Every finding on record at United Helpers Canton Nursing Home

Based on record review and interviews, the facility failed to consult with the physician when there was a significant change in a resident's physical status for one of three residents (Resident #1) reviewed. Specifically, Resident #1 had an acute physical decline on 05/24/2026, including inability to swallow, unresponsiveness, and increased signs and symptoms of discomfort, and the physician was not notified of the resident's change in status. Resident #1 was subsequently hospitalized upon the family's request and diagnosed with sepsis (extreme response to infection). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy. The findings are:The 09/05/2019 reviewed facility policy, Notification of Resident Change, documented the facility must immediately inform the resident; consult with the resident's physician; and the resident's legal representative when: a significant change in the resident's physical, mental, or psychosocial status (i.e., a deterioration in health, mental, or psychosocial status in either life-threatening condition or clinical complications). Documentation of such notification would be documented in the proper location of the medical record. Resident #1 had diagnoses including Parkinson's Disease (progressive neurological disorder) and dementia (decline in mental ability). The Minimum Data Set (a resident assessment tool) dated 05/13/2026 documented the resident had severe cognitive impairment and required maximum assistance for activities of daily living. Resident #1's Medical Orders of Life Sustaining Treatment, signed 04/05/2026, documented do not attempt resuscitation (allow natural death), send to the hospital when medically necessary, use of intravenous fluids, determine use for feeding tube needs if the need arose, and use antibiotics to treat infections. The 05/24/2026 at 2:43 PM nurse progress note by Licensed Practical Nurse #11, documented Resident #1's Health Care Proxy was contacted and discussion about the resident's decline and possible need for end-of-life care. The Health Care Proxy wanted to set up a time to speak with the doctor. The doctor was aware and would discuss resident needs with the Health Care Proxy on [05/27/2026]. The 05/24/2026 at 8:40 PM nurse progress note by Licensed Practical Nurse #10, documented Resident #1 was unable to tolerate any liquid or oral medications during the shift, attempted crushed medications in pudding and the resident held in their mouth without initiating swallow. They were nonverbal and only groaned in response to attempts at communication or repositioning. After supper, the resident was transferred to bed. Resident #1 displayed facial grimacing and groaning with any movement, suggesting pain during repositioning, is non-rousable and does not respond to verbal or tactile stimuli beyond groaning. They would pass on to oncoming nurse to reposition resident every two hours and provide oral care as needed. The 05/25/2026 at 12:56 PM nurse progress note by Registered Nurse #9, documented Resident #1 was unable to tolerate any liquid or oral medications, attempted crushed medications in pudding and the resident held it in their mouth without initiating a swallow, no purposeful swallowing observed. They were nonverbal, groaned in response to attempts at communication or repositioning. After breakfast, the resident was transferred to bed. Resident #1 displayed facial grimacing and groaning with any movement, suggesting pain during repositioning, is non-rousable and does not respond to verbal or tactile stimuli beyond groaning. The 05/25/2026 at 10:53 PM nurse progress note by Registered Nurse #7, documented Resident #1 remained non-arousable, did not respond to verbal or tactile stimuli, moaned and displayed facial grimacing when being touched or repositioned. The resident's relative was notified; they arrived and made decision to send the resident to the hospital for intravenous fluids due to not eating since 05/24/2026 at lunch and total fluids 11 ounces. Emergency services were notified at 7:30 PM, arrived at 8:00 PM and the family requested no chest compressions if the resident's heart stopped, only fluids, oxygen, and medications as necessary. The 12/09/2025 Physician Orders documented Tylenol Extra Strength, 500 milligrams, two tablets twice per day and as needed. The last documented administration was on 05/24/2026 at 11:00 AM. The 05/2026 Medication Administration Record for Tylenol documented:- on 05/24/2026 the 8:00 PM dose was not given due to condition;- on 05/25/2026 the 11:00 AM dose was not given due to condition; and- on 05/25/2026 the 8:00 PM dose was not given due to condition. There was no documented evidence of any other pain medication provided to the resident on 05/24/2026 and 05/25/2026. There was no documented evidence that a medical provider was notified when the resident's condition changed and they were unable to swallow or take any medications, including pain medication, for over 24 hours. During an interview on 06/02/2026 at 6:43 PM, Licensed Practical Nurse #10 stated they last saw Resident #1 on the 05/24/2026 evening shift. The resident was not very arousable and could not eat or drink. They spoke with Licensed Practical Nurse #11, who said they spoke with the physician and the family about the resident's decline. They did not know what the conversations fully entailed, and it was Licensed Practical Nurse #10's understanding that there were plans for the physician and family to further discuss care and needs. They did not notify the physician due to Licensed Practical Nurse #11 stating they had already contacted the physician. The resident showed signs of pain when being put back to bed and then appeared comfortable. When they could not take their medications, Licensed Practical Nurse #10 stated they notified the supervisor, and could not recall who it was. During an interview on 06/08/2026 at 1:58 PM, Certified Nurse Aide #13 stated they provided care to Resident #1 during the day shift on 05/25/2026. They noted the resident was in pain and notified the nurses but could not recall who. The nurse stated it was not time for medications. Later in the shift, Certified Nurse Aide #13 asked one of the nurses for assistance in repositioning, the nurse tried to give the resident medication in applesauce or pudding, and they would not swallow. The aide cleaned out the resident's mouth and provided oral care. During an interview on 06/02/2026 at 4:37 PM, Registered Nurse #9 stated that on the 05/25/2026 day shift, Resident #1 was assisted out of bed, to the scoot chair (specialized reclining wheelchair), and taken to breakfast. The resident just let the food run out of their mouth and did not attempt to swallow. They did not contact the provider as there was a referral for a speech evaluation for swallowing already completed. The resident grimaced with pain during movement and repositioning. They had an order for Tylenol for pain, but they were not taking oral medications at that time. They spoke with the doctor about skin treatment for Resident #1, but they did not discuss the pain or the inability to take their oral medications. During an interview on 06/03/2026 at 9:29 AM, Physician #12 stated they were made aware Resident #1's Health Care Proxy wanted to discuss end-of-life care on 05/27/2026. They were not made aware when the resident was not able to swallow or take their medications. The physician was not notified of any urgency regarding end-of-life care, or they would have gone to see the resident. The resident had been declining, and the physician was aware the family was discussing what they wanted to do and then they were going to discuss with the physician on 05/27/2026. If nursing staff had notified the physician on 05/25/2026 when the resident was not eating or drinking, they would have notified the family sooner to obtain consent for pain management. 10 New York Codes, Rules, and Regulations 415.3(2)(ii)(a)

48052 48895 Based on record review, observation, and interview during the recertification survey conducted 8/6/2024-8/9/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 2 resident neighborhoods (North and [NAME] Neighborhoods). Specifically, hot water was not maintained at acceptable temperatures in the North and [NAME] neighborhoods; resident wheelchairs were soiled and in disrepair on the [NAME] Neighborhood; there were sticky floors in several areas of the North Neighborhood; and the kitchenettes on the North and [NAME] Neighborhoods were in disrepair. Findings include: The facility policy, Resident's Rights, dated 8/15/2017, documented residents of the facility had the right to live in a clean and safe environment. The facility policy, Maintaining and Monitoring Water Temperatures - SNF (Skilled Nursing Facility), dated 2/2021 documented the water temperature must be capable of attaining a temperature of 90 degrees Fahrenheit and must not attain a temperature more than 120 degrees Fahrenheit. A routine temperature check of the hot water temperature would be made at various points in the hot water system to verify that temperatures were in accordance with facility policy. The facility policy, Work Orders/Requests, dated 2/13/2024 documented repairs of any unsafe and failing equipment was completed in a timely manner, and facility staff used a maintenance work order system. The Maintenance Department would prioritize the maintenance work orders and keep the signed work order on file for at least one year. The electronic communication from the Administrator dated 8/8/2024 at 12:34 PM, documented the facility did not have written policy for floor cleaning, kitchenette cleaning, or housekeeping. The electronic communication from the Administrator dated 8/9/2024 at 12:10 PM, documented the facility did not have written policy for routine maintenance. Water Temperatures Not Maintained: During observations on 8/6/2024, the following water temperatures were measured: - at 1:25 PM, the Oak Cottage shower room's water temperature was 123.5 degrees Fahrenheit. - at 1:28 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 123.4 degrees Fahrenheit. - at 3:30 PM, the Maple Cottage shower room's water temperature was 85.4 degrees Fahrenheit; and the Oak Cottage shower room's water temperature was 122 degrees Fahrenheit. - at 3:32 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 121 degrees Fahrenheit. - at 3:41 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 89 degrees Fahrenheit. - at 3:42 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 123.3 degrees Fahrenheit. - at 3:45 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 122.1 degrees Fahrenheit. - at 3:47 PM, the [NAME] Cottage shower room's water temperature was 126.2 degrees Fahrenheit. - at 3:51 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 87.4 degrees Fahrenheit. During an observation on 8/7/2024, the following water temperatures were measured: - at 1:38 PM, the [NAME] Cottage shower room's water temperature was 121.9 degrees Fahrenheit. - at 1:42 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 122.3 degrees Fahrenheit. - at 1:44 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 122.8 degrees Fahrenheit, verified by Physical Therapy Assistant #10. - at 1:53 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 120.3 degrees Fahrenheit. - at 2:22 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 81.7 degrees Fahrenheit. - at 2:23 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 81.4 degrees Fahrenheit, verified by Certified Nurse Aide #11. - at 2:30 PM, resident room [ROOM NUMBER]'s bathroom sink water temperature was 81.4 degrees Fahrenheit, verified by Certified Nurse Aide #11. During an interview on 8/6/2024 at 1:02 PM, Resident #40 stated the water in their bathroom was never hot and the water was cold for several days last week and this week. During an interview on 8/6/2024 at 4:28 PM with the Director of Building and Grounds, and the Maintenance Coordinator, the Director of Building and Grounds stated hot water flowed from the boiler through the mixing valve, and there was a different valve for each unit. The circulation order for the hot water on the North Neighborhood was Oak, Elm, Willow, and the Birch Cottage was last. The circulation order for cottages for the hot water on the [NAME] Neighborhood was [NAME], Ash, Cherry, and Maple was last. The acceptable temperature range for hot water was 110-120 degrees Fahrenheit in sinks. The Maintenance Coordinator stated they checked the temperatures in every cottage. On 8/6/2024, they tested the water in the shower rooms between 8:00 AM and 8:30 AM, there were no abnormal temperatures. If the temperature was higher than 120 degrees Fahrenheit, they would see what happened and continue to check the temperatures until they were normal. The Director of Building and Grounds stated 122 degrees Fahrenheit was not an acceptable temperature. Hotter water could be caused by back feed, and colder water could be caused by not letting the water run long enough. Depending on the time of day it could take a couple minutes to get hot water. If the water was too hot it could burn a resident. They stated had not received any complaints about hot water but had complaints about cold water. The Maintenance Coordinator stated that if the water was cold the residents could refuse bathing or be uncomfortable while bathing. During an interview on 8/7/2024 at 8:45 AM, Maintenance Worker #7 stated in the morning they ran the sink water to get the hot water out of the pipes because the water would be sitting in them all night. The boiler constantly circulated the water, so it did not cool off in the pipes. They ran the water then checked the temperatures to ensure they were in acceptable ranges for resident showers. During an interview on 8/7/2024 at 2:30 PM, Certified Nurse Aide #11 stated sometimes residents complained that the water was cool or cold. There was a resident they cared for that ran the water in their room for 20 minutes before they got warm water. During an interview on 8/9/2024 at 11:01 AM, the Administrator stated they were aware that variances were found in the water temperatures from hot and cold, some were close to 120 degrees Fahrenheit and could creep over. They made some adjustments to made sure the temperatures did not go over the 90-120 degrees Fahrenheit. During an interview on 8/9/2024 at 11:30 AM, the Director of Nursing stated staff made them aware of showers being too cold. If a resident complained about the water, it would not be home like. Wheelchairs In Disrepair: During an observation on 8/6/2024 at 10:34 AM, Resident #59's electric wheelchair was dirty with food substances. Resident #71's wheelchair was observed: - on 8/6/2024 at 10:45 AM, the footrest was ripped in several places and the seat area was dirty with food substances. - on 8/7/2024 at 9:35 AM, the blue footrest was ripped in several places. - on 8/7/2024 at 10:13 AM, the black positioning cushion on the right side of the chair was soiled with food substances, and the footrest was ripped in several places. - on 8/8/2024 at 10:21 AM, the seat and the black positioning cushion were soiled with dried food substances. During an interview on 8/8/2024 at 10:24 AM, Housekeeper #15 stated they could not recall if they were instructed to clean equipment but if they saw that a wheelchair was dirty, they would wipe down the seat or armrest. During an interview on 8/8/2024 at 11:37 AM, Certified Nurse Aide #9 stated wheelchairs should be cleaned by all staff but was mostly done by the midnight shift when the residents were sleeping. It was not homelike to have a dirty wheelchair. During an interview on 8/9/2024 at 9:59 AM, Licensed Practical Nurse #8 stated anyone could clean a wheelchair, but the night shift staff was responsible for cleaning the wheelchairs. They stated Resident #59's wheelchair was not clean. Resident #71's wheelchair was always dirty and should be cleaned. It was not homelike to have unclean wheelchairs. During an interview on 8/9/2024 at 10:09 AM, Registered Nurse Manager #3 stated the midnight shift certified nurse aides were responsible for cleaning wheelchairs. The wheelchairs should be cleaned, as it was not homelike or dignified for the residents to have dirty wheelchairs. During an interview on 8/9/2024 at 11:30 AM, the Director of Nursing stated the midnight shift certified nurse aides were responsible for cleaning wheelchairs. Resident #71 frequently had a dirty wheelchair, and it was cleaned regularly. Accessories on the wheelchair should also be cleaned. It was important to create a homelike environment, and it was a dignity issue if the wheelchairs were dirty. Sticky Floors: The following observations of sticky floors were made on 8/6/2024: - at 9:46 AM, the floor in resident room [ROOM NUMBER] at the vestibule between the two sides. - at 9:49 AM, the floor in resident room [ROOM NUMBER] - at 9:52 AM, the floor in resident room [ROOM NUMBER] - at 9:56 AM, the floor in resident room [ROOM NUMBER] - at 10:08 AM, the floor in resident room [ROOM NUMBER] - at 10:16 AM, the floor in resident room [ROOM NUMBER] - at 10:19 AM, the floor in resident room [ROOM NUMBER] - at 10:34 AM, the floor in resident room [ROOM NUMBER] on side A - at 10:47 AM, the floor in resident room [ROOM NUMBER] - at 12:00 PM, there were sticky floors in the North Neighborhood in the back of the dining room near the countertop and windows. The following observations of sticky floors were made on 8/7/2024; - at 9:17 AM, in the Elm Cottage the floor in the dining room near the windows. - at 9:31 AM, in Birch Cottage the floor in the dining room near the windows, in front of the counter with cabinets. - at 12:18 PM, the floor in front of the nurses' station between Oak and Elm Cottages was sticky. During an interview on 8/9/2024 at 11:34 AM, Housekeeper #5 stated they were responsible for sweeping the floors, making rooms presentable, and using wet floor signs. If the floors were sticky they were supposed to use warm water with chemicals. They stated the stickiness might have been from a buildup of chemicals. They would use just hot water to help remove the buildup. They stated sticky floors were not homelike. During an interview on 8/9/2024 at 11:59 AM, the Maintenance Coordinator stated the process for cleaning the floor was to sweep then mop daily. The floors should not be sticky, it was not homelike. If staff noted the floors were sticky, they should let housekeeping know. Kitchenette Maintenance: The following observations were made in the North Neighborhood kitchenette on 8/6/2024 at 11:20 AM: - the cabinet door under the handwash sink was damaged (an approximate 2-inch section of the door was missing). - one of the drawers was missing the drawer front. - an upper cabinet located over the toaster was missing an approximate 3 feet by 1 foot access door. - the countertop near the handwash sink was water damaged and in disrepair. - hardware for two cabinets were not connected with doors and door handles were loose with missing screws. - in the kitchenette pantry miscellaneous cabinet fronts and door parts were found. The following observations were made in the [NAME] Neighborhood kitchenette with Dietary Aide #13 on 8/7/2024 at 11:55 AM: - a lower cabinet in the kitchenette pantry was missing an access door (where resident soda was stored). - the handwash sink faucet was loose and the hot water was not fully flowing out of the faucet. - part of the access door of a cabinet under the handwash sink came loose and fell off in the surveyor's hands. A side piece of the door had water damage and appeared to be swelled up. - the cabinet under the handwash sink had chemicals stored on top of unsealed plywood. The plywood was discolored, and water stained. - there was water on the floor on both sides of the dish machine, and wet debris around the edges of the floor base material (dish machine was not on at the time of the observation). During an interview on 8/7/2024 at 2:00 PM, Dietary Aide #13 stated they observed the hot water was not flowing properly out of the [NAME] Neighborhood kitchenette pantry handwash sink. They were told by the Maintenance Coordinator that it would be addressed. They stated the lower cabinet door had been missing for at least a week and was not sure where the door was located. They should tell a maintenance worker or the Food Service Director if they observed an issue. During an interview on 8/8/2024 at 1:55 PM, Dietary Aide #12 stated they worked in the North Neighborhood kitchenette, and there had been cabinet issues off and on for the last two and a half years. They were told they could fill out work orders if they identified issues but was never told where to find the work order forms. Dietary Aide #12 stated they were never shown how to fill out a work order and they reported their concerns directly to the Food Service Director. During an interview on 8/8/2024 at 2:28 PM, the Food Service Director stated they were not aware of the damaged/broken hardware and door handles in the kitchenettes. Within the last 4 months between April 2024 and August 2024 they asked the maintenance department about the status of the North Neighborhood kitchenette repairs and had been told they were being worked on. They were not aware of the damaged lower cabinet door under the hand wash sink. They stated it was important that work orders were filled out and completed so the facility was maintained in a safe and comfortable environment for residents. During an interview on 8/8/2024 at 2:40 PM, the Maintenance Coordinator stated when a work order form was completed for the Food Service Department, the department would be given the yellow completed work order form. They verified that a 4/1/2024 work order had been signed off as completed and a 4/2/2024 work order had been assigned to a maintenance worker for the North Neighborhood kitchenette. The Maintenance Coordinator stated they did not follow up after the repairs made to the North Neighborhood kitchenette on 4/3/2024. They stated they could not find any work orders for the issues identified in the [NAME] Neighborhood kitchenette pantry and was not aware of the damaged part of the lower cabinet door under the hand wash sink. The Maintenance Coordinator stated it was important that work orders were filled out and completed so the facility was maintained in a safe and comfortable environment for residents. 10 NYCRR 415.29(j)(1)

Based on observation, record review, and interview during the recertification survey conducted 8/6/2024-8/9/2024, the facility did not ensure residents were free of any significant medication errors for 3 of 4 resident (Residents #9, #53, and #59) reviewed. Specifically, Residents #9 and #53 did not receive medications as ordered and the medical provider was not notified, and Resident #59 did not receive their medication for Parkinson's disease (a progressive neuorological disorder) timely as ordered. Findings include: The facility policy, Medication Policies Program, revised 9/16/2024, documented all drugs were to be administered in compliance with the physician's orders, were administered safely, and were administered without error. The person who administered the medication would ensure the six rights of medication administration: the right person, the right medication, the right dose, the right time, the right method/route, and the right documentation. 1) Resident #9 had diagnoses including depression, heart failure, and hypothyroidism (underactive thyroid). The 6/4/2024 Minimum Data Set (a health assessment tool) documented the resident had severely impaired cognition, appeared down, depressed, or hopeless for several days, had no behavioral symptoms, was dependent or required touching assistance for activities of daily living, and took an antidepressant and a diuretic (waterpill) medication daily. The 2/1/2023 Nurse Practitioner #16's medical order documented one furosemide (diuretic) 40 milligram tablet twice a day for heart failure at 7:00 AM and 1:00 PM. The 12/14/2023 Physician #'17's medical order documented duloxetine capsule (antidepressant), delayed release, 30 milligrams once a day for depression at 7:00 AM. The 7/19/2024 Nurse Practitioner #16's medical order documented levothyroxine (thyroid medication) 137 micrograms one tablet once a day for hypothyroidism at 7:00 AM. The 8/7/2024 Medication Administration Record documented by Licensed Practical Nurse #2 included: - the 7:00 AM dose of duloxetine capsule, delayed release, 30 milligram was not administered due to the drug/item was unavailable. - the 7:00 AM dose of furosemide tablet 40 milligrams was not administered due to the drug/item was unavailable. - the 7:00 AM dose of levothyroxine tablet 137 micrograms was not administered due to the drug/item was unavailable. There was no documented evidence the medical provider was notified of the medications that were not administered due to being unavailable. During an interview on 8/9/2024 at 9:10 AM, Licensed Practical Nurse #2 stated the electronic medical record prompted the nurses on what medications to give and then the nurse double checked the dose against the medication card (blister pack) to verify what medication to give and how much. If they did not have the required medication card in the cart, they checked the medication room to see if a refill card was there. If there was no medication card in the medication room, they checked the electronic stock medication supply system. If the medication was not available in the electronic stock medication supply system, they made sure they notified the pharmacy to resupply the medication either by clicking the button in the electronic medical record if applicable, or by faxing the pharmacy. They documented the medication was not given. If the medication was not given, they wrote a progress note in the resident's electronic medical record. If the medication was a significant medication they let the providers and the oncoming nurse know the medication was not given. They considered levothyroxine and furosemide to be significant medications. Duloxetine was a behavior or depression medication and was not as significant. They did not inform the provider that Resident #9 did not receive their duloxetine, levothyroxine, or furosemide as ordered on 8/7/2024. They stated 8/7/2024 was the day they did their cassette exchange, which meant pharmacy brought the new month's supply of medication, and they were out of quite a few medications. They did not believe anything could happen to the resident from the missed doses. At 10:34 AM, Licensed Practical Nurse #2 stated when the new cassettes came in on 8/7/2024, they did not give the missed doses of medication to the resident as the medications came in around 10-10:30 AM. Some of the medications had an afternoon dose and they did not want the doses to be too close together. 2) Resident #53 had diagnoses including dementia with behavioral disturbances, depression, and type 2 diabetes without complications. The 6/5/2024 Minimum Data Set documented the resident had severely impaired cognition, had no behavioral symptoms, was dependent or required moderate assistance for most activities of daily living except, and took an antipsychotic (mood stablaizer) medication daily. The 11/16/2023 Nurse Practitioner #16's medical order documented Seroquel (antipsychotic) 25 milligram tablet, give 12.5 milligrams once a day at 6:00 PM for major depressive disorder. The Medication Administration Record documented on 8/5/2024 and 8/6/2024 the 6:00 PM dose of Seroquel 12.5 milligrams was not administered by Licensed Practical Nurse #18 due to the drug/item was unavailable. There was no documented evidence the medical provider was notified of the medications that were not administered due to being unavailable. During an interview on 8/8/2024 at 3:41 PM, Licensed Practical Nurse #18 stated they administered medications by pulling up the orders on the electronic medical record. Once the resident took the medication, they clicked off the order was completed in the medical record. If a resident refused their medications or the medications were not available, they marked it in the electronic medical record. They did not inform anyone because the information was on the electronic medical record the provider and nursing supervisor had access to so they would know if the resident took their medications or did not take their medications. During an interview on 8/9/2024 at 9:30 AM, Registered Nurse Unit Manager #3 stated if a resident refused their medication or missed their medication dose due to it not being in stock, they should be informed. It was not an acceptable practice to mark the medication was not given in the electronic medical record and not inform them, the nurse supervisor, or the medical providers. Levothyroxine, furosemide, duloxetine, and Seroquel were all significant medications.They were unaware that Resident #9 did not receive their levothyroxine, furosemide, and duloxetine as ordered on 8/7/2024 due to it not being in stock. They stated a missed dose of furosemide could lead to fluid overload and a missed dose of levothyroxine was important because it was thyroid related. They were unaware that Resident #53 did not receive their Seroquel on 8/5/2024 and 8/6/2024 due to it not being in stock. They stated missed doses of Seroquel could lead to behavior spikes and they needed to know the resident had missed doses when evaluating the resident's behaviors for medication changes. They stated the floor nurses should document a progress note in the electronic medical record the resident did not receive their medications as ordered and why, and that the Nursing Supervisor, the Nurse Manager, or the provider were made aware. The nurses were educated about informing the Nurse Manager/Nursing Supervisor or provider about missed medication doses. During an interview on 8/09/2024 at 10:14 AM, the Director of Nursing stated if a medication was not available or not in stock, the nurse should check the electronic stock medication supply system to see if it was available. The medication should immediately be reordered via the button in the electronic medical record. For any dose that was not given due to not having the medication in stock, the nurse should get an order to hold the medication. The nurses should make someone aware that a dose of medication was not given due to the medication not being in stock even if it is marked as not given in the electronic medical record. Levothyroxine, furosemide, and Seroquel were significant medications. Duloxetine was a significant medication, but the difference was a single dose did not treat immediate behaviors. 8/7/2024 was the day they received the new medication cards for the month and normally, if a resident was out of medications but the medication came, they would give the dose late. They were unaware Resident #53 had missed two doses of Seroquel on 8/5/2024 and 8/6/2024. They were unaware if Seroquel was stocked in the electronic stock medication supply system. 3) Resident #59 had diagnose including Parkinson's disease and muscle weakness. The 6/26/2024 Minimum Data Set assessment documented the resident #59 was cognitively intacthad no drug regimen review or medication follow-ups. The comprehensive care plan initiated 5/16/2024 documented the resident had Parkinson's Disease and required medication management to relieve or reduce the decline in activities of daily living. Interventions included determine assistance needed for activities of daily living, administer medications per physician order and monitor for side effects, report side effects to physician, and consult or meet with neurologist as needed. Physician orders documented: - on 7/23/2024 carbidopa-levodopa tablet; 25-100 milligrams; 2 tablets twice daily at 11:00 AM and 5:00 PM for Parkinson'r disease. - on 7/23/2024 carbidopa-levodopa tablet; 25-100 milligrams; 2 1/2 tablets teice daily at 8:00 AM and 5:00 PM for Parkinson's disease. - on 7/24/2024 carbidopa-levodopa extended release; 25-100 milligrams; 2 tablets every day at 8:00 PM for Parkinson's disease. The 8/2024 electronic Medication Administration Record documented; - carbidopa-levodopa tablet; 25-100 milligrams, administer 2 1/2 tablet at 8:00 AM and 2:00 PM with a start date of 7/23/2024. The medication was documented as administered late on 8/1/2024 at 10:32 AM scheduled for 8:00 AM (2 hours, 32 mins); on 8/5/2024 at 9:35 AM scheduled for 8:00 AM (1 hour 35 mins); on 8/6/2024 at 9:47 AM scheduled for 8:00 AM (1 hour, 47 mins); on 8/9/2024 at 9:19 AM scheduled for 8:00 AM (1 hour, 19 mins); and 8/3/2024 at 3:23 PM scheduled for 2:00 PM (1 hour, 23 mins). - carbidopa-levodopa tablet; 25-100 milligrams, administer 2 tablets at 11:00 AM and 5:00 PM with a strat date of 7/23/2024. The medication was documented as administered late on 8/4/2024 at 12:20 PM scheduled for 11:00 AM (1 hour 20 minutes); and at 6:16 PM scheduled for 5:00 PM (1 hour, 16 mins). - carbidopa-levodopa tablet extended release; 25-100 milligrams; administer 2 tablets at 8:00 PM with a start date of 7/24/2024. During an interview on 8/6/2024 at 10:34 AM, Resident #59 stated they were happy living in the facility and their only complaint was their Parkinson's medication was given late. They stated they received carbidopa-levodopa five times a day and their doses were always late. During an interview on 8/9/2024 at 9:51 AM, Licensed Practical Nurse #8 stated Resident #59 had Parkinson's disease and received medication for this several times throughout the day. The medication times were set by the neurology clinic. They stated the electronic medical record time stamped when a nurse gave a medication. If it documented late administration or charted late that meant the medication was given late. The computer system would not let them continue until they clicked they administered the medication.They stated it was important to give Parkinson's medications on time as it could affect the resident's whole body. During an interview on 8/9/2024 at 10:09 AM, Registered Nurse Unit Manager #3 stated the electronic medication records had a preperation side and an administration side for medication administration. The nurses clicked on the prepped side, administered the medications to the resident, and then clicked on the administered button to complete the task in the electronic record. They stated medications nurses should not click administered until the resident took their medications just in case they refused them. If the electronic medication record documented 'charted late', then the resident received their medication late. If Resident #59's Parkinson's disease medications were not administered on time it could affect their blood pressure. During an interview on 8/9/2024 at 11:30 AM, the Director of Nursing stated after looking in the resident's electronic medical record, the resident received medication for Parkinson's disease several times per day. If Resident #59 did not receive their medications on time it could lead to an exacerbation of their Parkinson's disease symptoms and could affect their whole body. 10NYCRR 415.12(m)(2)

Based on observation and interview during the recertification survey conducted 8/6/2024-8/9/2024, the facility did not ensure drugs and biologicals were labelled and stored in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions when applicable for 1 of 4 medication carts (North neighborhood, Oak, and Elm Cart) reviewed. Specifically, the North neighborhood (the secured unit) Oak and Elm medication cart was left unlocked and unattended. Findings include: The facility policy, Medication Policies Program, revised 9/7/2016, documented medication rooms, medication cupboards, medication carts, and drug preparation areas would be kept clean, neat, and orderly at all times and the area would be kept locked unless under direct visual control by the staff person responsible for the medication administration. All mobile medication carts must be under visual control of the designated staff administering medications at all times. The following observations were made on 8/7/2024: - At 12:24 PM, the medication cart for Oak and Elm was in the dining room. The medication cart had the computer screen open with visible resident information and the cart was unlocked and unattended. There were residents in the dining room awaiting lunch. - At 12:26 PM, the top drawer of the medication cart was opened and then shut by the surveyor to verify the cart was unlocked. Licensed Practical Nurse #2 (the assigned medication nurse) was not near the unattended medication cart. -At 12:28 PM, Licensed Practical Nurse #2 came back to cart, shut the computer screen, and walked away from the cart. The cart remained unlocked and unattended. -At 12:31 PM, Licensed Practical Nurse #2 was sitting on a resident's four wheeled walker in the dining room with their back to the medication cart. The cart remained unlocked. -At 12:32 PM, Licensed Practical Nurse #2 walked behind the kitchenette, out of sight of the medication cart. The medication cart was unlocked and unattended. During an interview on 8/9/2024 at 9:10 AM, Licensed Practical Nurse #2 stated the top drawer of the medication cart contained insulin pens and eye drops, the second and third drawers contained prescribed medications in blister packs, the third drawer contained stock medications, and the bottom drawer had treatment powders and creams. They stated the medication cart should not be left unlocked. They stated they left the cart unlocked on 8/7/2024 as they got busy running around. Residents or anyone could get into the cart and take things out if it was unlocked and unattended. During an interview on 8/09/2024 at 9:30 AM, Registered Nurse Manager #3 stated nurses should not leave the medication carts unlocked. If a medication cart was unlocked the residents, or anyone could get into the cart. The nurses were constantly educated on not leaving their medication carts unlocked. During an interview on 8/9/2024 at 10:14 AM, the Director of Nursing stated nurses should not leave their medication carts unlocked. If a nurse walked away from their unlocked medication cart, someone could get into the cart and possibly take the medications. 10 NYCRR 415.18(d)

Based on observation, interview, and record review during the recertification survey conducted 6/7/22-6/9/22, the facility failed to exercise reasonable care for the protection of resident property from loss for 1 of 3 residents (Resident #26) reviewed. Specifically, Resident #26's hearing aids were missing and there was no documented evidence the missing hearing aids were reported or an investigation was initiated. Findings include: The facility policy Misappropriation of Resident Property revised 6/26/17 documented: - All employees have the responsibility to protect the resident's property and to alert the appropriate individuals of any occurrence of misappropriation. - Upon receipt of an allegation of misappropriation (either verbally or written) by the resident, designated representative, or other individual or source, it shall be reported to the administrator or designee immediately and investigation will be undertaken not later than 48 hours after receipt. Resident #26 was admitted to the facility with diagnoses including [CONDITION(S)] (paralysis on one side of the body) and [CONDITION(S)] (partial paralysis on one side of the body) following a cerebral vascular infarction (stroke) and [CONDITION(S)] (difficulty speaking and understanding). The 4/5/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance for most activities of daily living, had moderate difficulty with hearing and used a hearing aid. The 8/23/21 physician order documented to place hearing aids in the resident's ears bilaterally every morning and remove at bedtime. The 4/6/22 revised comprehensive care plan (CCP) documented the resident had difficulty communicating their needs. The CCP did not document the resident had a hearing deficit or used hearing aids. The 4/12/22 CCP documented the resident had impaired hearing and had left and right hearing aids. The 5/2022 Medication Administration Record documented: - on 5/3/22 at 8:00 AM by licensed practical nurse (LPN) #18, the resident's left hearing aid was missing. - on 5/4/22 at 8:00 PM by LPN #7 the left hearing aid was missing, and the right was in the cart. - on 5/9/22 at 8:00 PM by LPN #10 could not find hearing aids. - on 5/18/22, by LPN #19 the resident refused to give their hearing aid back at 8:00 PM. - on 5/19/22, by LPN #19 the resident's hearing aids were missing. - from 5/21/22 through 5/30/22, the hearing aids were documented as not provided or removed as the item was unavailable. There was no documented evidence the missing hearing aids was reported or investigated. The 6/2022 MAR documented the resident's hearing aids were missing form 6/1/22 through 6/6/22. The order for hearing aids was discontinued on the MAR on 6/6/22. The 6/6/22 updated Care Plan documented the resident's hearing aids were discontinued. There was no documented explanation why the hearing aids were discontinued on 6/6/22. There was no other documentation the resident had missing hearing aids; the missing hearing aids were reported, or an investigation had been initiated. During an interview on 6/6/22 at 1:26 PM, the resident's representative stated both resident's hearing aids were lost and the staff had stated they would keep an eye out for them. The hearing aids were important for the resident to hear and understand. The representative was unsure what the next step was for the hearing aids. The representative stated they noticed one of the hearing aids had gone missing a few weeks before the second one. A nurse had notified the representative the other hearing aid had been missing the previous week and they were unsure which nurse had notified them of the second missing hearing aid. On 6/8/22 at 9:23 AM and 6/9/22 at 10:49 AM, the resident was observed without hearing aids in their ears. During an interview on 6/8/22 at 2:46 PM, social services assistant #6 stated the process for missing items was to do an initial check for the missing items (laundry, resident room) and complete a grievance form if the item was not located. Any staff, resident, or family member could complete the grievance form. The forms were to be submitted to the Social Services Department for follow up. During an interview on 6/9/22 at 11:18 AM, licensed practical nurse (LPN) #10 stated hearing aids were kept in the cart. The LPN looked in the medication cart in May 2022 and the resident's hearing aid case was empty. The resident had lost both hearing aids and the LPN was unsure when. The resident was without both hearing aids at this time, and they thought LPN Clinical Leader #11 was aware. During an interview on 6/9/22 at 1:10 PM, LPN Clinical Leader #11 stated residents with hearing aids had orders in the electronic medical record to place the aids in the morning and remove in the evening. The medication nurse had to sign off in the computer, which helped to track if a hearing aid went missing to know when it was last known to be in use. The LPN stated the resident was missing one hearing aid and they believed the resident still had one in place. They reviewed the resident's orders and saw the order was discontinued on 6/6/22 and the MAR documentation showed both hearing aids were missing through the month of June. The LPN stated the staff had searched for at least one of the hearing aids. The LPN stated they should have been notified that both hearing aids were missing. During an interview on 6/9/22 at 1:25 PM, social services assistant #12 stated missing items were reported to them and they would search the resident's room and unit. If an item was not found, they would contact the family to look into replacing them. Hearing aids had an order in the electronic medical record, which the social services assistant would review to find out when they were last seen or checked to initiate the investigation. The social services assistant stated they were unaware the resident was missing their hearing aids and no investigation had been started. They expected to be notified as soon as possible since that was the best chance of finding them. 10NYCRR 415.5(h)(1)

Based on observation, interview, and record review during the recertification and abbreviated surveys (NY 106) conducted 6/7/22 to 6/9/22, the facility failed to thoroughly investigate all alleged violations of abuse, neglect, exploitation, or mistreatment for 1 of 3 residents (Resident #46) reviewed. Specifically, Resident #46 had a bruise which was not thoroughly investigated to rule out abuse, neglect, or mistreatment. Findings include: The facility policy Reporting & Investigating Resident Incidents dated 6/26/17 documented: - If a resident was subjected to an incident, any employee must report such an incident or suspicion to the charge nurse/supervisor/department head/DON (Director of Nursing)/Administrator. - The supervisor or designee must complete an Incident Report. If an incident occurred, the Administrator or designee would be immediately notified, and an investigation initiated. - The Building Supervisor would notify the Administrator or designee if any injury of unknown origins occurred, which was considered a possible reportable incident to the New York State Department of Health. The facility policy Incident Management Program Overview dated 12/13/19 documented: - Regardless of how minor an accident or incident may be, it must be reported to the charge nurse/supervisor/department head immediately or when informed of such accident or incident is learned. - All resident incidents would be documented on an Incident Report to rule out potential abuse or neglect, as well as to determine cause or prevent recurrence. For injuries of unknown origin, such as skin tears or bruises, witness statements or interviews would be obtained from staff that had direct knowledge related to the incident up to the preceding 3 shifts as applicable. Resident #56 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/26/21 comprehensive care plan (CCP) documented the resident had dementia which resulted in the loss of ability to complete ADLs independently. Staff were to document any resistiveness to personal care. The 3/19/22 at 9:17 PM licensed practical nurse (LPN) #17's progress note documented the certified nurse aide (CNA) brought the resident to the nursing station; the resident had a skin tear on the top of their left hand. The area was cleansed with normal saline and Opsite (adhesive dressing) was applied. A new order was entered to cleanse the area on top of the left hand followed by Opsite, change every 3 days, and as needed, and to check placement each shift. There was no documentation regarding possible causes of the skin tear. On 6/7/22 at 1:28 PM, the resident was observed with dark purple/red bruising with some blue areas on the back of their left hand extending to the wrist. There was no documentation in the medical record of the bruising on the resident's left hand. On 6/9/22 at 8:20 AM, the Director of Nursing (DON) stated in an interview, there were no incident reports for the 3/19/22 injury or the bruising observed on 6/7/22. During an interview on 6/9/22 at 9:45 AM, CNA #14 stated the resident had a bruise on their left hand for a few days. During an interview on 6/9/22 at 11:06 AM, LPN #7 stated if a resident had a bruise, they would check the resident and possibly take vital signs. They would speak with LPN Clinical Leader #11 to see if it was an old or new bruise. If it was new, they would initiate an incident report and document in the electronic medical record (EMR) and include the measurements of the bruise. If they were unsure where the bruise came from, the incident report would include statements from everyone on the unit. It was important to fill out an incident report to keep track of patterns of bruising and a paper trail so they could identify any patterns, whether the bruises could be care related or medication related. If the LPN was unsure about abuse, neglect, or mistreatment, they would speak with LPN Clinical Leader #11 or the DON. Following the interview, the surveyor and LPN #7 went into the resident's room and observed their hands. LPN #7 stated they were previously unaware of bruising on the resident's left hand and needed to report it to LPN Clinical Leader #11. During an interview on 6/9/22 at 1:42 PM, LPN Clinical Leader #11 stated they were responsible for reviewing incident reports and incident reports should be completed for any bruises or skin tears. Incident reports were reviewed with the DON, Assistant DON, and registered nurse (RN) #15, and they would determine if there was abuse, neglect, mistreatment, or reportable incidents. If a resident had a bruise, they should look back 24 hours and all staff that were working should complete a statement to try to determine when the bruising happened. LPN #11 stated the resident had bruises on both hands and they should have been made aware of the bruises sooner. CNAs should be reporting issues immediately. LPN #11 stated it was important to know about bruises in a timely manner to rule out abuse with every bruise. During an interview on 6/9/22 at 2:04 PM, the DON stated they would investigate anything out of the ordinary which included skin tears and bruising, if the resident was unable to state what happened. They investigated 24 hours from when the bruise was found to try to find the source and put interventions in place. During the investigation, they would rule out abuse and neglect. An investigation started with the LPN, who would notify the RN. The Nurse Manager would get the incident report and obtain staffing for the previous 24 hours. The DON reviewed the incident reports to ensure all the information needed was provided and any follow-up notes. The ADON and the DON were ultimately responsible for determining if abuse or neglect occurred and signing off on the report. If there was no incident report for the resident, they would start interviewing staff who had cared for the resident. They would review the nursing progress notes; sometimes there was a late entry and the DON expected documentation regarding bruising in the nursing progress notes. The DON expected to be notified about the resident's left hand bruising sooner, and they expected documentation in the nursing progress notes, an incident report, and assessment sooner. There should have also been an investigation regarding the 3/19/22 skin tear as well. If they were unable to rule out abuse, neglect, or mistreatment, the DON would report to the New York State Department of Health. 10NYCRR 415.4(b)(3)

Based on observation, interview, and record review during the recertification and abbreviated surveys (NY 301) conducted 6/7/22-6/9/22, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #55) reviewed. Specifically, Resident #55 was not provided protective heel boots as care planned. Findings include: Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan (CCP) initiated 8/30/21 documented the resident was at risk for pressure ulcers due to impaired mobility and chronic disease. Interventions included observe skin daily with personal care and see the Care Sheet for prevention strategies. The 2/9/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident Care Sheet (care instructions) reviewed 5/3/22 documented the resident was dependent for positioning, was non-ambulatory, utilized a Geri-chair (a specialty wheelchair for comfort) and was to have booties on both feet while in the Geri-chair. The resident was observed in their Geri-chair: - on 6/7/22 from 1:04 PM to 2:00 PM with both feet on the foot pedals, a left heel boot upside down off the foot, and no right heel boot was observed. - On 6/7/22 at 4:37 PM with no right heel boot on. - On 6/8/22 at 9:13 AM, 12:24 PM, and at 1:19 PM with no heel boots on either foot. - On 6/9/22 at 9:25 AM, with a left heel boot coming off the foot and no right heel boot. On 6/9/22 at 9:45 AM, the resident's heels were observed in the presence of certified nurse aide (CNA) #15. Both heels were slightly [NAME] than the surrounding skin and no open areas were observed. During an interview with CNA #14 on 6/9/22 at 10:00 AM, they stated they could not locate the resident's right heel boot and the resident was to have heel boots on both feet while in the Geri-chair. The CNA stated it was in the care book the heel boots needed to be checked each shift and they were important for protection to prevent skin breakdown. During an interview with licensed practical nurse (LPN) #7 on 6/9/22 at 11:06 AM, they stated some heel boots were care planned and most residents who had skin prep treatments to the heels had heel boots. The LPN was not certain if the instructions for heel boots were on the care cards or how CNAs knew to utilize them. The LPN was not aware the resident had not had both heel boots on and that one was not on correctly. They had heard someone was missing a heel boot but was not sure who it was. The LPN stated heel boots were important for protection from skin breakdown for at risk residents. During an interview with LPN Clinical Support Leader #11 on 6/9/22 at 11:28 AM, they stated CNAs were responsible to ensure heel boots were placed on residents. Heel boots were to protect residents' heels from skin breakdown or injury. CNAs were expected to look at the care card in the book at the beginning of each shift. It was the responsibility of any staff to adjust a heel boot if not on properly and to obtain one if missing. 10NYCRR 415.12(a)(3)

Based on observation, record review and interview during the recertification survey, the facility did not ensure the provision of food and drink was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meals (West Unit dinner) tested . Specifically, food at a lunch meal was not served at palatable and safe temperatures. Findings include: The 2/13/12 Food Service Production policy documented hot food items must be stored at a temperature of at least 140 degrees Fahrenheit (F) to prevent food borne illnesses. All thermometers will be tested weekly to ensure accurate food temperatures. The 6/26/19 Temperature Sheet for the lunch meal documented that the whole grilled chicken had a measured temperature of 190 F and the mashed potatoes were 189 F. There was no documented time or location when the temperatures were obtained. During a unit dining observation on 6/26/19 at 12:21 PM, a tray was assembled by a staff member for a resident that was not eating and was set aside. Diet Technician/Supervisor #16 observed one of the burners on the steam table was turned off. The food located on the burner included whole grilled chicken, mashed potatoes, and gravy. At 12:24 PM, the tray was tested for temperature and palatability by the surveyor. The whole grilled chicken had a measured temperature of 102 F using the surveyor thermometer and 92 F using a facility thermometer. The chicken was bland and lacked flavor. At 12:30 PM, the mashed potatoes from the steam table had a measured temperature of 112 F using the surveyor thermometer. The mashed potatoes were lukewarm and lacked flavor. The gravy remaining in the steam table was observed to be very thick. During an interview on 6/28/19 at 9:34 AM, the Food Service Director stated there was no policy for steam tables and she expected steam table dial settings to be set at 8 of higher. She stated chicken was required to be held at 145 F or higher. The food service thermometers were calibrated once a week on Wednesdays and test trays were done quarterly by kitchen staff. During an interview on 6/28/19 at 9:46 AM, Diet Technician/Supervisor #16 stated she expected steam tables to be set at 8 of higher to keep food temperature warm and this was the first time she saw a food server not turn on a burner. She stated food temperatures should be measured just before serving time. 10NYCRR 415.14(d)(1)(2)

Based on interview and record review during the recertification survey, the facility did not ensure that each resident and/or resident representative, was involved in developing the plan of care and making decisions about his or her care for 1 of 1 resident (Resident #52) reviewed for care planning. Specifically, Resident #52 was not invited to attend her annual care plan meeting. Findings include: The 4/7/17 Resident/Family Participation policy documented residents are invited to attend and participate in the care planning conferences on at least an annual basis and advanced notice of the care planning conference is provided to the resident by mail, telephone, and/or in person. Social services maintains a record of such notices by documentation in the resident's medical record and/or keeping a copy of mailed notices. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/4/18 annual Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required limited or extensive assistance for most ADLs, and the resident and her family participated in the assessment. The 12/11/18 social work assistant #1 progress note documented the interdisciplinary team (IDT) met on that date for the resident's annual team conference. The progress note included a list of attendees. There was no documented evidence Resident #52 or her representative were invited to or attended the annual care plan conference On 6/25/19 at 11:02 AM, the resident stated she had never been invited to her annual care planning meeting and expressed interest in attending. During an interview on 6/27/19 at 11:18 AM, social work assistant #1 stated she was responsible for inviting residents and families to the annual care plan meetings. She invited families by phone and residents in person. If residents were present at the meeting, she included them in the attendance in the social work progress note. She did not document if Resident #52 was invited to the meeting or if the resident declined the invitation. She stated the resident did not attend the last annual care plan meeting and social work assistant #1 could not remember if she had invited the resident to that meeting, During an interview on 6/27/19 at 1:20 PM, the Director of Social Work stated the social work department was responsible for inviting residents to the care plan meetings. She expected social work staff to document in the IDT progress note if residents were invited and if the resident declined. Resident #52 should have been invited to the annual care plan meeting. 10NYCRR 415.11(c)(2)(ii)

Based on observation, record review and interview during the recertification survey the facility did not ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 residents (Resident #22) reviewed for ROM. Specifically, Resident #22 had recommendations for a palm protector for hand contractures and the resident was observed without the palm protector in place. Additionally, guidelines for use of the palm protector were unclear. Findings include: The 2/29/08 Documentation of Range of Motion Limitations and Contractures Policy documented a resident with limited range of motion will receive appropriate treatment and services to improve range of motion and/or prevent further decline in his/her range of motion. Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/20/18 occupational therapist (OT) #10 progress note documented the resident had decreased range of motion, stiffness, and discomfort in her left hand and a palm protector was implemented to prevent further decline and breakdown of the skin. There was no documentation referencing the wearing schedule for the palm protector. The 5/2/19 revised comprehensive care plan (CCP) documented the resident had a contracture of the left hand and required a palm protector. The 5/2/19 Certified Nurse Aide (CNA) Kardex (care instructions) documented the resident had a left palm protector to be worn while in bed. On 6/25/19 at 1:46 PM and 6/26/19 at 10:12 AM, the resident was observed in bed not wearing a palm protector. The palm protector was observed on the bed side stand. During an interview on 6/27/19 at 11:22 AM, registered nurse (RN) Unit Manager #7 stated the resident should wear the palm guard at HS (hour of sleep) and not during the day while in bed. During an interview on 6/27/19 at 11:25 AM, the Director of Nursing (DON) stated he expected staff to follow the care plan and Kardex for adaptive devices such as palm protectors. If the resident refused, the CNA should notify the charge nurse and a variance form was to be filled out. During an interview on 6/27/19 at 11:44 AM, OT #10 stated she recommended a palm protector for the resident a few months ago for arthritis and to prevent a further decline in range of motion. She expected the resident to wear the palm protector anytime she was in bed and if the resident refused, the nurse should be notified, and a variance form should be completed. OT #10 reviewed the Kardex and stated the wearing schedule should be clarified for the palm protector. During an interview on 6/27/19 at 1:12 PM, CNA #11, stated the resident's palm protector was to be worn anytime she was in bed. She stated that she had put resident in bed in the morning on 6/26/19 and could not recall if she put the palm guard on. During an interview on 6/27/19 at 1:20 PM, CNA #12 stated the resident wore the palm protector anytime she was in bed. During an interview on 6/27/19 At 1:53 PM, CNA #13 stated that she was instructed to place the resident's palm protector on at HS. She cared for the resident on 6/25/19 starting at 2:30 PM. The resident was in bed without her palm protector and she did not apply the palm protector because the resident was only taking a nap. The CNA stated the resident rarely refused to wear the palm protector. 10NYCRR 412.12(e)(2)

Based on record review and interview conducted during the recertificaiton survey for 2 of 6 residents (Residents #32 and 83) reviewed for use of [MEDICAL CONDITION] medications, the facility did not ensure all residents were free from unnecessary [MEDICAL CONDITION] medications. Specifically, Residents #32 and 83 had a change in their anti-psychotic medications, there was limited documentation of symptoms warranting the increase in anti-psychotic medications; and there was no documentation resident approaches and interventions were re-evaluated prior to the medication administration. Findings include: 1) Resident #83 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 01/23/18 Minimum Data Set (MDS) assessment documented the resident had was cognitively intact, required extensive assistance of two for most activities of daily living (ADLs), and received an anti-psychotic medication daily. The 11/07/17 comprehensive care plan (CCP) documented the resident was conflictive and manipulative with others, exhibited attention seeking behaviors, and verbally aggressive. Interventions included provide assistance with activities of her choosing, provide magazines, encourage contact with her daughter, monitor for changes, social work visits on a regular basis, provide one to one during behaviors, and redirection. The 08/07/17 certified nurse aide (CNA) care instructions documented the resident was transferred with assist of two and hoyer lift. There was no documentation on the CNA instructions the resident exhibited mood or behavioral symptoms or what interventions staff could use. Interdiscplinary progress notes between 01/01/17-02/24/17 had no documentation the resident was exhibiting behavioral symptoms affecting self or others. On 02/23/17 a nursing progress note documented the resident had confusion, child like with her responses, assisted with care, had pain in her left foot, and stated she was afraid of falling. The 02/24/17 physician progress notes [REDACTED]. There was no planned length of time documented for this medication. physician's orders [REDACTED].>- On 02/24/17, [MEDICATION NAME] 50 milligrams (mg) daily for [MEDICAL CONDITION]. - On 02/27/17, change [MEDICATION NAME] to 100 mg daily for 3 days. - On 03/02/17, increase [MEDICATION NAME] to 150 mg daily. Interdiscplinary and physician progress ntoes dated between 02/25-03/06/17 had no documentation the resident exhibited mood or behavioral symptoms affecting self or others. The 03/07/17 at 04:24 PM nurse progress note documented the resident had little to no speech, slurring speech, and her right arm flailed. She was unable to follow commands to squeeze the nurse's hand, and the resident was sent to the hospital. The 03/08/17 at 07:36 PM nursing note documented the resident returned from the hospital at 5:25 PM. Nursing progress notes dated between 03/09-04/01/17 had no documentation the resident had behavioral symptoms affecting self or others. On two occasion the resident spoke in a child like voice, and on two occasions the resident had pain symptoms and used the call bell several times. The 03/24/17 at 03:52 PM physical therapist (PT) progress note documented the resident was very behavioral during treatment and said she was going to return to her room. The note did not document the types of behavior exhibited and there was no further information regarding this date. Nursing progress note dated between 04/02-05/20/17 had no documentation the resident displayed behavior symptoms affecting self or others. On 04/10/17 the resident had a verbal altercation when another resident was disrepectful to her family member. Progress notes noted the resident was confused, at times weepy, and would talk in a child like voice or manner. Nursing progress notes dated between 05/21-05/31/17 documented the resident had been difficult and/or demanding with care on 3 times on the 03:00 PM-11:00 PM shift and 1 time during the 07:00 AM-03:00 PM shift. There was no further documentation of behavioral symptoms. The 06/01/17 physician's orders [REDACTED]. Nursing progress notes dated between 06/01/17-07/09/17 documented the resident was at times weepy, talked in a child-like voice and complained of left lower leg pain. A 06/23/2017 at 5:44 AM nurse progress note documented the resident was snoring in her bed, the CNA entered the room, woke the resident up and told the resident she needed to check for incontinence. The note documented the resident refused, the CNA re-approached at a later time, and refused again. The note documented the nurse asked her if she wanted pain medication, she began to fake cry, and stated she was in a lot of pain. Nursing progress notes on 07/10/17 at 04:14 AM nurse progress note documented the resident was rude to CNAs and stated she had a bowel movement when she did not. On 07/10/17 at 09:38 PM and on 07/11 at 09:36 PM, the resident declined care by staff, was demanding and used her call bell frequently. There was no documentation in nursing progress notes the facility attempted to determine the root cause of the resident's actions in 07/2017. The 07/14/17 physician progress notes [REDACTED]. The 07/14/17 physician's orders [REDACTED]. The 11/07/17, and 02/01/18 CNA care instructions did not document any types of mood or behavioral symptoms exhibited by the resident, or interventions for staff to use. The 08/11/17 and 12/16/17 pharmacy notes documented a recommendation to consider a GDR of the [MEDICATION NAME]. The physician noted on the form the benefits outweighed the risk. The 01/18/18 psychiatrist progress note recommended an increase in [MEDICATION NAME] from 300 mg to 350 mg to control her behavior and a gradual dose reduction (GDR) was contraindicated at that time. The 01/19/18 physician's orders [REDACTED]. During an interview on 02/14/18 at 11:35 AM, certified nurse aide (CNA) #6 stated there was no behavior tracking plan. If the resident had any behaviors staff would notify the licensed practical nurse (LPN) who would then document in a progress note or notify the registered nurse (RN) supervisor. During an interview on 02/14/18 at 11:43 AM, LPN #19 stated the resident's behaviors included being manipulative and making false accusations during care. There was no behavior plan or behavior log that would include interventions for staff to use with the resident. If there were any behaviors CNAs would notify LPNs and the LPN would either write the progress note or notify the supervisor who would document the instance. The CNAs did not document on behavior symptoms. During an interview on 02/14/18 at 12:09 PM, registered nurse (RN) Unit Manager #7 stated that the resident was manipulative and had childish behaviors. She would agitate other residents. Before she was on this medication she would be manipulative and accusatory. She would purposely wet or soil herself and say staff left her sitting in it. She would strike out at staff. Staff became afraid to work with her. She stated she had not seen any behaviors with medications. She was seen by the psychiatrist on 01/18/18 and he increased her [MEDICATION NAME] as her daughter stated she has mood issues over the winter months. During a telephone interview on 02/14/18 at 02:17 PM, physician #15 stated that the resident was not demented and had a [DIAGNOSES REDACTED]. He did not have any recollection of the changes made to the resident's regimine. To him, the resident seemed happy and appropriate. He stated the staff and facility would assess how a resident and their mood were doing. It would be a team effort to take a look at the resident's total program of care before medication changes. He stated he had discussed with staff in the past if it was not documented it was not done and staff may assume that others know what they have tried with the resident. 2) Resident #32 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The 12/12/17 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; did not have depressive symptoms; and displayed physical and verbal behaviors 1 to 3 days of the assessment period. The resident required extensive assistance for most activities of daily living (ADLs) and was on an anti-psychotic and anti-anxiety medication 7 of 7 days of the assessment period. The 09/26/17 comprehensive care plan (CCP) documented the resident was at risk for elopement, was a loner, had a history of [REDACTED]. Staff were to engage resident in activities, have social work visit reuglarly, check her whereabouts, assess for illness, and offer food and fluids. The 12/14/17 physician orders [REDACTED]. The 12/19/17 certified nurse aide (CNA) care instructions documented the resident could be resistive with care needs, staff were to retreat and re-approach, offer conversation/visits, offer cards, fluids and snacks. Interdisciplinary progress notes dated between 12/13/17- 01/18/18 documented: - The resident was upset with another resident on 12/13/17 for taking her purse. - A 12/19/17 note documented the resident's mood state was stable and she had fluctuating behaviors with care needs, redirection, and she was on secure unit and would say on occasion she wanted to go home. - On 12/26/17 was adamant that she had a hair appointment. - The resident had declined medications on 01/05/18 and declined to go to a meal on 01/14/18. - There was no further documentation of behaviors affecting self or others during that time period. A 01/18/18 psychiatrist progress note documented staff were not able to manage her behavior, he would not recommend to increase [MEDICATION NAME] and would increase her [MEDICATION NAME] to 75 mg in the morning and 100 mg at bed time. She continued to show severe cognitive impairment. Follow up would be in 3-6 months. A physician's telephone order documented on 01/18/18 to increase [MEDICATION NAME] to 75 mg in the morning and continue 100 mg at bed time for delusional thinking. No documentation interventions implemented to address a potential change in behaviors when the medication would decreased. During an interview with CNA #16 on 02/14/18 at 10:10 AM, she stated the resident would have an increase in symptoms in to the evening and state she wanted to go home and look for her family. She stated this happened after the resident was first admitted and she had adjusted to the facility since. She stated the resident was pleasant, she occasionally had her days, she required distant supervision so staff kept an eye on her, and she mostly say in the lounge and relaxed. During an interview with CNA #17 on 02/14/18 at 10:24 AM, she stated the resident would have some behavior symptoms starting in the afternoon. She would state she wanted to go home, would go to doors or exits, and did not seem to have purpose for these actions. She stated she would redirect and talk to her about other things, and it usually worked for her. CNA instructions had a location on the sheet to document interventions for residents. This resident did not have specific things to try. During an interview with social worker #13 on 02/14/18 at 11:44 AM, she stated the resident used to be behavioral and agitated when she was first admitted to the facility and her behaviors had improved over the last few months. She stated staff were to try magazines and contact her family to calm her. She stated at one point the resident was agitated during the day time. Staff tried diversional activities, she could not state what type of activities. She thought the facility had tried a behavior modification plan with her. The behavior care plan would have been the responsibility of social work to complete. She recalled [MEDICAL CONDITION] medications being implemented. She would verify information and follow up with the surveyor. During a follow up interview with social worker #13 on 02/14/18 at 01:01 PM , she stated she had followed up regarding the resident. The resident did not have a behavior modification plan in place and the CNA care plan only listed interventions to retreat, re-approach, offer activities and call family. During a telephone interview with physician #15 on 02/14/18 at 02:17 PM, he stated the facility would look at residents who are demented with behavioral disturbances to determine if medications were required and they are on medications because of that. It was a team decision and approach to assess how a resident was doing. Staff try to find things they can do to relieve symptoms of anxiety. Staff should look at other things they can try with a resident. It can appear that if something was not documented, it was not done, and staff assume others would know what they have tried with the resident. The process starts with looking at a behavior symptoms, tried redirection and other things, and then discuss what else can be done, including ruling out medical causes. 10 NYCRR 415.5(l)(1)

Based on observation, record review and interview conducted during the recertification survey it was determined for 1 of 4 residents (Resident #30) reviewed for dignity, the facility did not ensure all residents had the right to a dignified existence. Specifically, Resident #30 was not provided facial grooming as planned. Findings include: Resident #30 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 12/05/17 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition. The resident required extensive assistance of one staff for personal hygiene which included shaving. The 12/13/17 comprehensive care plan (CCP) documented the resident would accept assistance with her activities of daily living (ADLs) and to follow the ADL sheet. The 12/13/17 certified nurse aide (CNA) care instructions documented the resident required physical help with bathing and assistance of one with personal hygiene. There was no documentation on the care instruction regarding a plan for shaving. The resident was observed with long facial hair to her upper lip and chin on 02/12/18 at 10:57 AM and on 02/13/18 at 03:00 PM. During an interview on 02/14/18 at 02:53 PM, the resident stated she would like to be shaved so she did not have long hair on her upper lip and chin. During the interview the resident's long upper lip and chin hair were visible. During an interview on 02/14/18 at 03:01 PM, CNA #6 stated that female residents were shaved twice a week and more if they needed it. If the resident did not ask to be shaved, CNAs should perform the task as needed. There was no specific place to document shaving, it was included in the personal hygiene section of ADLs on their sheets, and they just notified the nurse when it was done. The CNA stated she had been assigned to provide care to the resident and she did not notice the resident was in need of shaving. During an interview on 02/14/18 at 03:03 PM, registered nurse (RN) Unit Manager #7 stated males should be shaved during daily personal care using their own razor. Women were shaved as needed or when they asked, daily if needed. It should be listed in the care plan if a resident needed to be shaved. If the CNA did not have time to complete the task, they should let the licensed practical nurse (LPN) know so she could ensure it got done. She had provided assistance and sat with the resident within the last couple days and she did not recognize the resident was in need of shaving. If the resident wanted to be shaved, she should have been. 10 NYCRR 415.5(a)

Based on record review and interview conducted during the recertification and abbreviated survey (NY 449), it was determined for 1 of 2 residents reviewed for abuse (Resident #71), the facility did not ensure residents were free from abuse/neglect. Specifically, when there was an alleged violation towards an employee providing care to Resident #71 the facility did not protect the resident during the investigative process when the employee, who has a history of resident neglect, continued to work the remainder of the shift. Findings include: Resident #71 was admitted [DATE], re-admitted [DATE], and had [DIAGNOSES REDACTED]. The 10/17/17 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, was extensive assist with most activities of daily living (ADLs), had limitations of one arm and both legs, was always incontinent of urine and frequently incontinent of bowels, took a diuretic (increase urinary output) daily, was on a toileting program, and was at risk for developing pressure ulcers The 01/26/18 certified nurse aide (CNA) care instructions documented the resident wore adult incontinence brief (brief), was an assist of 1 for incontinence care, and was on an incontinence program. The 01/27/18 CNA checklist documented CNA #8 provided resident care on the evening shift. The 01/27/18 resident ADL Data sheet documented CNA #9 provided incontinence care for the resident at 9:34 PM. The 01/27/18 CNA #9 witness statement documented she walked into the resident's room, saw CNA #8 pull up the resident's pants while having on a wet brief, informed the other CNA the brief was wet, and she continued to put her pants on. The 01/27/18 CNA #10 witness statement documented she was made aware CNA #8 did not change the resident, she offered to assist CNA #9 with care, and the resident's brief were saturated with urine. The 01/27/18 registered nurse (RN) Supervisor #11 witness statement documented she was made aware of the situation at about 03:45 PM that evening, directed CNA #9 to lead CNA #8 with resident care the rest of the evening, and report any further care issues to her. The 01/29/18 incident report documented on 01/27/18 at about 04:30 PM, CNA #8 was assisting Resident #3 to get up for supper and did not change the resident's wet brief, which was noted by CNA #9. CNA #9 told CNA #8 that it was time to wash the residents prior to supper, and CNA #8 told her they did not need to be washed, as they were washed that morning. CNA #9 informed the supervisor, and she and CNA #10 changed and cleaned the resident. The report documented the supervisor told CNA #9 and CNA #10 to take over and direct CNA #8 for the rest of the shift. The report documented CNA #8 worked the rest of the shift and did not work the next day. The report documented Resident #3 received proper care from other staff and suffered no negative outcomes. The report documented CNA #8 previously did not follow a resident's plan of care on 11/16/17, abused a resident on 12/21/17, and received re-training after those incidents. When interviewed on 02/14/18 at 10:00 AM, registered nurse (RN) Unit Manager #7 stated she had been the unit Manager since 09/2017, was responsible for what goes on on the unit at all times, and was familiar with the resident. She stated the resident was quiet, walked and joked with staff, and was incontinent of bowel and bladder. She was to be toileted at least every 4 hours and as needed. CNA #8 was a slow worker, needed a lot of direction, and did what she was told for resident care. She stated the facility had issues with her on the evening shift, as that was the shift the CNA worked. The facility tried to provide consistency with her assignments, as she had difficulties when assigned to another unit. The CNA did not interact with a lot of the residents and just provided the needed care. She was aware that the CNA told the resident to shut up once in 12/2017. She was reprimanded, received a written warning, and the DON and Administrator formally reprimanded her. Extra training was given to her regarding resident interaction. She had difficulties when her routine was changed, became nervously excited and had difficulties managing the situation. About 3 weeks ago, it was reported by 2 CNAs that CNA #8 pulled up the resident's pants, despite her Attends being wet with urine. She did not toilet her or change her briefs. An investigation was done, she denied the allegation and quit. She stated she was aware the CNA did not follow policies for transferring with a Hoyer lift shortly after she started working here. Staff were trained on abuse and neglect at least yearly, and the CNA had that training. When interviewed on 02/14/18 at 12:26 PM, the Director of Nursing (DON) stated abuse/neglect training was given to staff yearly and as needed. It was brought to her attention that CNA #8 put dry pants over the resident's wet brief, staff told her not to, and CNA #8 stated the resident was washed that morning. She stated 2 other CNAs provided incontinence care to the resident at that time. An investigation was done, she reviewed CNA #8's work record, and CNA #8 quit prior to terminating her. She stated CNA #8 had other incidents such as failing to follow plan of care, and telling a resident to shut up, and the facility gave her another chance after she was re-educated. On 2/14/2018 at 12:29 PM, the surveyor attempted to call CNA #8 and received a message that her voice mailbox was full and a message could not be left. When interviewed via telephone on 02/14/18 at 12:35 PM, CNA #10 stated she was at the nursing station before supper when CNA #9 was telling the nurse that CNA #8 had pulled pants over the resident's soaked Attends. She stated she helped CNA #9 change the resident's brief and clean her up. She stated CNA #8 continued to work the rest of that shift. On 2/14/2018 at 12:37 PM, the surveyor called CNA #9 and left a message for her to return the surveyor's call. The CNA did not call back prior to the end of the recertification survey. When interviewed via telephone on 02/14/18 at 12:58 PM, RN Supervisor #11 stated CNA #9 told her that CNA #8 put on the resident's pants on and did not change the resident's wet brief. She stated CNA #9 informed CNA #8 that the resident had to be changed, and CNA #8 responded the resident had already been washed that day. She stated CNA #9 and CNA #10 then proceeded to change the resident's wet brief, and she did not speak to CNA #8 about the situation. She stated she told CNA #9 to direct CNA #8 for the rest of the shift and let her know if there were any further issues. She stated CNA #8 continued to work the rest of the shift on the same unit. She stated she called and spoke to the DON when the situation occurred, gave a written statement, and obtained CNA #9's statement. 10 NYCRR 415.4 (c)(vii)

Based on observation, record review and interview conducted during the recertificaiton survey it was determined for 1 of 1 residents (Resident #83) reviewed for range of motion, the facility did not ensure all residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, Resident #83 did not have a plan in place to prevent further contracture to her left hand. Findings include: The 02/29/08 Policy and Procedure regarding documentatoion of range of motion limitations and contractures documented in section K to monitor and track each resident's deterioration, maintenance or improvement in joint range of motion by conducting repeat assessment annually and as needed due to significant changes in the resident's health and/or functional status. Resident #83 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 02/01/18 certified nurse aide (CNA) care instructions documented the resident required assistance of one staff for personal hygiene and dressing. The care instructions did not include a plan for range of motion to her upper extremities or interventions to the residents left hand contracture. The 02/01/18 comprehensive care plan (CCP) had no documentation a plan was in place to address the resident's left hand contracture. The resident stated on 02/12/18 at 10:46 AM she had a left hand contracture, she used to have a brace and did not have one anymore. The resident was observed with a contracted left hand without a device on 02/12/18 at 10:46 AM, on 02/13/18 at 04:24 PM the resident's left arm and hand hung down in the chair between her left leg and the side of the chair. The resident used her right hand to lift the contracted hand and 02/14/18 at 09:55 AM. During an interview on 02/14/18 at 10:30 AM with CNA #6 (who provided care for the resident), she stated the resident had ROM (range of motion) exercises for her left foot and she wore a brace on that foot. She stated that she had never seen the resident do any exercises with her left hand. The resident did not have any devices that she used on her left hand. Upon interview with Charge licensed practical nurse (LPN) #19 on 02/14/18 at 10:45 AM, she stated she did not know of any exercises or devices for the residents left upper extremity just for her left foot. During an interview with occupational therapist #20 on 02/14/18 at 11:00 AM , she stated she was aware of the resident's contracture. She knew that the resident had a ROM plan and AFO (ankle-foot orthosis) brace for her left lower extremity. She stated she was unsure what had been recommended for her contracture of the left hand. She would have to check her records to see what the plan of care and suggestions were. She checked the record and stated the OT assigned to the resident when she was being treated no longer worked there and did not recommend a discharge exercise/ ROM plan when her care was discontinued in 05/2017. When asked, the OT stated she would have had her doing ROM to stretch and exercise the hand and wear a palm guard each day after each meal or at HS. She stated she would look into it and see if the ROM and palm guard would help. 10 NYCRR 415.12(e)(1)

Based on observation and interview conducted during the recertification survey, it was determined the facility did not ensure the environment was maintained in a sanitary and orderly manner for 7 of 8 resident units (Birch unit, Willow unit, Elm unit, Oak unit, Maple unit, Cherry unit, and Ash unit). Specifically, these units had resident room divider curtains not attached to ceiling track hooks, damaged/delaminated doors, and damaged walls. Findings include: On 10/24/2016 from 1:28 PM - 1:35 PM, the following observations were made on the Birch unit: - in room 216, the room's divider curtain was not attached to five ceiling track hooks; and - in room 209, the edge of the access door to the room was delaminated and worn. On 10/24/2016 at 1:45 PM, in Willow unit room 204, the B side divider curtain was observed not attached to two ceiling track hooks. On 10/24/2016 from 2:06 PM - 2:16 PM, the following was observed on the Elm unit: - in room 216, the A side divider curtain was not attached to four ceiling track hooks; and - in rooms 230, 232, and the shower room, the edge of the access doors to each room was damaged/delaminated. On 10/24/2016 at 2:33 PM, in room 217 on the Oak Unit, the edge of the access door to the room was observed to be damaged/delaminated. On 10/24/2016 from 2:55 PM - 3:10 PM, the following was observed on the Maple unit: - in rooms 113 and 116, the edge of the access doors to each room was damaged/delaminated; and - in room 109, a wall by the B side bed was damaged and the top of the ceiling wall joint was peeling. On 10/24/2016 at 3:13 PM, room 108 on the Cherry unit, the edge of the access door to the room was observed to be damaged/delaminated. On 10/24/2016 from 3:33 PM - 3:46 PM, the following was observed on the Ash unit: - in room 132, a wall on the side of the bed was damaged/scratched; - in room 130, a wall in the bathroom had a spackle layer which was not yet painted; and - in room 126, a wall by the bed had an area of peeling paint. During an interview with housekeeper #9 on 12/28/2016 at 12:40 PM, she stated she did not see or look for environmental repair concerns. She stated if she saw an area in need of repair while she was in a resident's room, she would call maintenance. She stated basic cleaning needs were addressed in residents' rooms on a daily basis including: trash pick up, cleaning the bathroom, and wiping call cords. She stated 4 rooms received detailed cleaning daily Monday - Friday, and she was not responsible for completing any environmental reports/logs. When interviewed on 10/24/2016 at 2:10 PM, the Director of Maintenance stated housekeeping did daily rounds of the resident rooms. If they found an issue, a maintenance work order would be filled out. He also stated the Director of Housekeeping completed quarterly quality analysis audits on building maintenance. 10NYCRR 415.5(h)(2)

Based on record review, observation, and interview conducted during the recertification survey, it was determined for 4 of 8 residents (Residents #4, 5, 8, and 12) reviewed for unnecessary medications, the facility did not ensure all residents were free from unnecessary drugs. Specifically, Resident #4 was on an antipsychotic medication, a gradual dose reduction was not attempted, and there was insufficient documentation the medication remained appropriate for the resident. Resident #5 was administered an intramuscular (IM) antipsychotic medication and started on a routine antipsychotic without documentation the facility attempted to determine the root cause of the behaviors and implement non-pharmacological intervention prior to the antipsychotic administration. Resident #8 was restarted on an antipsychotic medication dose without evidence the resident's interventions were re-evaluated for effectiveness prior to implementing the medication. Resident #12 was receiving multiple sedating medications without justified medical rationale. Findings include: 1) Resident #12 had [DIAGNOSES REDACTED]. A pharmacy Note to Attending Physician/Prescriber dated 12/22/2015 documented the resident was on a benzodiazepine ([MEDICATION NAME], used to treat anxiety or [MEDICAL CONDITION]). The pharmacist documented the newest BEERs update (a list of medications considered to be inappropriate for long-term care facility residents) recommendations were to avoid these types of medications for any length of time due to increasing evidence showing harm with minimal efficacy in treating [MEDICAL CONDITION]. The pharmacist requested a physician review of the continued need for the medication and to update documentation on benefits outweighing risk. The physician signed the form on 1/13/2016 and documented the benefits outweighed the risks. A physician progress notes [REDACTED]. (antipsychotic) and [MEDICATION NAME]. This has her in a fairly happy spot where she seems content. She was not agitated or anxious and the physician would not be changing her medications. The resident received [MEDICATION NAME] (benzodiazepine used for anxiety) routinely and prn (as needed). The resident was very, very anxious and very unsettled before and I think her life was rather miserable. I think we have her in a better spot now. A physician progress notes [REDACTED]. The physician had attempted to withdraw these medications and the resident always seems to get more agitated and the medications were continued for resident comfort. Physician orders [REDACTED]. A physician progress notes [REDACTED]. The resident seemed sleepy in the daytime and the plan was to decrease [MEDICATION NAME] from 7.5 mg to 5 mg, watch her for 1 week and then if all is well reduce it further to 2.5 mg. A physician order [REDACTED]. Between 5/11/2016 - 5/25/2016, nursing progress notes documented during the 2:00 PM - 10:00 PM shift 4 episodes of hollering out. The 6:00 AM-2:00 PM shift nursing progress notes documented 2 episodes of increased lethargy in the morning and the resident did not eat breakfast. A physician progress notes [REDACTED]. When the medication was reduced, the resident's behaviors of screaming and crying out had worsened considerably so much she is keeping other residents awake and has had to have prn [MEDICATION NAME] which is also sedating. The plan was to increase the [MEDICATION NAME] back to 7.5 mg at bedtime. A physician order [REDACTED]. Between 5/27/2016 - 10/25/2016, nursing progress notes documented during the 2:00 PM - 10:00 PM shift 21 episodes of yelling, hollering, and increased vocalization. Nursing progress notes for the 6:00 AM - 2:00 PM shift documented 24 episodes of daytime lethargy with frequent refusal of meals. The resident received prn [MEDICATION NAME]: - in 5/2016, 10 times during the 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM shifts; - in 6/2016, 10 times during the 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM shifts; - in 7/2016, 2 times during the 2:00 PM - 10:00 PM shift; - in 8/2016, 4 times during the 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM shifts; - in 9/2016, 12 times during the 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM shifts; and - from 10/1/2016 - 10/26/2016, 12 times during the 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM shifts. A pharmacy note to Attending Physician/Prescriber dated 6/29/2016 documented the resident did not have an allowable [DIAGNOSES REDACTED]. The second pharmacy note dated 6/29/2016 recommended a GDR for [MEDICATION NAME]. The physician's response to both was disagree, benefit outweighs risk and was dated 7/13/2016. No further explanation was provided. A physician rounds/resident status update form dated 7/13/2016 documented the resident had periods of lethargy as well as periods of increased anxiety and yelling out. She was better on [MEDICATION NAME], and prn [MEDICATION NAME] was used on occasion. A pharmacy Note to Attending Physician/Prescriber dated 7/25/2016 documented a recommendation to consider a GDR of [MEDICATION NAME]. The physician's response was disagree, benefit outweighs risk and was dated 8/17/2016. No further explanation was provided. The comprehensive care plan (CCP) reviewed by the Interdisciplinary Team on 8/2/2016 documented the resident had behaviors including vocalization, resistiveness to care, and disruption to other residents. Approaches included a behavior management plan, administer medications as ordered, monitor for side effects of medications, and monitor for complications including confusion and lethargy. The resident had a need for [MEDICAL CONDITION] medications (there was no documentation in the CCP why the resident required [MEDICAL CONDITION] medications). Approaches included to administer the medications as ordered. The family preferred anti-anxiety medications to be used only as needed. The family did not want the resident overly sedated, and for staff to use all other interventions to try to calm the resident before giving medications. The staff were to monitor and report any changes in the resident's behavior and mood state and evaluate the effectiveness and side effects of medications for possible decrease/elimination of the [MEDICAL CONDITION] medications. A physician rounds/resident status update form dated 9/8/2016 documented a reduction of [MEDICATION NAME] was tried and was unsuccessful due to increased anxiety with vocal disruption. The original dose was resumed with effect. A physician assistant progress note dated 9/27/2016 documented the resident was lethargic and the resident was treated for [REDACTED]. Physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognitive functioning, exhibited behavioral symptoms not directed toward others and rejected care at times. The resident was dependent on staff for most activities of daily living (ADLs) with the exception of requiring extensive assistance with eating. The resident had an active [DIAGNOSES REDACTED]. The resident was observed sitting at the dining room table in her wheelchair on 10/25/2016 at 8:05 AM. Her breakfast tray was in front of her and she was sleeping. The certified nurse aide (CNA) attempted to arouse her multiple times during the meal without success. The resident was observed on 10/27/2016 at 9:10 AM, sitting in her wheelchair at a table in the dining room with her head down and sleeping. During an interview with the consulting pharmacist on 10/26/2016 at 2:30 PM, she stated she made a recommendation to attempt a GDR on the resident's medication. She stated she would offer the opportunity for the physician to disagree noting benefits outweigh the risks. She stated the physician was confident in his decisions on the use of antipsychotics. She stated medications ultimately depended on how they were working for the resident. The physician was interviewed on 10/27/2016 at 8:10 AM. He stated antipsychotics were typically used for psychiatric disorders including [MEDICAL CONDITION] disorder, [MEDICAL CONDITION], and occasionally anxiety. He would use them for adjunctive treatment for [REDACTED]. He stated he would expect staff to attempt non-pharmocological approaches such as involving family and looking for potential pain or other forms of distress. He stated he did not like to use benzodiazepines in this population as they tend to aggravate dementia. The physician stated he was not sure why the resident was on benzodiazepines and would have to review her medical record. He stated he had tried different doses of the antipsychotic and the resident had more episodes of distress. He stated he had usually seen the resident in mid to late morning and she had not been very sleepy at those times. He would expect to be notified if the resident had any changes in mood or behavior and would adjust medications if needed. Licensed practical nurse (LPN) #1 was interviewed on 10/27/2016 at 9:10 AM. She stated the resident had vocal outbursts and increased anxiety. She stated there were multiple interventions the staff used such as talking to the resident, checking if she needed to use the bathroom, asking if she were hungry, and involving the family during periods of increased anxiety. She stated the resident rarely had outbursts during the day shift and knew there were more outbursts during the night and she would get prn [MEDICATION NAME]. She stated the [MEDICATION NAME] that was given to her at bedtime was taken away at one point and the resident was awake all night. She stated they had tried to cut down on the [MEDICATION NAME] and the resident screamed for days so they had to increase the dose again. Registered nurse (RN) Manager #2 was interviewed on 10/27/2016 at 9:40 AM. She stated the resident was on [MEDICATION NAME] due to behaviors such as hollering out and her fear of not being able to breathe. She stated they had tried to discontinue the [MEDICATION NAME] for [MEDICAL CONDITION], but the resident was awake all night and her vocalizations got worse. She stated the resident was not as lethargic as she had been and it was usually early morning when she was more tired. She stated the resident would receive prn [MEDICATION NAME] mostly in the evening when her behaviors seemed to escalate. 2) Resident #5 had [DIAGNOSES REDACTED]. The 10/4/2016 certified nurse aide (CNA) Care Plan (care instructions) did not document specific resident behaviors or interventions to implement if a behavior was observed. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident did not have a memory problem and his cognitive ability was moderately impaired. The comprehensive care plan (CCP) reviewed 10/25/2016 did not address an anxiety disorder or document interventions for behaviors. Nursing progress notes documented the following behaviors: - on 10/09/2016 at 9:55 PM, the resident was agitated and told staff a thief was attacking him; - on 10/11/2016 at 12:48 PM, he was yelling out and his call light was within reach; - on 10/15/2016 at 10:02 PM, he was very anxious while in bed, yelled out, and thrashed around; - on 10/16/2016 at 9:35 PM, he was anxious and more confused, and stated his right arm wasn't his and he needed his shovel; - on 10/17/2016 at 3:30 AM, he yelled out from his room all shift and stopped when staff came in the room; - on 10/19/2016 at 12:53 PM, he was yelling out from his room and stated he was cold, staff applied blankets, and he quieted down. He was yelling out 5 minutes later and complained of stomach pain, [MEDICATION NAME] was given with some effect; - on 10/20/2016 at 9:21 PM, he became anxious and yelling out after being put to bed; - on 10/21/2016 at 12:00 PM, he was yelling out from his room and stated his stomach hurt and he needed to have a bowel movement; - on 10/23/2016 at 9:10 PM, he was increasingly agitated after the evening meal, and leaned out of his wheelchair. Staff placed him in bed and he attempted to get out of bed. He complained of something in his left eye and a warm cloth was used to cleanse the eye with good effect; and - on 10/24/2016 at 4:15 AM, he was agitated and screaming, sitting at edge of bed, and requested to be put in wheelchair. He was brought to the dining area and continued to scream, then requested to go back to his room. He stated he wanted to go home. Staff called the resident's wife and she stated he used to get [MEDICATION NAME] when he became agitated in the hospital. The resident continued to yell and swing at staff and tell them to get out. The physician assistant on-call was notified, who ordered [MEDICATION NAME] (anti-anxiety medication) intramuscularly (IM) at 1:15 AM. The progress note documented no changes were made to the care plan at that time and follow-up was to continue. A physician order [REDACTED]. A 10/24/2106 physician order [REDACTED]. The family inquired about routine anti-anxiety medication, as well as something on an as needed basis so he would not require an injection. The resident did not have a [DIAGNOSES REDACTED]. The physician responded on the form and ordered [MEDICATION NAME] (antipsychotic) 50 mg daily at noon and 50 mg at bedtime as needed. When observed 10/24/16 at 2:30 PM, the resident was in his bed, asleep. His wife was sitting in a chair next to his bed. When observed 10/25/2016 at 9:30 AM, the resident was in his bed, asleep. His wife was sitting next to him with his breakfast tray on the end-table. A telephone interview was conducted with licensed practical nurse (LPN) #11 on 10/26/2016 at 1:15 PM. She stated on the evening of 10/23/2016, the resident had been anxious and attempting to stand up from his wheelchair and trying to remove the Hoyer (mechanical) lift pad that was under him. She stated staff took him to bed. LPN #11 stated when the Nursing Supervisor came to the room, the resident was complaining of eye pain. Staff gave him a cool cloth for his eye and he seemed better. She stated she was not aware of him receiving IM [MEDICATION NAME] during the next shift. When observed 10/26/2016 at 1:45 PM, the resident was in his bed, awake, staring straight ahead. His wife was sitting in a chair next to him. When interviewed 10/26/2016 at 2:55 PM, CNA #13 stated the resident would get agitated if his wife left. She stated he did not hit staff and did not get agitated that often. She stated if staff sat and talked with him, he was okay. A nursing progress note dated 10/26/2016 documented the resident's [MEDICATION NAME] was discontinued. When interviewed 10/27/2016 at 8:05 AM, the physician stated the resident had some agitation. He stated redirection from family can settle residents down. He stated if it got to the point where a resident needed an injection, they should probably be sent out to the hospital. He stated the [MEDICATION NAME] ordered on [DATE] was discontinued on 10/26/2016. A telephone interview was conducted with RN #12 on 10/27/2016 at 10:10 AM. She stated in the early hours of 10/24/2016 the resident was anxious, screaming, and attempting to get out of his wheelchair. She stated staff put him to bed, turned the light on, and offered him a drink. She stated he attempted to get out of his bed so they put him in his wheelchair and brought him to the dining area. She stated staff called his wife, but she could not come in. She stated the nurse called the on-call physician assistant and he ordered the IM [MEDICATION NAME], which was administered at 1:15 AM. 3) Resident #8 had [DIAGNOSES REDACTED]. A 5/11/2016 physician rounds/resident status update documented the resident was on [MEDICATION NAME] ([MEDICATION NAME], antipsychotic) for [MEDICAL CONDITION]. The resident's behaviors were stable and she was calmer/quieter. A hospice licensed master social worker (LMSW) progress note dated 5/24/2016 documented the resident had a history of [REDACTED]. The resident would attempt to vocalize, but her words were not understandable. A hospice LMSW progress note dated 6/7/2016 documented the resident was in an activity when she arrived to see the resident. The resident appeared to enjoy the activity as evidenced by her increased vocalizations. The resident's mood and behavior were stable. A 6/8/2016 physicians rounds/resident status update documented the resident was on [MEDICATION NAME] for [MEDICAL CONDITION] and was stable. Nursing progress notes documented on 6/11 and 6/13/2016 the resident was very vocal. A nursing progress note dated 6/13/2016 documented the resident was discharged from hospice services that morning. A LMSW progress note dated 6/14/2016 documented the resident was very vocal today which indicated she is in a good mood. A 6/21/2016 nursing quarterly progress note documented the resident was taking [MEDICATION NAME] for [MEDICAL CONDITION] and that had been tapered down related to her previous nutritional decline. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired. The resident displayed little interest or pleasure in doing things, had trouble with her sleep pattern, felt tired or had little energy, and had a poor appetite and trouble concentrating. The resident exhibited verbal behavioral symptoms directed toward others at times, and rejected evaluation of care daily. The resident was totally dependent on staff for most activities of daily living (ADLs), and received an antipsychotic medication. A social services progress note dated 6/28/2016 documented the resident was recently discharged from hospice services related to improved stable condition. The resident's medication and mood state were monitored for medication effectiveness. The resident's care plan and quality measures had been reviewed and remained appropriate. The comprehensive care plan (CCP) dated 6/28/2016 documented the resident's activity pattern and daily routine were impacted by her confusion and socially inappropriate behavior related to progression of dementia. The resident was on a [MEDICAL CONDITION] drug use related to [MEDICAL CONDITION], delusional disorder, or [MEDICAL CONDITION]. Staff were to observe for a change in mood and behavior and attempt to determine cause. Staff were to offer 1:1 visits, and include the resident in activities of past enjoyment and of short duration. The resident was to be placed on the perimeter of large group events to allow quick accessibility if the resident became anxious or inappropriate. Staff were to administer medications as ordered and monitor effectiveness and side effects of medications for possible decrease/elimination. The certified nurse aide (CNA) care instructions dated 6/28/2016 documented the resident was easily distracted and could be verbally and physically inappropriate. The Medication Administration Record [REDACTED]. Nursing progress note documented the resident was vocal or had random vocal outbursts on 7/7 and 7/18/2016. There was no further documentation of verbalizations or behavioral symptoms during these dates. A 7/13/2016 physician rounds/resident status update documented the resident had intermittent vocalization and was on [MEDICATION NAME] for [MEDICAL CONDITION]. A 7/13/2016 physician note documented the resident was no longer under hospice services. She was on [MEDICATION NAME] related to very agitated crying out type of behavior. The medication had been successful in controlling the behavior. The physician would continue to monitor and further adjustments may be needed. Nursing progress notes documented: - On 7/24/2016 at 2:30 PM, the resident had vocal outbursts and was moved to other areas with less environmental stimuli. The change in environment was effective for short periods and the resident would yell out again. - On 7/25/2016 at 6:45 AM, the resident was more vocal on and off through the night and she did not respond to redirection. At 12:09 PM, she had increased vocal outbursts throughout the shift, which became upsetting to the surrounding residents. The resident was moved to a quieter environment with no effect, she was not incontinent, had 1 episode of loose stools, and redirection not accepted. - On 7/26/2016 at 2:46 PM, the resident was vocal that shift, it was upsetting to peers, and moving to a quieter environment was only effective for a short time. At 5:34 AM, the resident was very vocal, was checked and changed, and she did not respond to redirection. - On 7/27/2016 at 1:34 PM, the resident continued to have disruptive yelling, and kept other residents awake, especially her roommate. [MEDICATION NAME] was increased to 05 mg in AM and 1 mg in evening. A physician order [REDACTED]. A physician note dated 7/27/2016 documented the resident was getting more vocal again, hollering out, and she did not seem to be in any distress. The physician stated the resident's yelling was very disruptive to the other residents, particularly next door neighbors who were not getting any sleep. The physician documented he increased the [MEDICATION NAME] to 0.5 mg in the morning and 1 mg in the evening and to adjust as necessary. There was no documentation in the CCP the interventions were re-evaluated for effectiveness prior to increasing the resident's [MEDICATION NAME] on 7/27/2016. Nursing progress notes between 7/28/2016 - 9/13/2016 documented 1 instance where the resident was vocal during the dinner meal. There was no further documentation of verbal or physical behaviors affecting others. The MDS assessment dated [DATE] documented the resident was severely cognitively impaired and did not exhibit behavioral symptoms toward self or others. A 9/14/2016 physician round/resident status update documented the resident was on [MEDICATION NAME] 0.5 mg in AM/1 mg in evening, had short lived vocal outbursts, and behaviors were stable. A physician progress notes [REDACTED]. The resident had occasional vocal outbursts each day, and they were short lived and tolerable. The physician documented he would not address the medications at this time. A social services progress note dated 9/20/2016 documented the resident was on medication for mood state and and the medication would continue to be monitored for effectiveness. The note documented she had a history of [REDACTED]. The physician continued to monitor and make adjustments as needed. The resident had a gradual decline in overall condition. The resident's care plan was reviewed and remained appropriate. The resident was observed: - On 10/24/2016 at 11:50 AM in bed asleep, and from 12:12 PM - 12:55 PM and 5:34 PM - 5:45 PM in the dining room quietly receiving assistance with her meal. At 5:46 PM, the resident made an ahh sound briefly. At 5:50 PM, staff attempted to assist the resident with her meal and she was drowsy. - On 10/25/2016 at 9:00 AM, 10:00 AM, and 10:58 AM in bed asleep. In the dining area at 12:32 PM, she made an ahh sound for 1 second and a CNA stated the resident's name and the resident stopped. At 1:46 PM, the resident was sleeping in bed. During an interview with CNA #5 on 10/26/2016 at 3:30 PM, she stated the resident did not holler out often. She stated when there was an increase in stimulation, the resident may have hollered out more. She stated she would usually walk up to the resident in these instances and talk with her and the resident would calm. She stated the resident normally had an increase in stimulation at dinner time. CNA #5 stated the resident did not seem distressed during these intervals and it seemed as though she was trying to communicate. She stated there was not anything documented to attempt with the resident, the nurse would ask them to check and change her, and they would normally try to find interventions that worked for the resident. She could not state any further specific interventions. During an interview with the physician on 10/27/2016 at 8:07 AM, he stated the resident had been crying out a lot and he did not feel it was pain related. He stated it was a sound similar to ahh. He stated it could range for a couple minutes up to a few hours. He stated it was not clear what was causing the resident distress. He stated he would hear a verbal report from nursing during rounds regarding the resident's verbal symptoms and he did not necessarily record this information. He stated the resident had been on hospice services when she was on [MEDICATION NAME]. He stated hospice staff would communicate to nursing, and nursing would in turn notify him of updates. He stated he was not aware of the notes documented by the hospice LMSW documenting the resident's outbursts. He stated he felt the resident would be embarrassed by her sounds and the medication would be appropriate to alleviate the calling out/verbalizations. During an interview with RN Manager #2 on 10/27/2016 at 10:00 AM, she stated the resident a history of sexual comments toward males and that had decreased over the year. She stated the resident could become vocal now, it came out as a sound/noise and not as words. She stated it did not seem purposeful. She stated it happened daily in short instances. She stated staff should be addressing the resident's verbalizations by talking with her, offering her a position change, and re-approaching her. She stated new staff should discuss interventions with her and/or other staff. RN Manager #2 stated other residents used to be bothered by the verbalizations and this did not bother them any longer, as there had been a change in the residents living in her cottage. She stated if interventions were not effective the physician was notified and he would address a possible medical cause. During an interview with the Director of Social Services on 10/27/2016 at 12:25 PM, she stated the social services department would be informed if there was a change or addition of an antipsychotic medication. She stated it was pharmacy and nursing's responsibility to address gradual dose reductions (GDRs). She stated social services would monitor for behavioral symptoms and the Director of Social Services stated behavioral interventions would be the responsibility of the IDT (interdisciplinary team) as a whole. She stated social services would add non-pharmacological interventions to resident care plans and she was not sure if this was done for this resident. She stated if interventions were not working or no longer necessary, they would need to be re-evaluated. She stated the resident had a GDR done on [MEDICATION NAME] and she yelled out for no reason. She stated the resident would have increased yelling out when in the cottage and other residents would tell her to shut up. She stated staff should offer comfort to the resident and determine the cause of her verbalizations. She stated if this was not working the nurse should be notified so that it could be addressed by the IDT. 10NYCRR 415.12(l)(1)

Based on record review, observation, and interview conducted during the recertification survey, it was determined for 1 of 2 residents (Resident #8) reviewed for pressure ulcers, the facility did not ensure that a resident having pressure ulcers receives necessary treatment and services to promote healing. Specifically, when Resident #8 developed a pressure ulcer, the assessment of the pressure ulcer was unclear and the resident's plan of care was not reviewed and revised timely to include pressure relieving devices to promote healing when the pressure ulcer worsened. Findings include: Resident #8 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 6/28/2016 documented the resident was at risk for altered skin integrity and pressure ulcers related to a history of pressure ulcers, and loss in ability to complete activities of daily living (ADLs) independently. Staff were to observe skin daily with personal care and evaluate prevention strategies and make changes as needed (prn) if area identified. The 6/28/2016 certified nurse aide (CNA) care instructions documented the resident required assistance of 2 staff for positioning and was to be repositioned every 2 hours in her bed and chair. The resident had a pressure reducing mattress and cushion in place. A nursing progress note dated 8/22/2016 documented the resident had an area on the coccyx (tailbone) that was starting to get red. Staff were educated on repositioning and PeriGuard (protective ointment) was to be applied every shift and prn (as needed). A physician order [REDACTED]. There was no documentation changes were made to the CCP or CNA care instructions following documentation of skin impairment. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired and was totally dependent on staff for transferring, bed mobility, and toilet use. The resident had impairment to her upper and lower body, was always incontinent, was at risk of pressure ulcers, did not have pressure ulcers, and had a pressure reducing device for the bed and chair. A registered nurse (RN) progress note dated 9/30/2016 at 9:27 PM documented the resident had a Stage II (partial thickness skin loss) pressure area on the coccyx measuring 0.5 centimeters (cm) x 0.1 cm. PeriGuard was applied, and would be applied every shift until healed. A Wound Referral form dated 9/30/2016 documented the resident developed a Stage II pressure ulcer to the left coccyx area. The form did not document the description of the wound bed, drainage, or size. The form documented the pressure ulcer was not avoidable. The form documented the resident was incontinent of bowel or bladder and had a history of [REDACTED]. The Wound Referral form dated 9/30/2016 documented an additional comment by an RN on 10/1/2016. The RN documented staff reported the area was larger and was now open. The pressure ulcer measured 1.2 cm x 0.5 cm, and had a pink wound bed with no drainage. The treatment was changed to [MEDICATION NAME] cream (protective cream) three times daily (TID) until healed. The nurse provided teaching with staff regarding turning and repositioning every 2 hours. There was no documentation what staff were educated on turning and repositioning. A nursing progress note dated 10/1/2016 at 7:32 PM documented staff reported during incontinence care the Stage II on her coccyx appeared larger and open. The pressure ulcer had no odor, redness, or drainage. The care plan was reviewed and the resident was turned and repositioned every 2 hours. The 9/1/2016 - 10/1/2016 care plan approach checklist(s) for nurse aides documented that the resident's care planned approaches were followed. There was no documentation specifying when/what 2 hour intervals turning and repositioning was completed. physician progress notes [REDACTED]. The treatment administration record (TAR) documented on 10/4/2016 at 7:30 PM the treatment was applied, and the resident's Stage II pressure ulcer remained open and was not improving. A nursing progress note dated 10/5/2016 at 2:17 AM documented the pressure ulcer on the resident's coccyx had no change and continued to be dark and red. A weekly wound assessment dated [DATE] documented the resident's Stage II pressure ulcer to the coccyx measured 1.4 cm x 1 cm, had no drainage, and the wound bed was red. The assessment documented to continue the same treatment. A nursing progress note dated 10/12/2016 at 7:03 AM documented the resident's buttocks continued to be very red, sore, and open. Cream was applied liberally and the resident was repositioned off her buttocks every 2 hours. A nursing progress note dated 10/12/2016 at 12:31 PM documented the resident's buttocks was noted to be sore, and she was being repositioned every 2 hours on to her sides. A weekly wound assessment dated [DATE] documented the Stage II pressure ulcer to the coccyx measured 1.4 cm x 0.6 cm with slough (moist dead tissue) to the wound bed. The resident's treatment was changed to: apply Replicare (protective dressing) and cover with Opsite (transparent dressing); change every 3 days and prn until healed. A 10/19/2016 at 9:53 PM, a licensed practical nurse (LPN) progress note documented the resident now had an air mattress on her bed related to a pressure ulcer on her buttocks. The CNA care instructions were updated on 10/19/2016 and documented the resident had an air mattress in place. A weekly wound assessment dated [DATE] documented the Stage II pressure ulcer to the resident's coccyx measured 0.8 cm x 0.6 cm with slough, and to continue the same treatment. The resident was observed in her room in bed on 10/24/2016 at 11:50 AM, at 3:28 PM leaning to the left side, and at 5:03 PM. From 5:34 PM to 6:13 PM, the resident was seated in her wheelchair at the dining table. The resident was observed on 10/25/2016 at 9:00 AM and 10:00 AM in her room in bed, leaning to the left. At 10:00 AM, an LPN was standing outside the door and stated she needed to complete a treatment on the resident, as the resident had a Stage II pressure ulcer and there was not a dressing on the area. At 10:55 AM, the resident was in bed lying flat on her back. From 12:15 PM - 1:09 PM, the resident was seated in her wheelchair at the dining table. From 1:46 PM - 1:51 PM, the resident was lying in her bed on her left side. During an interview with CNA #5 on 10/26/2016 at 3:30 PM, she stated the resident required assistance of 2 staff for bed mobility, and was to be repositioned with a pillow every 2 hours from her left, back, and to her right side. She stated the resident used to have a standard mattress and a firm anti-thrust cushion in her wheelchair. She stated the resident now had an air mattress and a thicker cushion in her wheelchair. CNA #5 stated the resident was to be placed back into bed every 2 hours if she had been seated in her chair. She stated she would know what care needed to be provided by reading the CNA care instructions. During an interview with CNA #6 on 10/27/2016 at 9:26 AM, she stated the resident needed repositioning every 2 hours and she was unable to do this herself. She stated the resident seemed sore when she was seated in her wheelchair and she knew to lay the resident down in bed after meals. CNA #6 stated the resident had a chair cushion that tilted back. CNA #6 was not sure of the cushion type, and stated it had been put in place when the resident was skootching in her chair. During an interview with RN Manager #2 on 10/27/2016 at 10:00 AM, she stated a CNA had reported to a nurse working the weekend the resident had a pressure ulcer to the coccyx. RN Manager #2 stated she became aware of the pressure ulcer the following Monday (10/3/2016) and assessed the area. Upon assessment, she found the resident had a Stage II pressure ulcer. She stated the resident had a standard skin preventative mattress and a firm cushion to her wheelchair in place at that time. She stated it was not documented in the resident's record the resident had received a Roho cushion (specialized cushion that adjusts with a person's seated positioning) on 10/6/2016. She stated the resident had been placed on weekly rounds that RN Manager #4 attended. She stated an air mattress was added to the resident's plan of care on 10/19/2016, as the resident's pressure ulcer had worsened. During an interview with RN Manager #4 on 10/27/2016 at 11:45 AM, she stated she had recently acquired the responsibilities of wound nurse for the facility. She stated she was notified of the resident's pressure ulcer on 10/1/2016 via a Wound Referral Form, and a CNA reported to her the pressure ulcer was larger and it had opened. She stated she assessed the pressure ulcer, and changed the treatment to [MEDICATION NAME] TID. She stated she initiated the [MEDICATION NAME] when she spoke to staff and they reported the resident had a history of [REDACTED]. She stated at that time she also provided education to the CNAs regarding ensuring turning and repositioning every 2 hours. She stated she did not evaluate the resident's wheelchair cushion until wound rounds on 10/6/2016, when she felt the cushion and found it was firm. They then changed the cushion to one that provided more cushion/padding. She stated during wound rounds on 10/13/2016, the pressure ulcer wound bed was seen to contain slough, and remained a Stage II pressure ulcer as the size decreased. She stated the treatment was changed at that time to a Replicare dressing to provide extra cushioning and it was to be changed every 3 days. She stated she did not initiate the air mattress on 10/19/2016, as that was done by the unit's LPN. She stated on 10/20/2016 during wound rounds, the pressure ulcer continued to be a Stage II, as it continued to decrease in size and the wound bed contained a minimal amount of slough. She stated there was no documented evidence the resident was turned and positioned every 2 hours as planned, as the CNAs only provided one signature, indicating the resident's entire plan of care was followed. 10NYCRR 415.12(c)(1)(2)

Based on observation, interview, and record review conducted during the recertification survey, it was determined for 1 of 19 sampled resident rooms (Resident #13), 2 additional resident rooms (Residents #20 and 21), and 3 of 8 unit shower rooms (Oak unit, Maple unit, and Cherry unit), the facility did not ensure the nurse call system was functional. Specifically, the nurse call system for Residents #13, 20 and 21's rooms, the Oak unit shower room, Maple unit shower room, and the Cherry unit shower room were wrapped around grab bars and were inaccessible to residents during the survey. Findings include: 1) Resident #13 had [DIAGNOSES REDACTED]. The certified nurse aide (CNA) care plan (care instructions) initiated 6/16/2016 documented the resident was incontinent of bladder and was to be taken to the bathroom every 4 hours and as needed (prn). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. She required extensive assistance for most activities of daily living (ADLs) except for eating, and she was on a toileting schedule. The comprehensive care plan (CCP) dated 9/15/2016 documented the resident was at risk to fall and she had urinary incontinence related to advanced age. Interventions included to educate resident on safety needs and maintain toileting plan per the CNA care sheet. The resident's bathroom call cord was observed on 10/24/2016 at 3:13 PM wrapped around the toilet seat handle. During an interview with CNA #8 on 10/27/2016 at 9:15 AM, she stated the resident was placed on the toilet every 4 hours, and when the resident was done, she would pull the call bell string to alert staff she was finished. During an interview with registered nurse (RN) Manager #4 on 10/27/2016 at 9:30 AM, she stated the call bell would not be in working order if it was wrapped around a bar in the bathroom. 2) Resident #20 had [DIAGNOSES REDACTED]. The certified nurse aide (CNA) care plan (care instructions) dated 7/12/2016 documented the resident was toileted every 2 hours and as needed (prn). The comprehensive care plan (CCP) dated 7/26/2016 documented the resident would maintain her ability to assist in personal hygiene. Interventions included to ensure privacy and toilet the resident prior to activities. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired and she required extensive assistance for all activities of daily living (ADLs). The resident's bathroom was observed on 10/24/2016 at 2:28 PM and the call bell cord was wrapped around the grab bar. Licensed practical nurse (LPN) #3 was interviewed on 10/26/2016 at 3:35 PM. She stated the resident would know to pull the call bell cord in the bathroom if she were in there and needed assistance. She stated the resident was confused, but knew how to call for help using the call bell. During an interview with registered nurse (RN) Manager #4 on 10/27/2016 at 9:30 AM, she stated the call bell would not be in working order if it was wrapped around the grab bar in the bathroom. 3) Shower Rooms On 10/24/2016 between 2:35 PM and 3:24 PM, wrapped and/or non-functioning nurse call cords were observed in the following rooms: - Oak unit shower room had two nurse call cords wrapped around grab bars. One was located by the toilet and the other was located in the tub room; - Maple unit shower room had a nurse call cord wrapped around a shower curtain rod and would not function when pulled; and - Cherry unit shower room had a nurse call cord wrapped around a shower grab bar and would not function when pulled. When interviewed on 10/24/2016 at 2:37 PM, registered nurse (RN) Manager #2 stated certified nurse aides (CNAs) were supposed to do shift checks every day, and checking nurse call cord locations would have been included in the checks. When interviewed on 10/24/2016 at 4:09 PM, RN Manager #4 stated CNAs checked the nurse call cords whenever they entered a room. 10NYCRR 415.29(b)

Based on observation, record review, and interview conducted during the recertification survey, it was determined the facility did not thoroughly develop, review, and revise a comprehensive care plan (CCP) for 2 of 19 sampled residents (Residents #5 and 15). Specifically, Resident #5's CCP was not updated to reflect his behaviors or interventions for behaviors related to his anxiety disorder. For Resident #15, there was no evidence the CCP was re-evaluated for effectiveness when he displayed behavioral symptoms, declined care, and current interventions were not consistently effective. Findings include: 1) Resident #5 had [DIAGNOSES REDACTED]. The 10/04/2016 certified nurse aide (CNA) Care Plan (care instructions), kept in the resident's room, documented the resident's cognitive status was alert and pleasantly confused. He had right-sided weakness related to stroke, required a mechanical lift for transfers, used a wheelchair for locomotion, used a bedpan or commode for toileting, and required extensive assist for most activities of daily living (ADLs). He had [MEDICAL CONDITION] and it took him a while to process and formulate words. He had impaired peripheral vision and staff were to stand directly in front of him when talking. He was to be left in bed until 9 AM, as his wife was in most days to fed him breakfast. There were no behaviors listed or interventions for behaviors addressed related to his anxiety disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognitive ability was moderately impaired. He required extensive assistance to total dependence for most of his ADLs. A review of the CCP binder on 10/25/2016 at 1:00 PM revealed no paper copy of the resident's care plan. The electronic CCP reviewed on 10/25/2016 listed the following problems: - the resident was at risk for low activity related to his stated embarrassment at his need for increased assistance and his difficulty finding the words he needs; - the resident was at risk for falls related to impaired mobility secondary to [DIAGNOSES REDACTED].>- the resident was at risk for nutritional decline related to advanced age and multiple comorbidities including [MEDICAL CONDITION] dysphagia (difficulty swallowing). The CCP did not address the anxiety disorder or interventions for behaviors associated with his anxiety disorder. Progress notes documented Resident #5's behaviors on the following dates: - 10/9/2016 at 9:55 PM, the resident was agitated and told staff a thief was attacking him; - 10/11/2016 at 12:48 PM, the resident yelled out and the call light was within reach; - 10/15/2016 at 10:02 PM, the resident was very anxious while in bed, yelled out, and thrashed around; - 10/16/2016 at 9:35 PM, the resident was anxious and more confused, stated his right arm wasn't his, and he needed his shovel; - 10/17/2016 at 3:30 AM, the resident yelled out from his room all shift, and stopped when staff came in the room; - 10/20/2016 at 9:21 PM, the resident became anxious and yelled out after being put to bed; - 10/23/2016 at 9:10 PM, the resident was increasingly agitated after the evening meal, and leaned out of his wheelchair; staff placed him in bed and he attempted to get out of bed; and - 10/24/2016 at 4:15 AM, the resident was agitated and screaming, sitting at edge of the bed and requested to be put in wheelchair; he was brought to the dining area and he continued to scream, requesting to go back to his room; he stated he wanted to go home; the staff called the resident's wife and she stated he used to get [MEDICATION NAME] when he became agitated in the hospital; the resident continued to yell and swing at staff and told them to get out; the physician assistant on-call was notified and an order for [REDACTED]. When interviewed 10/24/2016 at 2:30 PM, the resident's wife stated she hoped to take him home soon, but he had not progressed as much as she thought he would. She stated she came almost every day at breakfast and stayed through lunch, usually leaving by evening. She stated her presence made him feel more at ease. A review of the CCP binder on the unit 10/26/2016 at 11:15 AM revealed no paper copy of the resident's care plan. When interviewed 10/26/2016 at 2:55 PM, CNA #13 stated the resident did not get agitated or anxious very often, but if somebody sat with him and talked with him he was okay. She was not aware of any other interventions in place for his anxiety. When interviewed 10/26/2016 at 3:00 PM, registered nurse (RN) #4 stated the resident's CCP was not in the binder on the unit because the interdisciplinary team (IDT) had it for a meeting scheduled on 10/27/2016. She stated what was on the computer was all they had for his care plan and the rest of it would be there after the IDT meeting. 2) Resident #15 had [DIAGNOSES REDACTED]. The CCP dated 4/12/2016 documented the resident displayed verbal abuse and anger toward staff and residents, had an onset of wandering, exhibited pacing, was anxious later in the day, and was difficult to redirect. The resident was to be provided with activities of short duration, 1:1 during periods of frustration/anxiety, sit quietly, talk with a calm voice, offer snacks/fluids, walk the resident, and encourage the resident to ask for assistance. Interventions included to develop a behavior management plan and administer medications as ordered. The resident had dementia with cognitive loss affecting his ability to assist with activities of daily living (ADLs). The resident tended to spend more time in his room and enjoyed puttering and fixing things. The plan was for the resident to find a comfortable pattern of activity later in the day to reduce anxiety. Staff were to evaluate effectiveness and side effects of medication for possible decrease/elimination. Nursing progress notes documented between 5/3/2016 - 5/13/2016, the resident refused to attend several meals in the dining area, and retreat and return was ineffective. A physician round/resident status update dated 5/2016 documented the resident could be resistive to routine care needs and redirection and he needed more care as dementia was progressing. A physician progress notes [REDACTED]. Nursing progress notes documented: - On 5/25/2016, the resident declined to attend breakfast, and retreat/return was ineffective. - On 6/10/2016, the resident declined to come out for breakfast, and retreat and return was ineffective. The resident refused evening care. - On 6/27/2016, the resident could be verbally and physically aggressive with staff during care needs and during periods of redirection. The resident seemed to only tolerate the presence of one staff member in his personal space at a time. - On 6/30/2016, the resident declined medications, refused care, and 3 attempts at reapproaching were ineffective. He declined to have his morning meal, and continued to decline care through 10:00 AM. A physician round/resident status update dated 6/2016 documented the resident's dementia was progressing, physical abilities were declining, and the resident refused routine care needs on occasion. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired, and did not exhibit physical, verbal, or other behavioral symptoms. The resident rejected evaluation of care and wandered. He required extensive assistance for most ADLs. The certified nurse aide (CNA) care instructions dated 7/5/2016 documented the resident could be verbally aggressive, resistive to care, and would also strike out. Staff were to offer to close the resident's bedroom door while resting, and could provide night care prior to supper as the resident liked to go to bed directly after supper. The instructions documented the resident enjoyed music, outdoors, puttering, fixing things, TV, books, and had a history of [REDACTED]. Nursing progress notes documented between 7/4/2016 - 7/18/2016, the resident refused medication and meals at times, and retreat and return was ineffective. A nursing progress note dated 7/18/2016 documented the resident had poor interaction with staff and other residents, could be both verbally and physically aggressive, and this was most likely related to dementia. The resident preferred to stay in his room, wandered on occasion, and sitting in a chair activity going on around him would annoy him. The resident did refuse medications, meals, and care at times. The MDS assessment dated [DATE] documented the resident exhibited verbal behaviors directed towards others at times. A social services team progress note dated 7/26/2016 documented the resident was on antipsychotic medication and had behaviors. The resident had a history of [REDACTED]. The resident's behavioral symptoms were focused around his care needs. Staff retreated and re-approached with some effect. The resident enjoyed sitting in a chair on the unit or in his room resting. The resident's care plan was reviewed and remained appropriate. The CCP was updated on 7/26/2016 and documented the resident had a decline in attendance at activities, no longer paced or joked around, and was to be encouraged to attend activities. There was no documentation on the CCP the resident's interventions to address behavioral symptoms affecting self and others were re-evaluated for effectiveness. A physician round/resident Status Update form for 8/2016 documented the resident was physically aggressive at times, was resistive, and refused meals and medications. A physician assistant progress note dated 8/10/2016 documented the resident was difficult with the nurses and was quite agitated over the prior few days. The resident would be re-checked in a few days. There was no documentation the resident's behavior symptoms were rechecked by a medical professional/physician services within a few days of the note. The CCP was updated on 8/30/2016 and documented the resident was unable to make concrete requests regarding his care needs, and was unable to recall interests and hobbies once important to him. The CCP documented the resident required staff assistance with ADLs and ambulation. The resident enjoyed music and children and was to be invited to programs, offered social work visits, and provided with support. There was no documentation the resident's current interventions were re-evaluated for effectiveness or to reflect his current status/change in mood or behavioral symptoms. Nursing progress notes documented between 8/31/2016 - 9/24/2016, the resident refused to attend meals, declined care including toileting, refused medications, yelled, wheeled his walker into a CNA, his hand made close contact to a CNA during care attempts, and kicked at staff. The resident remained soiled at times and did not eat all meals related to declining care and assistance. A physician progress notes [REDACTED]. A social services team progress note dated 10/18/2016 documented the resident was on an antipsychotic medication, had behaviors affecting others, and required increased ADL assistance. The resident could become aggressive with care needs, and staff retreated and re-approached with some effect. The resident care plan was reviewed and remained appropriate. A social services team progress note dated 10/20/2016 documented the resident required more assistance during the night shift or during rising related to his behaviors. The resident was observed on 10/26/2016 at 11:30 AM and 12:10 PM seated in a recliner on his unit asleep, and at 12:35 PM in the unit dining room with his head down asleep and staff attempting to awaken him. During an interview with CNA #15 on 10/26/2016 at 3:40 PM, she stated the resident required full assistance with ADLs. She stated he had never had physical or verbal altercations with others residents, did not yell at other residents, and was not physical with her, but was with other staff. She stated the resident liked to be in bed most of the time and he required encouragement to go to meals. CNA #15 stated his confusion had worsened and the staff would attempt to retreat and reapproach when he declined assistance or care. She stated the resident wanted things done a certain way and it could take several attempts to determine what he wanted. She stated she had not received any guidance or direction on how to address the resident's refusals. During an interview with licensed practical nurse (LPN) #11 on 10/26/2016 at 9:25 AM, she stated the resident did not like to get out of bed, was often soaked in bed and would decline to get up. She stated staff were to retreat when he declined care. If he was soaked, staff were to go back several times and eventually he would give in. During an interview with CNA #6 on 10/27/2016 at 9:26 AM, she stated the resident never talked in an aggressive manner; it appeared so at times as his voice and tone were loud. She stated the resident declined care at times, and he was a taller man and it was difficult to assist him when he did not want to get up. She stated she would have to get staff to assist her with care often. She stated sometimes it took up to 3 times to re-approach him. She stated at times he would say no. During an interview with registered nurse (RN) Manager #2 on 10/27/2016 at 10:00 AM, she stated the resident slept on and off and would come out to the dining area for meals. She stated he liked to sit in his recliner and he did not like more than one staff member working with him. RN Manager #2 stated she would expect staff to retreat and reapproach, offer to change him or use the bathroom, and let him rest. She stated if he was continually refusing/declining care, staff was to notify the nurse, who was to document the refusal. She would become aware of the refusal on the next working day during on the facility's 24 hour report. During an interview with the Director of Social Services on 10/27/2016 at 12:25 PM, she stated social services was responsible for updating any mood or behavioral care plans. She stated the resident's behavioral symptoms occurred more during care times. She stated the resident would yell at others in his personal space. The Director of Social Services stated staff should retreat, reapproach, and encourage the resident to get out of bed. She stated the resident had a functional decline and the care team recently met on his changes. She stated she was not sure what the resident would do if others entered his space, and it was the responsibility of the facility to keep others safe. She stated care planned updates were made in the past, she could not recall when, and no recent changes were made to the resident's CCP/interventions to address the resident's mood or behavioral symptoms. 10NYCRR 415.11(c)(1)

Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 2 of 19 residents (Residents #8 and 9) reviewed for abuse/neglect. Specifically, there was no documented evidence a thorough investigation was completed to rule out abuse or neglect when Resident #8 sustained a skin tear of unknown origin; and when Resident #9 sustained falls. Findings include: 1) Resident #9 had [DIAGNOSES REDACTED]. The 6/21/2016 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired and had disorganized thinking. The resident required extensive assistance of 1 staff for most activities of daily living (ADLs). The MDS documented the resident had 2 falls with no injury and 1 fall with injury during the assessment period. The 6/28/2016 certified nurse aide (CNA) care instructions documented the resident required assistance of 1 for ambulation, transferring, and toileting and required set up with supervision for eating. The resident was to be repositioned every 2 hours in the bed and chair. The 8/4/2016 at 10:15 PM incident report dated 8/4/2016 at 10:15 PM documented the resident slid out of her wheelchair and was found sitting at the bottom of her wheelchair with her right buttock on the right foot pedal. A staff statement attached to the report documented the staff member (discipline not identified) found the resident on her bottom in her wheelchair and the alarm was still under her buttocks. The staff member documented the resident was anxious and kept wanting to get up during the shift. The report documented the care plan was followed and there was no reasonable cause to believe the incident was the result of abuse. The report documented steps taken to prevent recurrence included providing interventions when anxious. There was no documentation that direct care staff were interviewed to determine if mood/behavioral interventions were implemented prior to the resident's fall, when staff noted she was anxious throughout the shift. A nursing progress note dated 8/5/2016 at 3:57 AM documented the resident had fallen out of her chair at 10:15 PM (8/4/2016) and was found by the CNA. The resident was assisted back to bed. The incident report dated 8/10/2016 at 6:05 PM documented the resident slid out of her wheelchair, onto the floor on her buttocks, with her legs out in front of her and her wheelchair behind her. The report documented the care plan was followed and there was no reasonable cause to believe the incident was the result of abuse. A statement completed by a CNA documented she was assisting another resident and felt a chair back into her chair. The resident slid from her foot pedals to the floor and the wheelchair was tipped forward. The statement documented the resident was not anxious that shift, and the CNA did not have information on how the fall occurred. Steps to prevent recurrence documented, the CNA stated the resident tended to be incontinent after drinking milk and the family used to bring in almond milk in the past. There was no documentation which CNA stated the resident was incontinent, if it was determined the resident was incontinent prior to the fall, or if the resident's incontinence and meal profile were reviewed to determine a possible relationship and if the appropriate meal plan was in place for the resident. There was no documentation additional staff were interviewed to determine if the care plan was followed prior to the fall. A nursing progress note dated 8/10/2016 at 6:24 PM, for 6:00 PM, documented the resident slid to the floor off her wheelchair pedals and was assisted by 2 staff to the bathroom for toileting and cleansing. The 9/13/2016 fall risk evaluation documented the resident was at high risk to fall related to a history of falling. There were no further fall risk evaluations in the resident's medical record for 2016. The incident report dated 9/15/2016 at 4:20 AM documented the resident was found in another resident's room on the floor. The report documented three staff were working at the time of the incident. The report documented the alarm device was present and the alarm sounded. The report documented the care plan was followed and there was no reasonable cause to believe the incident was the result of abuse. The report documented the alarm was fixed by maintenance staff and the bed alarm is now working properly. There was no documentation the direct care staff working at the time and prior to the incident were interviewed to determine if care planned interventions were followed. There was no documentation how it was determined acute medical conditions were a potential cause of the fall. There was no documentation how it was determined the bed alarm was to be fixed by maintenance when the report documented the alarm had sounded. A nursing progress note dated 9/15/2016 at 4:30 AM documented the resident was found on the floor in another resident's room at 4:20 AM. The comprehensive care plan (CCP) dated 9/20/2016 documented the resident was at risk to fall. She was to wear non skid footwear and have the call light within reach. The resident was observed on 10/24/2016 from 5:34 PM - 6:13 PM seated in a dining room chair at the dining table with a chair alarm in place. During an interview with CNA #10 on 10/26/2016 at 4:00 PM, he stated the resident displayed anxious symptoms in the evening following family visits. The resident would also display signs of discomfort and need to use the bathroom following meals related to a lactose intolerance. He stated the resident would become more fidgety when she needed to use the bathroom. He stated he was here on one date when the resident had a fall. He was out of the area and assisting another resident. CNA #10 said the resident was anxious in the dining room chair and slid out of the chair. He stated a Supervisor had asked him what occurred. He stated normally he was given a statement to complete. He stated no one had asked him to complete a statement on the date of the fall. He stated the resident was anxious when she was seated in the dining area that evening. During an interview with the Administrator on 10/27/2016 at 11:00 AM, she stated all incidents were discussed in morning meetings. She stated the determination if the care plan was followed was made by the Nurse Manager after she reviewed direct care staff statements. If the Nurse Manager felt comfortable, she would sign off on the incident report. She stated she or the Social Worker would not get involved with the incident unless there were concerns regarding the incident report or for further clarification about what was needed. She stated her expectation was that statements were obtained from all staff involved to assist with the determination of what happened and how to prevent recurrence. During an interview with registered nurse (RN) Manager #2 on 10/27/2016 at 10:00 AM, she stated interviews were completed with direct care staff and the licensed practical nurse (LPN) present at the time of the fall. She stated the LPN would be interviewed to determine if the resident had any acute medical changes. She stated to determine if the care plan was followed, the incident was discussed in the interdisciplinary team meetings. She stated the investigation should include information to determine if alarms sounded properly and if they had alarms in place if care planned for. She stated she would check nursing notes to determine if interventions were offered when a resident displayed anxious symptoms. She stated sometimes she would have to call staff to get this information. During an interview with the Director of Social Services on 10/27/2016 at 12:25 PM, she stated statements should be provided by staff. She stated if she reviewed an incident report and statements were not included, she would speak with staff to determine how an incident occurred. She stated ultimately it was the Administrator's responsibility to rule out abuse, neglect, or mistreatment. She stated for the 8/10/2016 incident report it was reviewed by herself and the nurse Manager. She stated at times they obtained verbal statements from staff to determine if care planned interventions were completed. She stated they would ask if interventions were completed when a resident was anxious. She stated these statements were not always documented and were given verbally. When reviewing the 9/15/2016 investigation, she stated it was difficult to tell if the resident's alarm was working or was not working. 2) Resident #8 had a [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 6/28/2016 documented the resident had impaired communication. She required total assistance with activities of daily living (ADLs), was at risk for altered skin integrity, and her skin was to be observed daily during personal care. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired. She required total dependence on staff for bed mobility and transferring, and extensive assistance with dressing and personal hygiene. A nursing progress note dated 9/18/2016 at 1:37 PM documented the resident had a small scratch under her right abdominal fold. An Incident Report dated 9/18/2016 documented the resident sustained [REDACTED]. Three staff were listed on the incident report as on duty at the time of the incident. The report documented the care plan was followed and there was no reasonable cause to believe the incident was the result of abuse. The staff statement attached to the report documented the staff member noticed the scratch while doing morning care and reported it to the nurse. Staff interviews were completed on 9/18/2016 (unknown time) for the 10:00 PM - 6:30 AM and 2:00 PM - 10:30 PM shifts. There was no documentation if the staff interviewed had worked prior to the identification of the scratch. Staff documented they did not see the scratch. There was no documentation what care the staff provided to the resident to determine the root cause of the injury. An RN statement included in the report documented the resident had contractures to her hands that caused her thumbs to stick out, her nails may have been difficult to trim, and the resident's thumb nail may have made contact with her abdomen. There was no documentation direct care and nursing staff were interviewed to determine if the resident was receiving nail care as planned or if it was reported by staff the resident's nails could not be trimmed. The resident was observed in her room in bed on 10/24/2016 at 11:50 AM, at 3:28 PM leaning to the left side, and at 5:03 PM. From 5:34 PM to 6:13 PM, the resident was seated in her wheelchair at the dining table. During an interview with the Administrator on 10/27/2016 she stated all incidents were discussed in morning meetings. She stated the determination the care plan was followed was made by the Nurse Manager after she reviewed direct care staff statements. If the Nurse Manager felt comfortable, she would sign off on the incident report. She stated she or the Social Worker would not get involved with the incident unless there were concerns regarding the incident report or for further clarification about what was needed. She stated her expectation was statements would be obtained from all staff involved, to assist with the determination of what happened and how to prevent recurrence. During an interview with CNA #5 on 10/26/2016 at 3:30 PM, she stated the resident required total assistance from staff with all ADLs. During an interview with registered nurse (RN) Manager #2 on 10/27/2016 at 10:00 AM, she stated the nurse present for the incident would begin an incident report. She stated the report was then placed in her mailbox. She stated she would follow up with staff to determine if there were any environmental factors that may have caused an injury. She stated when a resident sustained [REDACTED]. During an interview with the Director of Social Services on 10/27/2016 at 12:25 PM, she stated statements should be provided by staff. She stated if she reviewed an incident report and statements were not included, she would speak with staff to determine how an incident occurred. She stated ultimately it was the Administrator's responsibility to rule out abuse, neglect, or mistreatment. She stated at times they obtained verbal statements from staff to determine if care planned interventions were completed. She stated these statements were not always documented and were given verbally. 10NYCRR 415.4(b)