observed entering Resident #35's room without donning the appropriate personal protective equipment (PPE) when droplet precautions were in place. Additionally, the facility infection prevention control program policies were not reviewed annually as required. Findings include: Contact precautions: The facility's undated Droplet Precautions policy documented the procedure for a resident on droplet precautions would include: -Use the designated green droplet precaution sign on the bathroom door and the magnet with a green dot on the doorframe. -Masks and gloves will be placed outside the resident room. -Staff and/or visitors will wear a mask upon entering the room or when working within 3 feet of the resident. -Masks will be removed when leaving the resident's room and placed in the appropriate waste receptacle. The 2/20 facility policy Prevention and Control of Influenza/Febrile Respiratory Illness documented when a resident was on droplet precautions staff would don a face mask when entering the room of a resident with suspected or confirmed influenza. When leaving the resident's room, the facemask will be removed, disposed of in a waster container, and staff would perform hand hygiene. The undated Droplet Precautions in Addition to Standard Precautions sign documented a mask/face shield was indicated for those who come within 3 feet of patient/resident. Resident #35 had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident was cognitively intact and had received the influenza vaccine on 10/17/19. A 2/3/20 at 5:23 PM nursing progress note documented the resident was to receive oseltamivir (used to treat and prevent influenza) [MEDICATION NAME] due to presence of influenza in the facility. A 2/8/20 at 1:12 AM nursing progress note documented the resident had cold symptoms, a low-grade temperature and had been expectorating yellow phlegm with cough. The resident continued oseltamivir and would be placed on droplet precautions. A physician order [REDACTED]. A 2/11/20 at 2:41 AM nursing progress note documented the resident was congested, had an occasional productive cough and was on droplet precautions. On 2/11/20 at 11:35 AM, room [ROOM NUMBER] was observed without a droplet precaution notification sign on the door frame. However, room [ROOM NUMBER] to the right side of room [ROOM NUMBER] had 2 green droplet precaution signs hanging on each side of the door frame. There was no PPE directly outside of either room [ROOM NUMBER] or #5 (the resident and the resident's spouse occupied both rooms #3 and 5 together). During an interview with Resident #35 on 02/11/20 at 11:54 AM, the resident stated they had a cough and was told by the nurses they may have pneumonia. During an interview on 02/11/20 at 12:42 PM, Housekeeper #4 stated Resident #35 and the resident's spouse were placed on droplet precautions over the weekend. She stated to go into the room a mask would be required, and the masks were available in the isolation cart across the hall in front of room [ROOM NUMBER]. Housekeeper #4 added that room [ROOM NUMBER] was used as a living room and room [ROOM NUMBER] was the sleeping room for the couple. During an observation on 02/12/20 at 11:59 AM, diet technician #5 entered room [ROOM NUMBER], she did not don a mask and was observed leaning on the residents personal dining table while asking the resident their request for the next scheduled meal. Diet technician #5 then exited the room to go to the next resident room. When interviewed immediately after the observation, diet technician #5 stated a mask was not donned prior to entering the room because there was not a droplet precaution sign on the door to room [ROOM NUMBER] and she was unaware the resident was on precautions. She stated if there was a droplet sign on the door, she would have donned a mask and gloves. During an interview on 02/13/20 at 12:55 PM the Infection Control Nurse/Director of Staff Development stated the facility had been closed due to a positive influenza case. She confirmed Resident #35 was not positive for influenza but was on droplet precautions because the resident presented with hoarseness, cough, and a stuffy nose. She stated staff must wear a mask within 6 feet of providing direct care. The unit registered nurse (RN) or licensed practical nurse (LPN) should place the green droplet precaution sign on the appropriate room door as soon as there were clinical indications the resident may have respiratory infection or influenza. She was made aware of any new precautions during morning report or staff notification. Infection Prevention Control Program: Review of the facility infection prevention and control program documented the facility had an established Infection Prevention and Control Program, with policies and procedures (P&P). There was no documented evidence the P&Ps were reviewed annually. The following P&P did not include an approval date: -Hand Hygiene; -Resident Immunization policy; -Influenza season: unvaccinated personnel; -Standard Precautions; and -Droplet precautions. During an interview on 2/13/20 at 12:55 PM, the Infection Control RN stated policies were reviewed regularly but there was no formal documented evidence of annual review. She stated when she made changes to a policy, she would review the changes with the Director of Nursing (DON). Policies were usually reviewed and approved at the quarterly Quality Assurance Meetings. 10NYCRR 415.19 (b)(4)

Based on observation, interview, and record review during the recertification survey, the facility did not ensure residents who used [MEDICAL CONDITION] drugs were not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the medical record for 1 of 5 residents (Resident #22) reviewed for unnecessary medications. Specifically, Resident #22 was receiving an antipsychotic and there was no documented evidence of specific clinical indications to support its continued use. Findings include: The facility's Restraint Policy and Procedure, revised 7/2017 documents: - Medication can be considered a chemical restraint. The Medical Director and/or attending physician must have a supportive [DIAGNOSES REDACTED]. - The care plan will address the type of restraint being utilized, the specific purpose for resident use and the period of time the restraint will be utilized. - The consultant pharmacist as well as consultant psychiatrist will assist the facility in assuring chemical restrains are imposed only when it is clearly identified they are in the best interest of the resident. - Continuing monitoring of all residents associated with restraint usage will be evaluated quarterly and may include: increased agitation, loss of balance, symptoms of withdrawal or depression, reduced social contact. - Certified nurse aide (CNA) documentation for behaviors will be documented in the electronic CNA module and should be logged for the individual resident. Interventions and the success of the interventions as outlined in the resident care plan will assist in determining the need for psychoactive medication administration. Resident #22 had [DIAGNOSES REDACTED]. The 1/3/20 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, no behavioral symptoms, no signs of [MEDICAL CONDITION], and mild symptoms of mood disturbance including difficulty concentrating. The resident received antipsychotic medications 7 of 7 days during the assessment period. The Resident Nursing Instructions initiated 6/5/17 and updated 7/20/19 documented the resident had behaviors of frequent restlessness. There were no other behavioral symptoms or monitoring needs documented. Physician orders [REDACTED]. The pharmacy consultant recommendation dated 7/23/19 documented the resident was on [MEDICATION NAME], it may cause involuntary movement including TD (tardive dyskinesia, involuntary, uncontrollable movements often related to use of antipsychotics and antidepressants) an AIMS (Assessment for Involuntary Movement) was not documented in the previous 6 months and to monitor for involuntary movement now and at least every 6 months. There was no signature or initials on the recommendation, and it was noted at the bottom there was no AIMS and to see the 12/5/19 nursing note. The comprehensive care plan (CCP) effective 7/27/19 and reviewed by the facility on 1/15/20 documented: - The resident had advanced dementia with behavioral disorder. Interventions included total assistance for activities of daily living (ADLs), identify common behavioral expressions and expected responses for person-centered care and document the results; - The resident was at risk for falls related to a [DIAGNOSES REDACTED]. Interventions included low bed, floor mats, bed alarm, Broda chair when out of bed, and [MEDICATION NAME] (antianxiety) and [MEDICATION NAME] (for involuntary movements) per physician order. - The resident received [MEDICAL CONDITION] medications for depression and anxiety. Interventions included document psychological and physical changes due to medication, observe for changes in emotional status, perform ongoing monitoring for target behaviors with documentation of possible risks and causes contributing factors to behaviors, desired outcomes, ongoing efficacy of non-pharmacological approaches, physician psychiatric review of medications per policy. - The CCP did not contain any documented needs or interventions for mood or behavioral disturbances. physician progress notes [REDACTED]. There was no documentation regarding specific mood or behavioral symptoms to be treated. The progress notes did not contain any information about the risk versus benefits of continued usage or discussions with the family regarding the rationale for continued usage. Nursing progress notes from 8/1/19-2/13/20 contained no documented evidence of mood or behavioral concerns or of any interventions utilized. The pharmacy consultant recommendation dated 11/22/19 documented the resident received [MEDICATION NAME]. Target behaviors were not found, to document in the next quarterly assessment, describe how the behaviors impact the resident and others, perform ongoing monitoring of target behaviors, document risk, desirable outcome, and ongoing efficacy of individualized non-pharmacological interventions and potential adverse consequences. The Director of Nursing (DON) signed the review form 12/6/19 and noted to refer to 12/5/19 progress note regarding no AIMS to be done. The Resident CNA Documentation History Detail from 11/30/19-2/13/20 documented the resident had no behavioral symptoms. There were no psychiatric progress notes in the resident's medical record. Social services progress notes from 1/1/2019-2/13/20 contained no documentation regarding the resident's mood or behaviors or utilization of [MEDICAL CONDITION] medications. The resident was observed with no apparent signs of distress, agitation, [MEDICAL CONDITION], or other alteration in mood: - on 2/11/20 at 10:09 AM to 11:18 AM, in the lounge in a chair; and from 12:23 PM-12:48 PM, in the dining room being fed by a family member; - on 12/12/20 from 11:01 AM to 11:43 AM, in the lounge in a chair, - on 2/13/20 at 9:35 AM, 9:46 AM, and 10:50 AM, in a chair; and at 12:44 PM, in the dining room being fed by a family member; and at 2:24 PM and 2:45 PM, while lying in bed. During an interview with the DON on 2/13/20 at 10:55 AM, she stated the facility had no routine meetings where [MEDICAL CONDITION] medications were reviewed. When a resident was due to have [MEDICAL CONDITION] medications reviewed, a list was generated and the physician, social worker, charge nurse and possibly the psychiatrist would review the medications. There was no psychiatrist available for the past 6 months and the attending physician reviewed [MEDICAL CONDITION] medications with staff and documented in the medical record. When interviewed on 2/13/20 at 12:50 PM, physician #2 stated antipsychotic medications were not typically for dementia with behaviors unless the resident had severe agitation, hallucinations, or [MEDICAL CONDITION]. Resident #22 had a behavioral disorder and was on [MEDICAL CONDITION] medications before the resident was admitted , and the resident remained on the medications for dementia with behaviors. She stated the resident had not exhibited any type of behavioral or mood symptoms, had no hallucinations, or delusions, and no agitation or aggression. The physician stated more than 2 years ago, the resident had flailing arms and legs and frequent urinary tract infections (likely causing behavioral symptoms) as the possible indications for usage historically. The resident had involuntary movement disorder and TD, and this was not related to the [MEDICAL CONDITION] medications, as it had improved. The physician stated she was reducing the medications per federal regulatory guidelines (annually after the first year). She stated there was no team review, rather she discussed the resident's condition with RN Charge Nurse #1. She had not reviewed the resident's medication use with the psychiatrist, social worker, or DON. The rationale for continued usage should be included in the progress notes and it had not been discontinued because the family wanted the resident to remain on the medication. During an interview with RN Charge Nurse #1 on 2/13/20 at 2:31 PM, she stated the process for reviewing [MEDICAL CONDITION] mediation use included documenting the type, the dosage, and when or if the dosage was changed. She stated the resident's history of behavioral symptoms included restlessness, anxiousness, and body movements resulting in falls. She was unaware of any combativeness, agitation, or psychotic episodes. She created the care plans and stated there was no behavioral or mood care plan because the resident did not exhibit any behavioral or mood issues. There was no team discussion regarding the use of [MEDICAL CONDITION] medications or related behavioral concerns. The RN spoke to the physician only, the social worker got involved only if a psychiatric referral was needed. During a follow-up interview with the DON on 2/14/20 at 10:44 AM, she stated the resident's medications were reviewed with dose reductions per federal guidelines. The resident entered the facility on the [MEDICAL CONDITION] medications and the family wanted all the resident's medications to continue initially as the resident was to only be at the facility short term. The DON stated there was no formal monitoring of [MEDICAL CONDITION] medications in regard to targeted behaviors, mood concerns, and overall rationale for continued usage. She stated Resident #22's medical record lacked documentation for identification of a specific clinical condition and mood/behavioral monitoring for justification for continued use. 10NYCRR 415.12(l)(2)

Based on observation, record review and interview conducted during the recertification survey the facility did not ensure all residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, person and oral hygiene for 1 of 3 residents (Residents #6, 26 and 58) reviewed for ADLs. Specifically, Resident #58 was not provided nail care. Findings include: The undated policy Providing hygiene/grooming and comfort needs documented cleanliness, skin care and mouth care are necessary for comfort, safety and health. Resident #58 was admitted [DATE] and had [DIAGNOSES REDACTED]. The 09/07/18 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired. The resident required extensive assist of one staff for dressing, eating, personal hygiene and total assist of one staff for bathing. The updated 08/29/18 comprehensive care plan (CCP) did not document self-care deficits or interventions related to bathing, showering, or nail care. The updated 08/27/18 certified nursing aide (CNA) care card documented the resident showered on the 7:00 AM-3:00 PM shift on Fridays with extensive assistance for bathing, personal hygiene, and toileting. The CNA activities of daily living (ADL) record documented bathing was completed on the 07:00 AM-03:00 PM shift for 09/20/18, 09/21/18, and 09/22/18; on the 03:00 PM-11:00 PM shift for 09/22/18; on the 11:00 PM-07:00 AM shift for 09/23/18; and on the 07:00 AM-03:00 PM shift for 09/24/18 and 09/26/18. The resident's nails were observed to be long, unpainted, and had large quantities of dark brown/orange tinged matter under them on 09/24/18 at 10:57 AM, 09/24/18 at 03:04 PM, 09/25/18 at 02:21 PM, and 09/26/18 at 09:06 AM. During an interview on 09/26/18 at 10:30 AM, CNA #9 assigned to Resident #58 on 09/26/18 stated nail care was performed on bath days or whenever needed. They were soaked and filed. Some residents had this care planned. She stated she did not look at or clean the resident's nails because they were short staffed. When interviewed on 09/26/18 at 11:05 AM, RN Unit Manager #10 stated nails were clipped and cleaned on bath days unless they were dirty and needed it. She had not looked at Resident #58's nails but stated if they were dirty they should be cleaned. During an interview on 09/26/18 at 12:56 PM, CNA #11 assigned to Resident #58 on 09/25/18 stated nail care was done on bath day after they were soaked or when needed. She had not looked at Resident #58's nails during her shift on 09/25/18, nor had she ever showered her. She was floated to that unit so was unfamiliar with the residents. During a telephone interview on 09/26/18 at 01:30 PM, CNA #12 assigned to Resident #58 on 09/21/18 and 09/24/18 stated that nails were cleaned, filed and clipped during the resident's bath unless the resident was diabetic. She did not remember if she gave Resident #58 her shower when she worked on Friday 09/21/18. She did not remember if she looked at Resident #58's nails when she worked on Monday 09/24/18. 10NYCRR 415.12(a)(3)

Based on record review, observation, and interview conducted during the recertification survey, it was determined for 4 of 5 residents (Residents #7, 11, 16, and 17) observed for blood glucose monitoring, the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission. Specifically, for Residents #7, 11, 16, and 17, glucometers were not properly disinfected after use. Findings include: 1) Resident #17 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact. She required extensive/total assist with most activities of daily living and she received daily insulin injections. Resident #16 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident was cognitively intact, she required extensive/total assistance with most activities of daily living and she received daily insulin injections. The physician orders [REDACTED]. During an observation on 4/26/2017 at 8:00 AM, licensed practical nurse (LPN) #1: - entered Resident #17's room with blood glucose monitoring supplies; - performed the fingerstick, obtained the blood sugar result, and exited the resident's room with the supplies; - placed the unclean glucometer into a plastic bin on the medication cart. The bin contained new unused lancets and a bottle of blood glucose test strips; - administered medications to the resident; and - returned to the cart, disinfected the glucometer, and placed it into the plastic bin. During an observation on 4/26/2017 at 8:15 AM, LPN #1: - entered Resident #16's room with the plastic bin containing blood glucose monitoring supplies; - performed the fingerstick, obtained the blood sugar result, and exited the resident's room with the supplies; - placed the unclean glucometer on top of the medication cart; - administered medication to the resident; and - returned to the cart, disinfected the glucometer, and placed it into the medication cart. LPN #1 was not observed to disinfect the glucometer: - before placing it into the plastic bin of unused lancets/test strips. - before placing it on top of the medication cart. During an interview on 4/27/2017 at 8:40 AM, LPN #1 stated the glucometer was disinfected after every resident. She stated it was considered unclean after using and she did not realize she placed it in the bin and on the cart without cleaning. During an interview on 4/27/2017 at 10:30 AM, the registered nurse (RN) #7 stated she was the Staff Development and Infection Control Nurse. She stated the glucometer was to be wiped down with a bleach wipe after each use. She stated she would not expect the nurse to carry an unclean glucometer in the plastic bin. She stated she trained nurses on proper cleaning in orientation. She also stated she expected nurses to put down a tissue or other surface barrier when using the glucometer. 2) Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. She required extensive assistance to total dependence for all activities of daily living. She had diabetes and received daily insulin injections. During an observation on 4/25/2017 at 4:52 PM, licensed practical nurse (LPN) #2 took the glucometer out of a plastic bin on the medication cart and placed it directly on the cart. She put gloves on, took a bleach wipe out, and wiped down the glucometer. She then put the glucometer back on the cart in the same place it was prior to sanitizing. She took supplies out of the bin the glucometer had been in and entered the resident's room. She put the glucometer and supplies on the overbed table, put gloves on, performed the fingerstick, and put the glucometer back on the table. She then picked the glucometer up and put it in her pocket, went into the resident's bathroom and washed her hands. She returned to the cart, took the glucometer out of her pocket, and placed it in the plastic bin with the supplies. The glucometer was not disinfected. She proceeded to prepare the resident's insulin and oral medication, and then went back to the resident's room to administer the medication. During an interview on 4/26/2017 at 5:05 PM, LPN #2 stated the glucometer was to be sanitized with a bleach wipe after each use. She stated she sanitized the glucometer prior to using on Resident #7 on 4/25/2017 and after sanitizing the glucometer, she placed it back on the cart. She stated she did not use a barrier and thought she placed the glucometer on a different area of the cart. She stated she took the glucometer back out of the bin and sanitized it after the surveyor left. During an interview on 4/27/2017 at 9:00 AM, registered nurse (RN) Manager #6 stated the glucometer was supposed to be sanitized with a bleach wipe between residents. She stated the glucometer could be set on the resident's overbed table and did not need a barrier. She stated the glucometer should not be placed in the nurse's pocket. She stated the glucometer should be sanitized before putting it away. During an interview on 4/27/2017 at 10:30 AM, RN #7 stated she was the Staff Development and Infection Control Nurse. She stated the glucometer was to be wiped down with a bleach wipe after each use. She stated she would not expect the nurse to carry an unclean glucometer in the plastic bin or pocket. She stated she trained nurses on proper cleaning in orientation. She also stated she expected nurses to put down a tissue or other surface barrier when using the glucometer. 3) Resident #11 was admitted to the facility 5/13/2010 and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. He had diabetes and received daily insulin injections. The physician orders [REDACTED]. During an observation on 4/26/2017 at 4:45 PM, licensed practical nurse (LPN) #3 opened the drawer of the medication cart, pulled the glucometer and supplies out of a bin, and placed them on top of the cart. He took the glucometer and supplies off the cart and walked into the resident's room, setting the glucometer on the newspaper on the resident's bed. He cleaned the resident's finger, performed the fingerstick, and put the glucometer on the resident's bedspread while waiting for the result. He then picked up the glucometer, discarded the test strip, and put the glucometer in his pocket while he went into the resident's bathroom and washed his hands. After leaving the resident's room, he went back to the medication cart, took the glucometer out of his pocket, and put it in the plastic bin in the medication cart. He did not sanitize the glucometer. During an interview on 4/26/2017 at 5:10 PM, LPN #3 stated the glucometer was supposed to be wiped with a bleach wipe between uses. He stated he used it on another resident earlier that shift and sanitized it at that time. He stated he did not sanitize the glucometer after using it on Resident #11. He also stated he was not instructed to use a barrier when performing a finger stick. During an interview on 4/27/2017 at 9:00 AM, registered nurse (RN) Manager #6 stated the glucometer was supposed to be sanitized with a bleach wipe between residents. She stated the glucometer could be set on the resident's overbed table and did not need a barrier. She stated the glucometer should not be placed on the resident's bed or in the nurse's pocket. She stated the glucometer should be sanitized before putting it away. During an interview on 4/27/2017 at 10:30 AM, RN #7 stated she was the Staff Development and Infection Control Nurse. She stated the glucometer was to be wiped down with a bleach wipe after each use. She stated she would not expect the nurse to carry an unclean glucometer in the plastic bin or pocket. She stated she trained nurses on proper cleaning in orientation. She also stated she expected nurses to put down a tissue or barrier when using the glucometer. 10NYCRR 415.19(b)(2)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure appropriate treatment and services were provided to 1 of 2 residents (Resident #7) reviewed for Foley catheters (flexible tube passed through the urethra into the bladder to drain urine). Specifically, Resident #7 had a Foley catheter without valid medical justification and the size was changed without rationale. Findings include: Resident #7 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. She required extensive assistance to total dependence for all activities of daily living (ADL). She was incontinent of bowel and had an indwelling catheter for bladder. The hospital discharge summary dated 8/15/2016 documented the resident was admitted to the hospital on [DATE] for emergency embolectomy (surgical removal of blood clots). The discharge summary did not document the resident had a Foley catheter or any urinary impairment. Review of the resident's medical record prior to the hospitalization from ,[DATE] - 8/15/2016 did not reveal documentation of any prior use of a Foley catheter. The nursing admission assessment dated [DATE] documented the resident was incontinent, used incontinence briefs, and had no voiding problems. The area for time of the resident's last void documented a Foley catheter was removed prior to leaving the hospital. The nursing progress note dated 8/15/2016 at 10:32 PM documented verbal report was called from the hospital to the facility at 5:00 PM. The resident had a left lower leg embolectomy and had 8 sutures in the left groin. Her Foley catheter was removed, she voided twice, and was returning to the facility. The nursing progress note dated 8/15/2016 at 11:08 PM documented the resident returned to the facility at 6:20 PM. The resident was incontinent of a large amount of urine. The readmission history and physical dated 8/16/2016, written by the resident's attending physician, documented the resident returned to the facility following an embolectomy. The note did not document the resident had a Foley catheter or any history of [MEDICAL CONDITION]. The nursing progress note dated 8/16/2016 at 2:30 PM documented the resident did not void all shift. A bladder scan showed 611 milliliters (ml) of urine in the bladder. The physician's office was called, and the nurse practitioner (NP) ordered to insert a Foley catheter 14 French (F, a tubing size) with a 10 cubic centimeter (cc) balloon (inflated balloon to keep the Foley in place after insertion) for [MEDICAL CONDITION] and re-evaluate in a week. The physician's orders [REDACTED]. The attending physician's progress note dated 8/23/2016 documented the resident's sutures remained in place. The note did not document the resident had a Foley catheter or any history of [MEDICAL CONDITION]. The nursing progress note dated 8/25/2016 at 3:33 PM documented the resident had no output from the Foley catheter, and irrigation was attempted without success. The Foley catheter was removed and a new Foley 14 F with 5 cc balloon was inserted, with return of 200 cc of concentrated urine with mucus shreds. The NP note dated 9/16/2016 documented the resident had multiple open areas to both feet. She required a Foley catheter to promote wound healing due to her incontinence and [MEDICAL CONDITION]. The physician's progress note and order, both dated 10/11/2016, documented the resident's Foley catheter to be discontinued and to verify that resident voided every shift. If the resident did not void, a bladder scan was to be done and if greater than 400 ml of residual urine, the Foley was to be re-inserted. The nursing progress note dated 10/11/2016 at 9:23 PM documented the Foley was discontinued and the resident voided without difficulty. The nursing progress note dated 10/12/2016 at 6:25 AM documented after multiple attempts to assist for voiding without success, the resident was bladder scanned. The resident retained over 400 cc and an 18 F Foley catheter was inserted with 10 cc of normal saline in the balloon. The resident was able to follow directions to assist with the insertion and over 400 cc of clear dark urine drained. The physician's orders [REDACTED]. There was no documented rationale for changing the size of the catheter. The NP progress note dated 11/4/2016 documented to discontinue the Foley catheter and to check bladder scan after voiding. If the resident did not void for 8 hours, check a bladder scan and re-insert the Foley if greater than 250 cc of residual urine. The physician's orders [REDACTED]. - discontinue the resident's Foley catheter; - put on the toilet according to schedule to encourage natural voiding process; - no bed pan; - if no void each shift, bladder scan to be done; and - to replace Foley catheter if scan was over 250 ml. The nursing progress notes dated 11/4/2016 documented: - at 1:55 PM, the resident's Foley catheter was discontinued at 1:50 PM; and - at 8:45 PM, resident did not void this shift, and bladder scan showed 114 ml. The nursing progress notes dated 11/5/2016 documented: - at 4:36 AM, bladder scan prior to toilet was 256 ml, the resident was put on the toilet and had a bowel movement and voided 250 cc; - at 9:07 AM, the resident was toileted at 7:30 AM and voided a good amount with bowel movement; - at 10:48 AM, the resident refused 10 AM toileting when offered; - at 12:35 PM, the resident was toileted before lunch and voided outside of the specipan (container to catch urine for measuring purposes); the urine was clear without odor; the resident's liquid intake was less than optimal; and - at 8:59 PM, the resident voided twice during shift. The nursing progress notes dated 11/6/2016 documented: - at 1:33 AM, the resident was up with 2 assist, sit to stand lift, and voided 200 cc of urine; - at 2:18 PM, the resident was toileted per schedule and the bladder scan showed 89 ml after voiding; - at 9:37 PM, the resident was taken to the bathroom and did not void. The bladder scan showed 388 ml of urine and the resident denied pain/discomfort and urgency. The on-call physician was called and the ordered the catheter be inserted with a gravity drainage bag. An 18 F Foley was inserted with a 5 cc balloon and yellow urine drained. (Amount not documented). The physician progress notes [REDACTED]. The nursing progress note dated 2/9/2017 at 2:28 PM documented the resident's appetite was poor, fluids were encouraged, and the Foley was draining cloudy yellow urine. The nursing progress note dated 2/10/2017 at 12:33 PM documented the resident had increased confusion, sleepiness, and cloudy urine. The NP was notified and a urinalysis with culture and sensitivity was ordered. The nursing progress note dated 2/13/2017 at 4:37 PM documented the attending physician was called with the urine culture results and ordered Bactrum DS (antibiotic) twice a day for 7 days for UTI (urinary tract infection). The nursing progress note dated 4/1/2017 at 1:47 PM documented the resident ate poorly at breakfast and refused lunch. She complained of nausea with no vomiting and was shivering and teary-eyed. Her temperature was 99.4 degrees Fahrenheit and her urine was thick dark yellow with a foul odor. The attending physician was called and ordered medication for the nausea and did not want to send a urine sample for testing. The nursing progress note dated 4/1/2017 at 2:59 PM documented the resident's daughter was updated and insisted on a urinalysis. A call was placed to the attending physician, who ordered a urinalysis with culture and sensitivity. The nursing progress note and physician's orders [REDACTED]. The nursing progress notes documented: - on 4/20/2017 at 10:24 PM, the resident's urine was dark and cloudy with foul odor; - on 4/24/2017 at 9:09 PM, the resident's urine was dark, cloudy, and foul-smelling; - on 4/25/2017 at 7:32 AM, the resident's urine continued to be cloudy with foul odor and the resident refused drinks; - on 4/25/2017 at 10:37 AM, the attending physician was made aware of the urinary concerns and said to monitor; and - on 4/25/2017 at 2:12 PM, the resident continued to have dark foul-smelling urine. During an observation on 4/25/2017 at 4:45 PM, the resident was sitting in her room in her wheelchair. She was alert, had a blanket over her lap, and her Foley drainage bag was covered and hanging under her wheelchair. During a dressing change observation on 4/26/2017 at 9:15 AM, the resident was lying in bed on her back. Her left leg was propped on a pillow and a barrier was placed under her foot. The resident had open areas on her left outer heel, outer mid-foot, and ankle. The dressing change was performed and the heel boot was placed back on her foot. There was a strong foul urine odor and the covered Foley drainage bag hung from the bed frame. During an interview on 4/27/2017 at 7:05 AM, registered nurse (RN) #5 stated when a resident's Foley catheter was discontinued, the physician usually provided parameters to scan the bladder after voiding and to re-insert a catheter according to the parameters. She stated Resident #7 had a Foley catheter as she was contracted, had frequent UTIs, wounds on her foot, and when her Foley was discontinued in the past, her bladder did not fully empty. She stated the physician determined the size of the catheter to use. She reviewed the record and stated on 10/12/2016 at 6:25 AM, she inserted a Foley catheter size 18 F with 10 cc balloon. She stated she did not know why the size was changed from a 14 F to 18 F, and maybe a 14 F was not available. She reviewed the order and stated she entered the order into the computer and normally would call the physician to get the size changed. She stated she did not document the reason the size was changed and did not remember. During an interview on 4/27/2017 at 9:00 AM, RN Unit Manager #6 stated the resident had a Foley catheter for [MEDICAL CONDITION] as diagnosed by her attending physician. She stated she heard they had attempted to discontinue the Foley on a couple occasions before she assumed the Unit Manager position. She did not know if the resident had a urology consult or any attempts of bladder training. RN #6 stated a size 14 F Foley catheter was smaller than an 18 F and a smaller catheter was preferred as it was less invasive. She stated a physician's orders [REDACTED]. She stated the same size catheter that was discontinued should have been re-inserted unless there was a reason for the change. She stated she could not tell from the documentation if the physician was aware and did not know the rationale for changing the size. During a telephone interview on 4/27/2017 at 10:35 AM, the NP stated Foley catheters were used for residents with [MEDICAL CONDITION], Stage II or greater open skin areas with incontinence, and for end of life care. She stated she when a Foley catheter was discontinued, she would have a bladder scan done after the resident voided to check for residual. She stated if the bladder scan showed greater than 250 ml, she would have the catheter put in and then pursue the underlying cause for the [MEDICAL CONDITION]. She stated she would put the resident on a trial of [MEDICATION NAME] (medication to increase urine flow) for a week and then try to discontinue the Foley again. She stated if that did not work, she would send the resident to a urologist. After reviewing the resident's record, she stated she did not know why there was no documentation regarding the resident's Foley catheter and no follow-up after the Foley catheter was re-inserted on 11/6/2016. She stated she did not know if following up with a urologist slipped her attention, or if the family opposed the consult. She stated the resident frequently refused medication and may not have wanted to try the [MEDICATION NAME]. She also stated the same size catheter should have been used when it was re-inserted, and if there was a problem with the size she expected to be notified. She stated the 18 F Foley was larger and it was best to use the smallest size that works to prevent stretching or other problems. During an interview on 4/27/2017 at 11:35 AM, the attending physician stated if an attempt to discontinue a Foley catheter was unsuccessful, he tried [MEDICATION NAME]. If the resident did not respond to that, he would consult the urologist. He stated the urologist would determine the underlying cause of the resident's [MEDICAL CONDITION] and he would follow the recommendations from the urologist. He stated he was unsure why he did not follow-up with a urologist, as that was his normal practice. He stated he was unaware the catheter size was changed for the resident. 10NYCRR 415.12(d)(2)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure that 1 of 5 residents (Resident #14), reviewed for nutrition, maintained acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Specifically, Resident #14 returned from the hospital with weight loss and her nutritional needs were not reassessed. Additionally, the resident had fluctuating weights and was not reweighed. Findings include: The facility's weight policy revised 5/2013 documented residents with a weight gain/loss of 5 pounds (lbs) or more from the previously recorded weight must be reweighed the next day for a verification of gain/loss. The reweigh will be recorded on the 24-hour report for interdisciplinary awareness, and the Registered Dietician (RD) or Diet Technician (DT) will will respond within 48 hours for clinical conferencing and intervention. Resident #14 was initially admitted on [DATE] and readmitted on [DATE]. She had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, required extensive assistance for activities of daily living (ADLs), and was on a mechanically altered diet. The resident's medical record documented the following weights: - 10/3/2016 was 131.9 lbs - 10/17/2016 was 131.3 lbs - 10/31/2016 was 127.4 lbs - 11/14/2016 was 129.3 lbs - 11/28/2016 was 119.8 lbs - 12/12/2016 was 126.9 lbs - 12/26/2016 was 118.7 lbs - 1/6/2017 was 130.4 lbs - 1/9/2017 was 129.2 lbs - 1/25/2017 was 136.7 lbs - 2/2/2017 was 128.3 lbs, and - 4/4/2017 was 124.4 lbs There was no documented evidence that the resident was reweighed following the weights obtained on 11/28/2016 (9.5 lb loss), 12/12/2016 (7.1 lb gain), 12/26/2016 (8.2 loss), 1/25/2017 (7.5 lb gain), or 2/2/2017 (8.4 lb loss). Additionally, there was no documented evidence that the resident's nutritional needs were reassessed following the weight fluctuations. The physician progress notes [REDACTED]. Dietary progress notes entered by the RD documented: - On 11/10/2016, the resident weighed 127 lbs, it was a 4 lb loss from previous weight, she was in her weight range, and to continue with the plan of care; - On 2/3/2017, the resident's weight was 128.3 lbs, it was in her usual weight range, and the plan of care would be continued; - On 3/2/2017, labs were reviewed, and to continue with current plan of care; and - On 3/17/2017, labs were reviewed, and there were no concerns. The comprehensive care plan (CCP) last updated 1/19/2017 documented the resident was at nutritional risk related to a consistency modified diet of blend (puree), nectar thick liquids, and [DIAGNOSES REDACTED]. The goals included 50% completion of meals and 1500-1800 cubic centimeters (cc) of fluid. Interventions included dietician consult as needed, weights every 2 weeks, and monitoring of food intake. A nutrition assessment dated [DATE] documented the resident was on a pureed diet with nectar thick fluids, estimated caloric needs were 1262/day, and fluid needs were 1500-1740 cc/day. The resident's weight was 128 lbs, it was a 2 lb loss over 30 days, and a 1 lb loss over 90 days. This information did not align with the information documented in the resident's weight record. Physician orders [REDACTED]. The admission nursing assessment dated [DATE] documented the resident weighed 111.9 lbs and there was no response documented if it was a recent weight change. It documented the resident was on a puree diet with nectar thick fluids, needed to be fed by staff, was at risk for dehydration and malnutrition due to poor appetite and poor intake. A dietary progress note dated 4/21/2017, entered by the facility's DT, documented the resident returned from the hospital, the diet was regular, pureed consistency, with pudding thick liquids. The resident was receiving a nutritional supplement, had a history of [REDACTED]. The resident's care instructions updated 4/21/2017 documented the resident was on a pureed diet with pudding thickened liquids, and required extensive assistance for eating. The clinical monitoring intake/output summary report for 4/21 - 4/26/2017 documented the resident's total daily fluid intake ranged from 420 cc to 780 cc. The intake/output monitoring sheet for 4/21 - 4/26/2017 documented the resident's meal consumption ranged from 0-25%. The resident was observed on 4/27/2017 at 9:15 AM, in the unit dining room, being fed her breakfast. The meal included pureed items and pudding thickened drinks. The staff attempted to feed the resident; she refused and turned her head away. When interviewed on 4/27/2017 at 11:32 AM, the DT stated the facility had an RD consultant, and they met at least monthly to review intakes, weights, and high risk residents. She stated any new concerns were communicated to her and she reviewed them with the RD. She stated she generally ran weight reports every two weeks, and nursing was responsible for notifying dietary of weight changes and/or poor intake. She stated she was not notified of the resident's weight differences and the resident should have been reweighed. She was not aware of reasons there were no documented weights for the resident for 3/2017, and no documentation the resident was reweighed when there was a greater than 5 pound difference. She stated the resident's intake was very poor and when intake was poor, a nutritional assessment should be done. When interviewed on 4/27/2017 at 12:30 PM, registered nurse (RN) Manager #4 stated nursing was responsible for notifying dietary when there was a weight loss and/or poor intake concern and she believed dietary was aware of the resident's poor intake. She stated weights with a 5 pound or more difference from a previous weight should be rechecked within 24 hours and documented. She stated the resident historically had poor intake, and it had worsened since her return from the hospital. During an interview with the RD on 4/27/2017 at 1:00 PM, she stated the weight difference from 1/25/2017 (136.7 lbs) to 2/2/2017 (128 lbs) was missed due to an error on the weight trend report, and she did not notice there were no weights recorded for 3/2017. The RD stated the resident's weight at readmission on 4/20/2017 was a 9% loss since the prior weight on 4/4/2017. She stated she had not reassessed the resident's nutritional needs since readmission. 10NYCRR 415.12(i)(1)

Based on observation, interview and record review conducted during the standard survey, it was determined the facility did not ensure 1 of 5 sampled residents (Resident #12) reviewed for self determination, and that 5 of 6 anonymous residents at the group meeting, had the right to make choices about significant aspects of their life. Specifically, residents at the group meeting stated they did not have independent access to snacks, and all 4 unit pantries were locked and not accessible to residents. For Resident #12, showers werew not provided as planned, and were not offered an alternate times when the shower was declined. Findings include: 1) During the initial tour of the facility on 2/10/2016 between 10:15 AM and 12:00 PM, the Carey, Jordan, MacDonald and Williams units were observed with locked food pantries (kitchenettes). No snacks were observed on the units for residents' independent access. During a resident group meeting on 2/11/2016 at 11:10 AM with 6 anonymous residents in attendance, 5 residents stated they did not have access to the pantries to obtain snacks or drinks, as the pantries were locked with a combination key pad. The Director of Environmental Services was interviewed on 2/12/2016 at 9:20 AM and stated the kitchenettes had to be locked, due to the potential for accidents and hazards from the hot liquids in the room (coffee and hot water). Certified nurse aide (CNA) #7 and the registered nurse (RN) Unit Manager were observed passing snacks to the residents on 2/12/2016 at 11:00 AM. They stated that no food was left out; if a resident wanted anything, they were to ask the staff. The RN UNit Manager stated the door to the pantry was required to be locked, due to safety concerns. The CNA stated Resident #18 frequently requested a drink during the day and waited outside the kitchenette for a staff member to obtain it for him. 2) Resident #12 had [DIAGNOSES REDACTED]. Nursing care instructions, dated 5/2/2015, documented the resident was scheduled for a shower on Sundays, during the 3 PM - 11 PM shift. A physician order [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required extensive assistance for personal hygiene and bathing. Nursing progress notes documented the resident refused her shower on: - 12/6/2015 at 9:57 PM; no reason for refusal was documented; - 12/20/2015 at 9:22 PM; refused shower due to illness; - 1/3/2016 at 9:49 PM; the resident did not feel well and refused her shower; - 1/17/2016 at 9:39 PM; resident stated she didn't feel well; and - 1/24/2016 at 9:32 PM; resident stated she was too tired. There was no documentation alternate shower days or times were offered to the resident. During an interview with the resident on 2/12/2016 at 11:45 AM, she stated she was scheduled for her shower on Sunday evenings, since she was admitted . She preferred evenings, but Sunday was sometimes a difficult day, due to activities she liked to attend. She stated when she returned from the activities, it was often after 9:00 PM, and the certified nurse aid (CNA) would ask her if she would like her shower at that time. When she declined her shower on her scheduled shower day, she stated she was not offered another day or time. She stated she was assisted with washing herself everyday, but she would really like a shower. She stated that on 2/7/2016, she had attended the Superbowl party; did not return until after 9:00 PM; and felt it was too late to receive a shower when the CNA asked. An alternate shower time was not offered. The registered nurse (RN) #1 Unit Manager was interviewed on 2/12/2016 at 12:05 PM. She stated showers were assigned to the CNAs at the beginning of shifts, and generally showers were given after dinner on the evening shift. She stated if a resident refused a shower, they were given a bed bath and asked if they would like their shower the following morning, or at a different time. The CNA would inform the charge nurse and it was communicated during shift report. The shower would be fit into the next day's bathing schedule. If the resident refusal occurred on a regular basis, the resident was offered a bath or shower on a different day. She stated she was not sure if the resident was offered an alternate shower day when she declined. During an interview with CNA #2 on 2/12/2016 at 12:15 PM, she stated when a resident refused their shower, she would leave and reapproach the resident at a later time. She would ask the supervisor if a change in shower day was possible, and ask the resident if they would like the alternate day instead. 10NYCRR 415.5(b)(1-3)

Based on observation and interview conducted during the standard survey, it was determined the facility did not ensure food was served in a way that was palatable and served at the appropriate temperature for 2 of 4 meals observed, and for 3 of 6 anonymous residents in attendance at the resident group meeting. Specifically, the milk was not cold when served during two meal observations, and the eggs and French toast were lukewarm. Three anonymous residents at the group meeting stated their milk was not always of palatable temperature. Findings include: On 2/10/2016 at 4:37 PM, an 8 ounce (oz) glass of milk was observed on Resident #17's table in the main dining room. Resident #17 arrived in the dining room at 5:28 PM. The milk temperature was tested by 2 surveyors and the Assistant Director of Nutritional Services at that time. The milk's temperature reading was 58 degrees Fahrenheit (F.) and was warm to taste. When interviewed on 2/10/2016 at 5:40 PM, the Assistant Director of Nutritional Services stated the drinks were placed on the dining room tables between 4:45 PM - 5 PM daily, prior to opening the doors to the dining room. When he observed the temperature of 58 degrees F, he stated the temperature should not have been that high. During the resident group meeting on 2/11/2016 at 11 AM, 3 of 7 anonymous residents stated the milk was often warm to taste, and was left sitting on the tables for awhile before the residents arrived in the dining room. On 2/12/2016, a surveyor observed breakfast in the dining room. The surveyor requested a resident tray at 8:08 AM from the steam table in the dining room. The replacement tray was served to the resident at 8:13 AM; the temperatures of the food on the initial tray were: - the scrambled eggs were 117 degrees F., - French toast was 103 degrees F. These food items lacked flavor and were not palatable. On 2/12/2016 at 8:24 AM, a resident entered the dining room and the surveyor requested the resident's glass of milk be replaced. The temperature of the initial glass of milk was 56 degrees F. When interviewed on 2/12/2016 at 8:24 AM, dietary staff member #6 stated she started setting the milk out on the tables in the dining room at 7:10 AM. When interviewed on 2/12/2016 at 9:10 AM, the Director of Nutritional Services stated there used to be a periodic monthly check of the resident trays for the temperature of the food served; and said this had not been done in several months. When interviewed on 2/12/2016 at 3:07 PM, the Nutritional Services Supervisor stated the temperature of milk should be between 40 and 45 degrees F., and hot food items should be served to the residents at 165 degrees F. or hotter. 10NYCRR 415.14(d)(2)

Based on observation, record review, and interview conducted during the standard survey, it was determined the facility did not ensure 1 of 3 residents (Resident #7) reviewed for restraints was free from physical restraints imposed for purposes of discipline or convenience. Specifically, there was not a consistent plan for the use of a lap buddy restraint for Resident #7. Findings include: Resident #7 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) documented the resident had a fall history prior to and since admission to the facility. The resident had a fall on 12/6/2015 with a [MEDICAL CONDITION], and falls on 12/15/2015, 12/21/2015, 12/22/2015, and 1/4/2016. A 1/4/2016 nursing progress note documented the resident was found on her knees, had slid out of her chair with a seatbelt, and had her right hand twisted in the seatbelt. A 1/5/2016 nursing progress note documented the resident's seatbelt would be replaced when not in arms reach of staff. A 1/5/2016 nursing progress note documented a new recommendation to discontinue alarming seatbelt and place a lap buddy on the resident when in the wheelchair. A physician order [REDACTED]. The lap buddy was to be released every 2 hours for toileting and at meals. The CCP was updated on 1/5/2016 and documented the resident was to have a lap buddy when out of bed in the wheelchair. The lap buddy was to be released every 2 hours for toileting and exercise, and the resident was to be supervised at activities and meals. The resident's current undated certified nurse aide (CNA) care instructions documented the resident had a lap buddy while in the wheelchair that was implemented on 1/5/2016. There was no further guidance on the care instructions for the use of the lap buddy. A 1/6/2016 Rehabilitation Fall Report documented the resident's alarms were discontinued on the wheelchair, and a lap buddy was added. The resident required supervision with the lap buddy related to multiple falls from the wheelchair. Nursing progress notes dated 1/6/2016 at 10:09 AM documented, a chair alarm was to be used with the lap buddy, while the resident was in the wheelchair. At 7:17 PM, nursing notes documented the resident removed her lap buddy and was trying to move her foot pedal. The resident was redirected by the nurse, the lap buddy was re-applied, and the resident was brought closer to the nurses' station for staff to monitor more closely. On 1/8/2016, nursing notes documented the resident was standing up by the fish tank at the nurses' station, and the chair alarm was sounding. Nursing notes documented the resident was repeatedly removing her lap buddy that shift, and was physically resistive and verbally disruptive. Nursing notes, dated 1/10/2016, documented the resident requested to get out of bed, had a snack, and requested to go back to bad. When staff brought her to her room, the resident stated she did not want to go to bed. The resident refused to allow staff to utilize lap buddy, so she remained in bed. On 1/11/2016, nursing notes documented the resident removed the lap buddy from her wheelchair; and at times became upset and yelled at staff to leave the lap buddy off. Nursing notes on 1/13/2016 documented the resident was upset with the lap buddy and hollering to have it removed. On 1/14/2016, nursing progress notes documented the resident was up in her wheelchair that morning with the lap buddy on and occasionally yelling out to have it removed. The resident's 1/14/2016 Minimum Data Set (MDS) assessment documented the resident cognition was moderately impaired; the resident did not have any falls during the assessment period; and used a trunk restraint daily. A 1/15/2016 nursing progress note documented the nurse was doing rounds and found the resident in the hallway in her wheelchair. The resident had removed her lap buddy and was trying to scoot herself around in the wheelchair. The resident was brought to the nurses' station and would not calm down. On 1/18/2016, nursing notes documented the use of the lap buddy was not needed for the resident, as she remained within arms reach with staff. Nursing notes, dated 1/20/2016, documented the resident was found on the floor as the CNA could not get to her in time. The resident stated she was getting up and nobody came. The resident was transferred back to her wheelchair and the lap buddy was applied. The CCP was updated on 1/20/2016 and documented the resident had a fall from her wheelchair. A 1/21/2016 nursing progress note documented the use of the lap buddy and other interventions attempted with the resident were reviewed with therapy. As always, the note documented the resident was to be monitored frequently and staff were to respond as necessary to chair and bed alarms. The CCP was updated on 1/21/2016 and documented the resident's safety would be maintained with the least restrictive device, a lap buddy. Interventions included to release restraints every 2 hours for 15 minutes, and to remove with meals and activities. The restraint was to be removed when the resident was in a supervised or 1:1 setting. A 1/22/2016 nursing progress note documented the resident continued to attempt to stand without assistance, refused the lap buddy, and became very agitated when staff attempted to put the lap buddy on in the wheelchair. The CCP was updated on 1/26/2016 and documented the lap buddy was to be applied, if the resident declined a nap or activity. A 1/28/2016 nursing progress note documented the resident did not have a lap buddy on most of the shift, and was very agitated when they applied the lap buddy. The CCP, updated on 1/28/2016, documented the lap buddy was to be utilized after 3 PM and released every 2 hours for toileting, meals, and supervised activities only at that time. The previous CCP interventions remained in place, were not discontinued, and conflicted with the plan documented on 1/28/2016. The CCP interventions conflicted with the physician's orders [REDACTED].>A 1/29/2016 nursing progress note documented restraint not used. A nursing progress note, dated 2/2/2016, documented the lap buddy was on for safety and the resident tried to remove it. During an initial interview with the registered nurse (RN) Manager on 2/10/2016 at 11:30 AM, she stated the resident used a lap buddy as needed. The resident was observed on 2/10/2016 from 3:50 PM to 4 PM, seated by the fish tank in the hallway, without the lap buddy in place. No staff were within arm's length. From 4 PM to 4:30 PM, the resident was taken to the lounge for an activity. The resident was seated between 2 other residents and a staff member was seated near the entrance to the lounge, not in arm's length of the resident. The lap buddy remained off. A nursing note dated 2/11/2016 documented the resident was seated at the nurses' desk within arms length of the resident. On 2/12/2016 at 9:25 AM, the resident was observed seated in the lounge area in her wheelchair. She did not have a lap buddy in place, and no staff were present in the room during the initial observation. At that time, the registered nurse (RN) Manager approached the resident and brought her to the nurses' station. At 9:40 AM, the resident was seated in the hallway near the fish tank; she did not have a lap buddy on; and no staff were present. The RN had left the unit. At 9:41 AM, the RN Manager returned to the nurses' station, and sat behind the desk, with her back to the resident. From 9:43 AM to 9:46 AM, the RN left the unit and no other staff were in the area. The resident was observed to remain seated in the hallway by the fish tank, without a lap buddy in place. During an interview with CNA #12 on 2/12/2016 at 10:25 AM, she stated she was responsible for applying and removing the resident's lap buddy. She stated she would apply the lap buddy, if the resident was acting really rowdy. She stated she was to keep the resident by the fish tank/nurses' station to keep an eye on her, as there was always staff in that area. She stated she was not sure what the CNA instructions documented regarding when to apply the lap buddy to the resident. She stated the resident was to always be supervised wherever she was, as she sometimes tried to get up. RN Manager #9 was interviewed on 2/12/2016 at 11:20 AM. She stated they started a reduction in lap buddy use during the day shift, and the change was noted on the resident's current CCP. RN #9 stated if staff attempted to place the lap buddy on the resident and she refused, staff were to keep her in eye sight. She stated sometimes the resident would take the lap buddy off. RN #9 said if the resident removed or refused her lap buddy on the evening shift, staff were to keep her occupied and supervised. During a combined interview with the Director of Nursing (DON) and the Director of Social Services on 2/12/2016 at 1:30 PM, they stated the resident's lap buddy was to be off during the day hours, when more people were available to trouble shoot. The lap buddy was to be on in the evenings, except during the dinner meal. They stated the lap buddy did not need to be on the resident when she was at the table, if the resident was seated in the wheelchair, with the wheels locked. They were not sure if the resident was able to unlock her own wheelchair. 10NYCRR 415.4(a)(2, 3, 5)