Every finding on record at Wayne County Nursing Home

Based on observations, interviews and record review conducted during an Abbreviated Survey (Intake ID: 2652860) from 11/03/2025 to 11/07/2025, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) (Resident #10) residents reviewed for accidents. Specifically, Resident #10 was transferred on 10/24/2025 using an extra-large mechanical lift sling that did not fit the resident's body size, and a registered nurse or therapist did not assess the resident upon readmission to determine the correct sling size which resulted in the resident falling from the sling and sustaining a subdural hematoma (bleeding around the brain) and an orbital fracture (fracture around the eye). The facility's failure to conduct a registered nurse or therapist assessment to determine correct sling size, failure to document sling size in the comprehensive care plan and care card, failure to ensure staff were trained or competent in sling selection, and allowing staff to use any available sling regardless of fit resulted in actual harm to Resident #10 and a likelihood for serious injury, serious harm, serious impairment, or death for all residents requiring the use of a mechanical lift in the facility (census 139), that was Immediate Jeopardy and Substandard Quality of Care.The findings include:The facility policy Lift/Transfer/Positioning, last reviewed November 2024, included nursing will determine a resident's ability to transfer upon admission and within 48 hours, a therapist will assess the resident's ability to lift and transfer. Approaches for resident lift/transfer will be incorporated in the resident care plan as determined per nursing or therapy. Lift and sling type are to be written on the care plan/care card. When a resident cannot be transferred per care plan or there is a change in resident condition placing a resident at risk, a Stop and Watch (communication tool used to help staff recognize and report changes in a resident's condition) should be done and reported to the nurse immediately. The resident must be reassessed for lift/transfer by the registered nurse or therapist, and the reassessment will be documented in the resident record. Any change in approaches for lift/transfer will be incorporated in the resident care plan and transcribed to the care plan flow sheet. The registered nurse or therapist may assign an alternate transfer/lift to a resident and will document specifics on when to use the alternate transfer/lift in the care plan and certified nursing assistant instructions. If staff are uncertain about the resident's ability to perform the transfer recommended or alternate transfer as posted, the staff may always opt to complete a transfer/lift that is physically less demanding (higher level of care), and the nurse must be notified if this occurs. The resident assessment should include examination of factors such as the level of assistance the resident requires, the size and weight of the resident, the ability and willingness of the resident to understand and cooperate, and any medical conditions that may influence the choice of methods for lifting or repositioning.The Medline (manufacturer) sling Instructions For Use, dated 2022, included: to always confirm the weight capacity of the sling against the patient's weight and ensure proper placement before performing a lift; use clinical judgement for body shape and patient comfort when selecting between sizes; do not remove sling labels and if labels are removed or no longer legible, the sling must be immediately removed from use.The undated Medline Model: MDS450EL Patient Lift Owner's Guide, included: to select a sling that will properly fit the patient and has the appropriate weight capacity; always ensure the sling is the correct size and capacity for the patient being transferred; use only Medline slings on Medline patient lifts; use of non-Medline slings could be unsafe and may result in injury to the patient or caregiver.Resident #10 had diagnoses including vascular dementia, dysphagia (difficulty swallowing), and chronic kidney disease. The Minimum Data Set (a resident assessment tool) dated 12/24/2024 documented the resident had severely impaired cognition. Review of the Comprehensive Care Plan dated 08/08/2025 and care card (used by certified nursing assistants to guide care), effective 10/24/2025, revealed Resident #10 required substantial/maximal assistance (significant physical help to complete task) by one (1) staff using a two (2) wheeled walker and gait belt (a safety tool used to help individuals who have difficulty walking, standing, or balancing) for transfers. There was no documented evidence of mechanical lift use, sling size, sling type, or any instruction on loop (used to attach a sling to the mechanical lift and helps to adjust the resident's position during a transfer) configuration.Resident #10 was hospitalized from [DATE] to 10/24/2025 for acute respiratory failure (inadequate gas exchange by the respiratory system) related to pneumonia. Review of a hospital After Visit Summary dated 10/24/2025, revealed Resident #10's weight was 125 pounds and height was 67 inches. The resident was readmitted to the facility on [DATE]. In a progress note dated 10/24/2025 at 3:19 PM, the Director of Nursing documented Resident #10 returned to the facility by ambulance, had unsteady gait and poor balance, and required a wheelchair for mobility. There was no documented evidence Resident #10's transfer status was assessed by a registered nurse or therapist following readmission to the facility. Review of the facility's investigation summary dated 10/30/2025, revealed on 10/24/2025, Certified Nursing Assistant #1 and Certified Nursing Assistant #2 attempted to transfer Resident #10 from the bed to a wheelchair using a mechanical lift (identified as the Medline Power Base, Model MDS450EL) after determining the resident was too weak to transfer per the care card instructions. Resident #10 slipped through the sling (identified as a blue full sling) during the lift, fell to the floor, and struck their head. Licensed Practical Nurse #1 was notified, and Registered Nurse #1 was called to assess the resident. Registered Nurse #1 documented Resident #10 had a large hematoma to the back of their head and slow responsiveness. Emergency services were notified, and the resident was transferred to the hospital. Additionally, an audit was conducted following the incident and nine (9) slings were removed from circulation due to the absence of visible size labels, which is required for proper sling identification and safe resident use. The facility's investigation did not include if a Medline sling was used during the transfer on 10/24/2025.In a Medical Intensive Care Unit admission note dated 10/24/2025, Physician #1 documented Resident #10 arrived at the emergency department following a fall from a mechanical lift resulting in a head strike to the back of their head. The resident was found to have a subarachnoid hemorrhage (life-threatening bleeding in the space between the brain and tissues that cover the brain ), subdural hematoma (bleeding under the outermost layer of tissue protecting the brain), and orbital fracture with a poor prognosis (condition may worsen and recovery is unlikely). Review of video footage recorded by the facility dated 10/24/2025, revealed Certified Nursing Assistant #1 and Certified Nursing Assistant #2 bringing a mechanical lift into Resident #10's room at 4:32 PM. At 4:33 PM, Certified Nursing Assistant #1 entered a supply room and returned to the resident's room holding a blue sling with blue trim, inspecting the sling while walking. At 4:38 PM, Certified Nursing Assistant #2 was running down the hallway and returned to the resident's room with Licensed Practical Nurse #1. At 4:40 PM, Registered Nurse #1 entered the resident's room. During an observation of the facility's sling inventory on 11/03/2025 at 11:07 AM, several full-body slings lacked size and weight guidelines and only provided maximum weight capacity. It was determined the sling observed in the video footage was an extra-large sling with a label that included only maximum weight capacity. Additionally, there were non-Medline slings in the facility's inventory. During an interview on 11/03/2025 at 10:34 AM with Certified Nursing Assistant #3 and Certified Nursing Assistant #4, Certified Nursing Assistant #4 stated the facility slings had patches sewn on each sling with weight and size recommendations and they were instructed by the facility to select a lift sling based on the resident's weight. Certified Nursing Assistant #3 stated they were instructed to use maximum assistance for any resident returning from the hospital until therapy evaluated the resident. Certified Nursing Assistant #3 and Certified Nursing Assistant #4 stated they check a resident's care card to determine transfer status, the nurses make the determination whether to use more assistance, and they never change a resident's transfer status without talking to a nurse. During an interview on 11/03/2025 at 11:18 AM, Licensed Practical Nurse #2 stated therapy determines a resident's transfer status and nursing updates the care plan only after therapy notifies them of a change. Licensed Practical Nurse #2 stated sling size and loop color were not documented in the care plan.During an interview on 11/03/2025 at 11:38 AM, Registered Nurse Manager #1 stated certified nursing assistants could independently determine the need for a full-body mechanical lift. Registered Nurse Manager #1 stated they were responsible for updating resident care plans but was not sure if the sling type and size were documented in the care plan.During an interview on 11/03/2025 at 1:14 PM, the Director of Rehabilitation stated therapy only assesses residents when there is a physician order, and some residents may not be assessed after admission or readmission because there is no order. They stated nurses or certified nursing assistants may determine the need for a full-body lift without therapy involvement. During a follow-up interview on 11/04/2025 at 1:46 PM, the Director of Rehabilitation stated therapy does not participate in educating staff on the use of mechanical lifts.During an interview on 11/03/2025 at 1:25 PM, Registered Nurse Manager #2 stated certified nursing assistants are educated on mechanical lift use and proper sling selection by the Nurse Educator during orientation. They stated an experienced certified nursing assistant might independently upgrade a resident to a full-body lift and inform the nurse afterward, but certified nursing assistants cannot determine how to transfer a resident when first admitted or returning from the hospital. Registered Nurse Manager #2 stated only therapy, or a registered nurse can assess a resident's transfer status following an admission or readmission and therapy is responsible for updating the care plan with the transfer status and appropriate equipment, including the type and size of sling size.During an interview on 11/03/2025 at 2:33 PM, Licensed Practical Nurse #1 stated sling size should be determined based on the resident's weight, but Resident #10 had not been weighed after returning from the hospital. Licensed Practical Nurse #1 stated on 10/24/2025, Certified Nursing Assistants #1 and #2 informed them Resident #10 appeared weak and asked to use the mechanical lift to transfer the resident. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 later informed them the incorrect sling was used because it was the only sling they could find on the unit.During an interview on 11/03/2025 at 2:46 PM, Certified Nursing Assistant #2 stated on 10/24/2025, Resident #10's care card documented a one (1) person assist with walker transfer, but the resident appeared weak. Certified Nursing Assistant #2 stated Licensed Practical Nurse #1 told them the resident needed to be sitting up due to aspiration risk and to use a full mechanical lift to transfer the resident. They stated they first attempted the transfer using a hygiene sling (used for toileting), but it did not secure the resident, so the only full sling available on the unit was used instead. Certified Nursing Assistant #2 stated they were taught to select a sling based on weight but did not know the resident's weight at the time. During a follow-up interview on 11/06/2025 at 11:47 AM, Certified Nursing Assistant #2 stated the sling observed in video footage from 10/24/2025 was an extra-large sling and recalled the sling straps were crossed behind the resident's thighs rather than between the legs.During an interview on 11/03/2025 at 3:03 PM, the Nurse Educator stated staff were trained to select a sling based on weight, height, and body shape, and a reference tag was sewn onto the slings indicating size. They stated registered and licensed practical nurses should make the determination to use a mechanical lift, but certified nursing assistants could also make the decision to use a lift and notify the nurse. The Nurse Educator stated the sling size should be documented in the resident's care plan. During a phone interview on 11/04/2025 at 10:11 AM, Certified Nursing Assistant #1 stated Resident #10's transfer status had not been evaluated after returning from the hospital and Licensed Practical Nurse #1 instructed them to use a full-body mechanical lift. Certified Nursing Assistant #1 stated on 10/24/2025, they took the first sling they found, did not verify the sling size, and did not know where to look for other slings. During a follow-up observation and interview on 11/06/2025 at 11:11 AM, Certified Nursing Assistant #1 demonstrated how the lift sling was applied to Resident #10 by crossing the sling straps behind the thighs rather than between the legs. They stated on 10/24/2025 they used the extra-large sling for the lift transfer, and it was probably too big. Certified Nursing Assistant #1 stated they did not complete hands-on training with the mechanical lift during their one (1) day of orientation and signed their orientation checklist without completing all tasks. During an interview on 11/04/2025 at 10:44 AM with Certified Nursing Assistant #4 and Registered Nurse Manager #2, Registered Nurse Manager #2 stated any sling could be used as long as the resident was below that weight. During an interview on 11/04/2025 at 1:15 PM, the Assistant Director of Nursing stated the certified nursing assistants used too large of a sling during the transfer of Resident #10 on 10/24/2025. During a follow-up interview on 11/05/2025 at 1:33 PM, the Assistant Director of Nursing stated when residents are readmitted to the facility, a registered nurse should determine transfer status, and a resident should not be transferred until a registered nurse or physical therapist determines how to do so.During an interview of 11/04/2025 at 4:36 PM, the Medical Director stated they were aware of the incident involving Resident #10 but had not personally reviewed the resident's medical record. The Medical Director stated the facility completed a thorough investigation and they were not aware of any issues related to the equipment used during the transfer. During an interview on 11/04/2025 at 4:54 PM, the Administrator stated they were aware of the incident involving Resident #10 and reviewed the investigation with the interdisciplinary team. The Administrator stated they expected residents to be properly assessed for transfers, the investigation found that proper equipment was used during the transfer, and they believed it was an accident. During an interview on 11/06/2025 at 11:41 AM, the Director of Nursing stated they did not assess Resident #10's transfer status when readmitted to the facility on [DATE]. They stated certified nursing assistants could make the decision to use a full mechanical lift and select the type and size of sling based on a resident's height and weight. The survey team identified Immediate Jeopardy, and the facility Administrator was notified on 11/07/2025 at 3:32 PM.On 11/07/2025 at 5:25 PM, the survey team determined the Immediate Jeopardy was removed based on the following corrective actions taken by the facility:The facility policy on resident admissions and readmissions was revised to include a registered nurse assessment which addresses a resident's height, weight, shoulder circumference, and chest circumference.The facility retrained 85 percent of all certified nursing assistants and licensed nursing staff on the admissions and lift/transfer policies and attested that all remaining nursing staff would complete mandatory training prior to their next scheduled shift. This was verified through interviews with nursing staff and review of training records with no identified concerns. All residents identified as needing a full mechanical lift for transfers were reassessed and assigned an appropriate lift sling. This was verified through review of resident records with no identified concerns. NYCRR 415.12(h)(2)

Based on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 2652860) from 11/03/2025 to 11/07/2025, the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, Resident #10 was transferred on 10/24/2025 using an extra-large mechanical lift sling that did not fit the resident's body size, and a registered nurse or therapist did not assess the resident upon readmission to determine the appropriate mode of transfer, including the mechanical lift sling size, which resulted in the resident falling from the sling and sustaining a subdural hematoma (bleeding around the brain) and an orbital fracture (fracture around the eye). Additionally, Administration did not ensure proper equipment was used, or the Medical Director was notified of any issues related to the equipment used during the transfer, and there were inconsistencies amongst staff with regard to who made the determination of a resident's transfer status and equipment needs. The findings included:For additional information see Centers for Medicare/Medicaid Services Form 2567, refer to F689 (Free of Accident Hazards/Supervision/Devices): The facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) (Resident #10) residents reviewed for accidents. This issue resulted in actual harm to Resident #10 and a likelihood for serious injury, serious harm, serious impairment, or death for all residents requiring the use of a mechanical lift in the facility (census 139), that was Immediate Jeopardy and Substandard Quality of Care. The facility policy Lift/Transfer/Positioning, last reviewed November 2024, included nursing will determine a resident's ability to transfer upon admission and within 48 hours, a therapist will assess the resident's ability to lift and transfer. Approaches for resident lift/transfer will be incorporated in the resident care plan as determined per nursing or therapy. Lift and sling type are to be written on the care plan/care card. When a resident cannot be transferred per care plan or there is a change in resident condition placing a resident at risk, a Stop and Watch (communication tool used to help staff recognize and report changes in a resident's condition) should be done and reported to the nurse immediately. The resident must be reassessed for lift/transfer by the registered nurse or therapist, and the reassessment will be documented in the resident record. Any change in approaches for lift/transfer will be incorporated in the resident care plan and transcribed to the care plan flow sheet. The registered nurse or therapist may assign an alternate transfer/lift to a resident and will document specifics on when to use the alternate transfer/lift in the care plan and certified nursing assistant instructions. If staff are uncertain about the resident's ability to perform the transfer recommended or alternate transfer as posted, the staff may always opt to complete a transfer/lift that is physically less demanding (higher level of care), and the nurse must be notified if this occurs. The resident assessment should include examination of factors such as the level of assistance the resident requires, the size and weight of the resident, the ability and willingness of the resident to understand and cooperate, and any medical conditions that may influence the choice of methods for lifting or repositioning.The Medline (manufacturer) sling Instructions For Use, dated 2022, included: to always confirm the weight capacity of the sling against the patient's weight and ensure proper placement before performing a lift; use clinical judgement for body shape and patient comfort when selecting between sizes; do not remove sling labels and if labels are removed or no longer legible, the sling must be immediately removed from use.The undated Medline Model: MDS450EL Patient Lift Owner's Guide, included: to select a sling that will properly fit the patient and has the appropriate weight capacity; always ensure the sling is the correct size and capacity for the patient being transferred; use only Medline slings on Medline patient lifts; use of non-Medline slings could be unsafe and may result in injury to the patient or caregiver.Resident #10 was hospitalized from [DATE] to 10/24/2025 for acute respiratory failure (inadequate gas exchange by the respiratory system) and was readmitted to the facility on [DATE]. There was no documented evidence Resident #10's transfer status was assessed by a registered nurse or therapist following readmission to the facility. Review of Resident #10's Comprehensive Care Plan dated 08/08/2025 and care card (used by certified nursing assistants to guide care), effective 10/24/2025, did not include documented evidence of mechanical lift use, sling size, sling type, or any instruction on loop (used to attach a sling to the mechanical lift and helps to adjust the resident's position during a transfer) configuration.Review of the facility's investigation summary dated 10/30/2025, revealed on 10/24/2025, Certified Nursing Assistant #1 and Certified Nursing Assistant #2 attempted to transfer Resident #10 from the bed to a wheelchair using a mechanical lift (identified as the Medline Power Base, Model MDS450EL) after determining the resident was too weak to transfer per the care card instructions. Resident #10 slipped through the sling (identified as a blue full sling) during the lift, fell to the floor, and struck their head. Additionally, an audit was conducted following the incident and nine (9) slings were removed from circulation due to the absence of visible size labels, which is required for proper sling identification and safe resident use. The facility's investigation did not include the specific sling size or if a Medline sling (as recommended by the lift manufacturer's guide) was used during the transfer on 10/24/2025. Additionally, the investigation did not include Resident #10's need to be reevaluated for transfer status by a registered nurse or therapist due to a change in condition at the time of their readmission.During an observation of the facility's sling inventory on 11/03/2025 at 11:07 AM, several full-body slings lacked size and weight guidelines and only provided maximum weight capacity. It was determined the sling observed in the video footage was an extra-large sling with a label that included only maximum weight capacity. Additionally, there were non-Medline slings in the facility's inventory.During an interview on 11/03/2025 at 3:03 PM, the Nurse Educator stated staff were trained to select a sling based on weight, height, and body shape, and a reference tag was sewn onto the slings indicating size. They stated registered and licensed practical nurses should make the determination to use a mechanical lift, but certified nursing assistants could also make the decision to use a lift and notify the nurse. The Nurse Educator stated the sling size should be documented in the resident's care plan. During a phone interview on 11/04/2025 at 10:11 AM, Certified Nursing Assistant #1 stated Resident #10's transfer status had not been evaluated after returning from the hospital and Licensed Practical Nurse #1 instructed them to use a full-body mechanical lift. Certified Nursing Assistant #1 stated on 10/24/2025, they took the first sling they found, did not verify the sling size, and did not know where to look for other slings. During a follow-up observation and interview on 11/06/2025 at 11:11 AM, Certified Nursing Assistant #1 demonstrated how the lift sling was applied to Resident #10 by crossing the sling straps behind the thighs rather than between the legs. They stated on 10/24/2025 they used the extra-large sling for the lift transfer, and it was probably too big. During an interview of 11/04/2025 at 4:36 PM, the Medical Director stated they were aware of the incident involving Resident #10 but had not personally reviewed the resident's medical record. The Medical Director stated the facility completed a thorough investigation and they were not aware of any issues related to the equipment used during the transfer. During an interview on 11/04/2025 at 4:54 PM, the Administrator stated they were aware of the incident involving Resident #10 and reviewed the investigation with the interdisciplinary team. The Administrator stated they expected residents to be properly assessed for transfers, the investigation found that proper equipment was used during the transfer, and they believed it was an accident. During an interview on 11/06/2025 at 11:41 AM, the Director of Nursing stated they did not assess Resident #10's transfer status when readmitted to the facility on [DATE]. They stated certified nursing assistants could make the decision to use a full mechanical lift and select the type and size of sling based on a resident's height and weight.10 NYCRR 415.26

Based on observations, interviews, and record review conducted during the Recertification Survey 11/20/2024 to 11/26/2024, for four (Residents #36, #37, #91, #94) of 10 residents reviewed, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, Residents #36 and #94 who were on Enhanced Barrier Precautions (a strategy in nursing homes to decrease transmission of infectious disease using enhanced personal protective equipment [PPE]) had indwelling urinary catheter drainage bags that were observed on the floor. Resident #36 received hands on care from staff who were not wearing the required personal protective equipment. Resident #37 received wound care and nursing staff did not change gloves or wash their hands appropriately during the wound care. Resident #91 was being transferred with a mechanical assistive device that had been used on another resident without being cleaned prior to use. This is evidenced by the following: The facility policy Standard,Transmission and Enhanced Barrier Techniques, revised July 2024, included Enhanced Barrier Precautions is an approach to the use of personal protective equipment to reduce transmission of Multidrug-Resistant Organisms between residents in skilled nursing facilities and expands the use of gowns and gloves to be worn during high contact activities with residents with indwelling medical devices. Indwelling medical devices include urinary catheters and high contact activities include transferring and device care or use. Contact precautions reduce the risk of transmission of microorganisms by direct or indirect contact. Gowns and gloves must be worn the entire time while in the room, must be removed prior to exiting the room, and hands must be washed with soap and water. Standard Precautions include infection control practices that are followed at all times with all residents, including properly cleaning, disinfecting, or sterilizing reusable equipment before use on another resident. The facility policy Urinary Incontinence Management and Prevention of Urinary Tract Infections, reviewed July 2024, included any resident with a catheter will be provided with a privacy bag in which the urinary collection bag is to be covered and serve as a barrier. The facility Skin Care policy for Wound and Skin Care, Protection, Identification, Risk factors, Staging, and Documentation, revised April 2024, included proper hand hygiene is to be completed prior to, between, and after all wound care including between different wound sites. 1. Resident #36 had diagnoses that included Alzheimer's disease, benign prostate hyperplasia (a condition where the prostate is enlarged, making it difficult to urinate), and diabetes. The Minimum Data Set Resident Assessment, dated 10/30/2024, documented Resident #36 had severe cognitive impairment and had an indwelling urinary catheter. The Comprehensive Care Plan, revised 09/12/2024, and the current undated Kardex (care plan used by the Certified Nursing Assistants for daily care) included that Resident #36 was on Enhanced Barrier Precautions, had an indwelling urinary catheter, and to follow the indwelling urinary catheter policy. During an observation on 11/20/2024 at 1:01 PM, Resident #36's door had a sign that included the resident was on Enhanced Barrier Precautions and for staff to wear gowns and gloves with all resident contact. Certified Nursing Assistant #1 and Certified Nursing Assistant #2 transferred Resident #36 using a mechanical lift device from their wheelchair to the bedside recliner. Both Certified Nursing Assistants had gloves on, but neither were wearing a gown. During the transfer, Certified Nursing Assistant #2 moved the urinary drainage bag that was attached to the indwelling urinary catheter and placed the drainage bag on the floor without a barrier. Certified Nursing Assistant #2 emptied the urine drainage bag without putting on a gown. During an observation and interview on 11/22/2024 at 9:29 AM, Certified Nursing Assistant #3 assisted Resident #36 to sit up on the side of the bed to get dressed and then transferred to the wheelchair. During care, the urinary drainage bag was sitting on the floor without a barrier. During an interview at this time, Certified Nursing Assistant #3 stated there should be a barrier between the urinary drainage bag and the floor, but they forgot to put a cover on the urinary drainage bag or a towel to set it on. During an interview on 11/25/2024 at 2:00 PM, Certified Nursing Assistant #1 stated residents on Enhanced Barrier Precautions have a sign outside their door which included when to wear personal protective equipment. Resident #36 was on Enhanced Barrier Precautions, and they should have worn a gown while transferring them. During an interview on 11/26/2024 at 9:22 AM, Certified Nursing Assistant #2 stated they knew Resident #36 was on Enhanced Barrier Precautions, but did not know they needed to wear a gown to transfer the resident or empty the urinary drainage bag. Certified Nursing Assistant #2 stated they had received education on Enhanced Barrier Precautions, but were confused on when personal protective equipment should be worn. During an interview on 11/26/2024 at 10:00 AM, Registered Nurse Manager #1 stated Certified Nursing Assistant #1 and Certified Nursing Assistant #2 should have worn gowns and gloves while transferring and emptying the urinary drainage bag for Resident #36. The urinary drainage bag should never be on the ground without a cover or barrier to protect Resident #36 from contamination and potential urinary tract infections. 2. Resident #37 had diagnoses that included diabetes, osteomyelitis (an infection in the bone) of a foot ulcer, and malnutrition. The Minimum Data Set Resident Assessment, dated 08/29/2024, documented Resident #37 was cognitively intact, had a diabetic foot ulcer, and received wound care and dressings to the feet. During observations and interview on 11/25/2024 at 8:11 AM, Licensed Practical Nurse #1 performed wound care to two diabetic ulcers on the resident's left foot and one on their right foot. During the course of the wound care, Licensed Practical Nurse #1 did not change gloves or perform hand hygiene between removing the old, soiled dressings and placing clean dressings or in between wound sites. During an interview at this time, Licensed Practical Nurse #1 stated they should have changed gloves and performed hand hygiene after removing the soiled dressings before placing a clean dressing and in between care for each wound site, but they forgot to. During an interview on 11/26/2024 at 10:00 AM, Registered Nurse Manager #1 stated they expect wound care to be performed following infection control practices. Gloves should be changed and hand hygiene completed after removing a soiled dressing prior to placing a clean dressing and should be completed in between each wound site. 3. Resident #91 had diagnoses that included Alzheimer's disease, depression, and repeated falls. The Minimum Data Set Resident Assessment, dated 10/04/2024, documented Resident #91 was rarely or never understood, was unable to complete the cognitive assessment, and was dependent on staff for transfers. During an observation on 11/20/2024 at 1:01 PM, Certified Nursing Assistant #2 removed a mechanical lift and sling (a device that is attached to the resident and the machine to assist in transfers) from Resident #36's room that had an Enhanced Barrier Precautions sign outside the door and took it to Resident #91's room that did not have an Enhanced Barrier Precautions sign on the door. Certified Nursing Assistant #2 and Certified Nursing Assistant #6 used the lift sling and the mechanical lift to transfer Resident #91. Neither the mechanical lift nor the sling was cleaned between use on Resident #36 and Resident #91. During an interview on 11/26/2024 at 9:22 AM, Certified Nursing Assistant #2 stated they brought the mechanical lift from Resident #36's room to Resident #91's room and did not recall if they had cleaned or sanitized the machine (or sling) in between residents, and that they should have cleaned the machine after using it on Resident #36 and before using it for Resident #91. During an interview on 11/26/2024 at 10:00 AM, Registered Nurse Manager #1 stated all equipment that is shared between residents should be cleaned and sanitized after every use and should not be used on more than one resident without cleaning. 4. Resident #94 had diagnoses including obstructive uropathy (inability to urinate) and bladder dysfunction. Review of the current Comprehensive Care Plan, revised 05/25/2022, revealed the resident had a suprapubic catheter (catheter inserted directly into the bladder via the abdomen). Interventions included to monitor for signs of infection. During an observation on 11/22/2024 at 9:50 AM, Resident #94's urinary drainage bag was lying directly on the floor with no barrier under it. During an interview on 11/26/2024 at 9:43 AM, Licensed Practical Nurse #3 stated the urinary drainage bags should have a cover over them to provide a barrier and should never be left on the ground. During an interview on 11/26/2024 at 10:54 AM, the Infection Preventionist stated hand hygiene should be performed before and after wound care, when gloves are changed after removing a soiled dressing, and before applying the new dressing and in between wound sites. Any equipment shared between residents should be cleaned prior to use with another resident, and all staff should wear personal protective equipment per the posted signs outside the resident room. The Infection Preventionist also stated residents with an indwelling catheter are placed on Enhanced Barrier Precautions and gowns and gloves should be worn with all direct care, including emptying the urinary drainage bags. Urinary drainage bags should be kept off the floor at all times. The Infection Preventionist stated Enhanced Barrier Precautions and the required personal protective equipment is an area that all staff have expressed confusion regarding when personnel protective equipment should be worn. 10 NYCRR 415.19(a)(1-3)(b)(4)

Based on observations, interviews, and record review conducted during the Recertification Survey 11/20/2024 to 11/26/2024 for three (Residents #89, #119 and #130) of three residents reviewed, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer medications or have medications left at their bedside unsupervised. Specifically, Resident #89 reported that nursing staff frequently left their pills in a medicine cup at their bedside for them to take later. Resident #119 had a nasal spray left unsupervised at their bedside. Resident #130 had an unlabeled and unsupervised medicine cup containing multiple pills in front of them at the table. None of the residents had an order to self-administer medications and had not been evaluated to have medications left with them unsupervised. This was evidenced by the following: The facility's policy Residents' Self-Administration of Medications, reviewed June 2024, documented a thorough assessment will be done by a nurse to determine if the resident is capable of safe self-administration of drugs. Resident's cognitive abilities to understand how and when to take the medications will be included in the assessment for safe administration of drugs. The care planning team will review the assessment and determine if the resident is capable. Nursing will provide the resident with information on medication usage and side effects via the electronic medical record. The resident will read, acknowledge, and sign the agreement for self-administration of their medications. The resident will be provided a locked box or locked drawer to secure their medications. Nurses will double-check that the drugs are appropriately labeled per the physician's orders and the Medication Administration Record must state that the person may self-administer. 1. Resident #130 had diagnoses that included Alzheimer's disease, dementia, and anxiety. The Minimum Data Set Resident Assessment, dated 10/01/2024, documented the resident had moderately impaired cognition. Review of the current Comprehensive Care Plan revealed that Resident #130 had impaired cognition related to dementia and was at risk for wandering and elopement with staff interventions to provide the resident with reorientation to their surroundings and environment (initiated 03/27/2024). The resident's care plan did not include documentation pertaining to self-administration of medication. Review of Resident #130's active medical orders did not include orders for self-administration of medications. During an observation on 11/22/2024 at 9:09 AM, Resident #130 was sitting at the dining room table with a medicine cup by their plate containing approximately six to seven pills of different sizes and shapes. No nursing staff were in sight at the time. 2. Resident #89 had diagnoses that included Parkinson's disease, chronic pain, and depression. The Minimum Data Set Resident Assessment, dated 09/08/2024, documented the resident was cognitively intact. Review of Resident #89's current Comprehensive Care Plan did not include documentation pertaining to self-administration of medication. During an interview on 11/22/2024 at 11:22 AM, Resident #89 stated they could have their nasal spray, eye drops, and inhalers left at the bedside unsupervised, but were not supposed to have their pills left there. Resident #89 stated the nurses would often bring their medications to them in a medicine cup, and if they were not ready to take them, the nurse would leave them at their bedside. The resident stated no one had explained to them what their medications were, and they were not familiar with all of their medications. The resident also stated there had been times when they dropped their pills on the floor and had to call the nurse. During an interview on 11/22/2024 at 11:35 AM, Licensed Practical Nurse #2 stated medical orders specified which medications could be left at the bedside unsupervised and there was no indication that Resident #89 could have pills left at their bedside unsupervised. Licensed Practical Nurse #2 stated for medications to be left unsupervised, the resident would have to be evaluated, be cognitively intact, able to voice their needs, have a medical order in place, and be care planned for self-administration of medications. 3. Resident #119 had diagnoses that included congestive heart failure, anxiety, and depression. The Minimum Data Set Resident Assessment, dated 09/24/2024, documented the resident had moderately impaired cognition. Review of the current Comprehensive Care Plan revealed that Resident #119 had impaired cognitive function with memory issues (initiated 06/06/2023). Staff interventions included to cue, reorient, and supervise the resident as needed, and administer medications as ordered. The resident's care plan did not include documentation pertaining to self-administration of medication. Review of Resident #119's active medical orders did not include orders for self-administration of medications. During an observation on 11/20/2024 at 1:18 PM, Resident #119 had normal saline nasal spray at their bedside unsupervised with no nurses in sight. During an interview on 11/26/2024 at 10:39 AM, the Director of Nursing stated before a resident could self-administer medications, they should have a completed evaluation form in place and a physician's order. The Director of Nursing stated nurses should educate the resident on their medications, what they are for, and should be discussed at the resident's care plan meeting. The Director of Nursing stated even if something were to come up, the nurses should take the medications with them and not leave them unsupervised with a resident who had not been assessed for safe self-administration. 10 NYCRR 415.3

Based on interviews and record review conducted during an Abbreviated Survey (ACTS Reference Number: NY00329762), the facility did not ensure that an investigation was initiated following a fall to rule out abuse, neglect, or mistreatment for one (Resident #11) of three residents reviewed. Specifically, Resident #11 had a witnessed fall, and the facility was unable to provide evidence that the fall was thoroughly investigated. This is evidence by the following: The facility policy Investigations of Incidents & Allegations of Abuse, Neglect or Mistreatment, reviewed February 2024, documented the purpose is to determine a cause for an incident or accident and to determine if there is reasonable cause to believe abuse, mistreatment, or neglect took place. The results of all investigations must be reported to the administrator or designee. Forms to be used include Incident and Accident Report Form (Occurrence Report) and Witness Statement Form. The procedure included the person who observes or discovers an incident must immediately document information on an incident/accident report or Investigators Statement form, and the immediate supervisor/designee must immediately make determination of suspected abuse, neglect, or mistreatment. Resident #11 had diagnoses including seizure disorder, brain tumor, and depression. The Minimum Data Set Resident Assessment, dated 11/06/2023, documented that Resident #11 was severely impaired cognitively and was dependent on staff for transfer. Review of the Comprehensive Care Plan revealed Resident #11 was at risk for falls related to a history of falls, decreased mobility, and poor safety awareness related to dementia. The Comprehensive Care Plan also included that Resident #11 was dependent on two staff members for transfers via a mechanical lift. In a nursing progress note, dated 12/05/2023 at 5:33 PM, Licensed Practical Nurse #2 documented that Resident #11 slid out of their wheelchair as the full lift (mechanical lift) was being used (to transfer the resident from bed to wheelchair). Resident #11 was assessed by the supervisor, returned to bed, the sling readjusted, and the resident was transferred back to their wheelchair. In a nursing progress note, dated 12/05/2023 at 10:40 PM, labeled Late Entry, Registered Nurse # 1 documented that upon entry into the room Resident #11 was observed sitting on the pedals of their wheelchair and per staff the resident was being lifted from the bed to the wheelchair and that there was a nurse and two Certified Nursing Assistants in the room at the time of the occurrence. A Post Fall Evaluation form, dated 12/05/2023 and signed by Licensed Practical Nurse #2, included the time of fall was 8:16 PM and the fall was witnessed by CNA (Certified Nursing Assistant) in Resident #11's room. The evaluation documented the resident was being lifted using a full lift to get from the bed to the wheelchair and slid out of the wheelchair and sat on the footboard of the wheelchair. During an interview on 09/12/2024 at 11:24 AM, Certified Nursing Assistant #4 (not involved in the incident on 12/05/2024) stated that two staff are required for all mechanical lifts and that the correct sling must be in place. During an interview on 09/12/2024 at 1:30 PM, the facility's Compliance Officer stated when an incident happens on the unit, the staff on site and the immediate supervisor on site should gather interviews and do reports. The Compliance Officer said they do not have an investigation for Resident 11's fall on 12/05/2023, any incident and accident report, or statements from any witness(es) present during the fall. The Compliance Officer stated there should have been an investigation for this fall. The facility was unable to provide any additional information such as an incident and accident report, witness statements, and/or a summary of the investigation to determine a root cause analysis, that the correct equipment was used, and the potential need for staff re-education or care plan revision. NYCRR 415.4(b)

Based on observations, interviews and record review, conducted during the Recertification Survey, completed on 10/13/22, it was determined that for one of one main kitchen reviewed, the facility failed to store, prepare, distribute or serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there was a high temperature automatic dishwashing machine in use that did not meet temperature sanitizing standards. This is evidenced by the following: Review of a facility policy, Food Safety Management, revised 4/1/22, directed that a high temperature dishwashing must have minimum final rinse temperatures of 180 degrees ( ) Fahrenheit (F) at the manifold and dish temperatures should be checked and recorded on the temperature log once per meal period as well as a validation check to be completed at least once per day. Observations during the follow up tour of the main kitchen on 10/11/22 at 11:10 a.m., revealed the high temperature automatic dishwashing machine digital temperature gauges on the machine were not functional and the alternate digital temperature gauges were also malfunctioning, reading 'error,' when run by the Food Production Manager (FPM). Observations during another follow up visit to the main kitchen on 10/11/22 at 1:08 p.m. revealed the digital temperature gauges on the automatic dishwashing machine read 118.7 F for the wash cycle and 'error' for the rinse cycle. Review of the daily temperatures log for the dishwashing machine revealed that from 10/1/22 to 10/11/22 breakfast only 3 of 31 opportunities to record the meal temperatures for each meal were completed. In September 2022 the meal temperatures were checked on just 28 of 90 opportunities. During an interview on 10/11/22 at 11:34 a.m., the FPM stated the temperature logs were behind. The FPM stated they did get a new dishwashing machine, but an install date was unknown. At 1:08 p.m., the FPM stated they would use the three-compartment sink for chemical sanitization until the dishwashing machine was evaluated. 10NYCRR: 14-1.112 U.S. Food and Drug Administration's (FDA) Food Code

Based on interview and record review conducted during the Recertification Survey and complaint investigation (# NY 261) completed on 10/13/22, it was determined for one (Resident #51) of one resident reviewed for notification of a change, the facility did not immediately inform the resident's representative of a transfer or discharge from the facility. Specifically, the facility did not notify the resident's primary or secondary emergency contact of a transfer to the hospital until six days after the transfer. This is evidenced by the following: Review of the facility's 'Change in Resident Status' policy revealed that to keep designated representatives apprised of changes in condition, licensed staff will call the resident's designated representative when medically ordered to transfer the resident to the hospital. Specifically, the policy states that the licensed staff in charge on the shift that the transfer occurred, will call the resident's designated representative. Resident #51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set Assessment, dated 9/17/22, revealed that Resident #51 was cognitively intact. In a progress note dated 7/6/22 at 5:30 p.m., Licensed Practical Nurse (LPN) #1 documented that Resident #51 barricaded themself in their bedroom, yelling out and verbalized [CONDITION(S)], that the [evening]supervisor was aware, and that 911 was notified for transfer to the hospital for mental health issues. The note included that Resident #51 left the facility via stretcher around 5:30 p.m., again screaming at staff, Emergency Medical Services (EMS) and the police. In a progress note dated 7/7/22 at 3:28 p.m., and electronically signed, Social Worker (SW) #1 documented that 'discharge/no bed hold' notices were sent to Resident's #51's emergency contact and to the Ombudsman. The note did not specify how the notices were sent. In a progress note dated 7/12/22 at 3:20p.m., SW #1 documented that they received a call from Resident #51's family (Emergency Contact) regarding a care plan meeting scheduled for the next day. SW #1 informed the family member that they do not hold care plan meetings when residents are not in the building. The family member revealed that they had not received any calls and had not been notified that the resident had been sent out or had been admitted to the hospital (six days prior). Review of the resident's electronic medical record (EMR) did not provide any evidence that the resident's representative had been notified of the resident's transfer to the hospital on 7/6/22. Review of the facility's Investigation Summary, dated 7/21/22 and signed by the compliance officer, revealed an email written by the acting Director of Nursing (DON) dated 7/12/22 at 2:50 p.m., which stated that the resident's family had not been informed of the resident's transfer for six days, which was absolutely unacceptable. Review of Resident #51's 'Transfer/Discharge Notification and Bed Reservation Notification' form, dated 7/7/22 and signed by SW #1, did not include any information that the resident's representatives were informed as soon as possible following the 7/6/22 transfer. During an interview on 10/11/22 at 9:10 a.m., Registered Nurse (RN) #1 revealed that LPN #1 had told them that they had called the resident's family about Resident #51's transfer but that there were not any progress notes regarding any phone calls to family members at that time. During an interview on 10/11/22 at 10:37 a.m., the DON stated that when a resident leaves the facility, the family should be notified as soon as the resident leaves. The DON also stated that a phone call should be completed by the nursing supervisor or the nurse on that unit, and the call should be documented in the EMR. During an interview on 10/11/22 at 11:17 a.m., LPN #1 stated that they did call the resident's representative on the day the resident was transferred, but the representative's voicemail message box had been full. During an interview on 10/11/22 at 12:25p.m., SW #2 revealed that when a resident is transferred, the discharge/transfer notification paperwork (Bed hold and Discharge/Transfer notifications) are completed and mailed out to the resident's representative and a note entered in the EMR. SW #2 said that on the back of the Discharge/Transfer notice, there was now a place to sign that a nursing progress note was entered and reviewed, addressing that the family was notified (new since this incident). 10NYCRR 415.3(e)(2)(ii)(b)

Based on observations, interviews and record review conducted during a Recertification Survey, completed on 10/13/22, it was determined that for 1 of 3 residents reviewed for behavioral, mental, and/or emotional health care services, the facility did not develop and implement a comprehensive person- centered care plan that included measurable objectives to meet all the resident's medical, nursing, mental and psychological needs as identified in their comprehensive assessments. Specifically, Resident #77's Comprehensive Care Plan (CCP) did not include goals, interventions and desired outcomes related to any behaviors such as repetitive hand movements on their body, innate objects, or the surrounding environment. This was evidenced by the following: Resident #77 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 8/12/22, revealed the resident had severely impaired cognition and no behaviors. A nursing progress note dated 5/12/22, documented that the physician was notified that Resident #77 had been placed on 24-hour monitoring for increased hand movements that have been on-going but now more obsessively. The increased repetitive hand movements had caused the resident to not sleep at night and was agitating other residents such as sitting at the dining room tables moving other residents' plates and drinks around. The Physician ordered a urinalysis to rule out a urinary tract infection and discontinued [MEDICATION(S)] (antidepressant medication) since the repetitive behaviors had gotten worse. [MEDICATION(S)] (antidepressant medication) was to start at night and a neurology appointment would be scheduled if the family agreed. The current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated 9/22/22, documented that Resident #77 was scheduled for a neurology consult in October 2022 for evaluation of repetitive hand movements and that the resident had started on [MEDICATION(S)] in June 2022 for symptoms as stated above. Resident #77's repetitive hand movements have improved significantly with use of medication and nonpharmacological therapies including the resident's stuffed animal cat. A Physician's progress note dated 9/25/22, documented that Resident #77 was anxious with nervous movements, that the trazadone was tolerated and titrated with good affect and the movements improved. The physician note directed to follow up with neurology as needed. The Physician questioned if the hand movements were voluntary due to anxiety or involuntary due to a neurological issue. Review of the CCP initiated on 1/21/21 revealed that Resident #77 received an antidepressant medication related to depression. The CCP did not include the resident's repetitive hand movements, the use of trazadone or any other interventions for staff to use to address and monitor those symptoms. When observed on 10/6/22 at 9:36 a.m., Resident #77 was repeatedly rubbing a stuffed cat. When observed on 10/7/22 at 11:02 a.m., Resident #77 was seated in the hallway in their wheelchair with a stuffed cat in their lap and vigorously rubbing the fur on the stuffed animal in one direction with their hands in a rapid constant motion. When interviewed on 10/7/22 at 11:05 a.m., the Certified Nursing Assistant (CNA) stated that the resident's stuffed cat had an active wander guard collar due to having lost so many of the stuffed cats and the resident loving the cat so much. CNA stated that the resident constantly rubs the stuffed cat while awake. When interviewed on 10/12/22 at 10:08 a.m., the Registered Nurse (RN) Charge Nurse stated that trazadone has helped with hand movements some. The RN Charge Nurse stated that the resident was supposed to see Neurology, but that Resident #77 is on comfort measures only, so the physician and the family decided not to pursue with neurology. The RN Charge Nurse said that the stuffed cat does appear to calm and soothe the resident. During an interview on 10/12/22 at 10;15 a.m., the Nurse Manger reviewed the Resident #77's CCP and stated that they did not see specifics related to behaviors or repetitive hand movements and how they were being addressed. The Nurse Manager stated that prior to having the stuffed cat and the trazadone, Resident #77 would repeatedly touch their hair and face and repeatedly rub the walls with a washcloth. NM stated that either the Charge Nurse or the Nurse Manager are responsible for the CCP and that these behaviors should be addressed in the CCP. 10NYCRR 415.11(c)(i)

Based on interviews and record reviews, conducted during the Recertification Survey, completed on 10/13/22, it was determined that for one (Resident #15) of two residents reviewed for hospitalization , the facility did not provide services consistent with professional standards of quality. Specifically, Resident #15, who was at risk for constipation, had no documented bowel movements for more than 5 days, and the facility had not assessed the resident's condition or administered physician ordered bowel medications. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 6/25/22, documented that, per staff assessment, the resident had moderately impaired decision-making skills (decisions poor, cues and supervision required), required extensive assist of staff for toileting and was occasionally incontinent of bowels. The facility policy, Management of Bowel Elimination, reviewed July 2021, included that documentation of bowel elimination will be recorded and if a resident has not had a bowel movement in the last 6 or more shifts (2 days), or has deviated from their usual bowel habits, the nurse will administer the [MEDICATION(S)] as ordered and follow up for results. If a resident has not had a bowel movement in the last 9 or more shifts (3 days), the nurse will administer an additional [MEDICATION(S)] as ordered and arranged for the medical staff to be notified the next business day. If no results are obtained, the team leaders and/or Registered Nurse (RN) Supervisor will be notified in the morning through the reporting process. The nurse manager or registered professional nurse will assess the resident and consult with the medical staff. Residents who have not had a bowel movement in the last three (3) days through a normal, individualized bowel program are to be evaluated for possible constipation/fecal impaction. Licensed staff will then notify the medical staff or follow orders for further bowel interventions. Healthcare provider orders need to be specific as to PRN (as needed) medications (i.e., what medication and when to be given). Refusals should be documented. Review of the Comprehensive Care Plan (CCP) revealed that Resident #15 was at risk for constipation due to immobility and multiple medications with a goal to have a bowel movement at least every 2-3 days. Interventions included to monitor medications for side effects of constipation and to keep the physician informed of any problems. Review of the Point of Care (POC) bowel records in the electronic medical record (EMR) for August 2022 revealed the Resident #15 did not have a bowel movement from 8/15/22 through 8/20/22 evening shift (16 shifts). Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Neither medication was signed off as given from 8/1/22 through 8/31/22. Review of progress notes 8/5/22 through 8/22/22 did not reveal any documentation regarding refusals of medications, lack of bowel movements, interventions, or any follow-up. During an interview on 10/12/22 at 8:43 a.m., the Certified Nursing Assistant (CNA) stated that resident's bowel movements were documented in the POC and if a resident reported they were unable to have a bowel movement on a few occasions through the day, they would have reported it to the nurse. During an interview on 10/12/22 at 8:52 a.m. and again on 10/13/22 at 9:05 a.m., the Licensed Practical Nurse (LPN) stated an electronic report could be ran anytime for residents who have not had a bowel movement and based on that report, the LPN would then assess the resident(s), administer any ordered medications, and contact medical. The LPN stated that they would expect the CNA to alert the nurse if a resident had not had a bowel movement in two or more days. The LPN said they were not aware of why the ordered PRN constipation medications for Resident #15 had not been given at that time. During an interview on 10/12/22 at 2:55 p.m., the Nurse Practitioner (NP) stated that the expectation was that PRN medications would have been utilized in addition to regularly scheduled bowel medications and if the PRN medications were ineffective, the staff should have notified medical. The NP stated they rely on nursing to notify medical regarding lack of bowel movements. During an interview on 10/13/22 at 9:16 a.m., the Registered Nurse Manager (RNM) stated alerts for lack of bowel movements were in the EMR but that the report was not necessarily run for the staff daily. The RNM stated there was a section on the staff assignment sheets for residents who have not had a bowel movement in greater than two days and this should have been passed to the next shift. The RNM stated that many residents have PRN medications for constipation ordered and the expectation would be to administer them after two or more days of no bowel movement. The RNM said that Resident # 15 should have received the PRN constipation medications and medical should have been notified. During an interview on 10/13/22 at 12:33 p.m., the Director of Nursing (DON) revealed that it was expected that the nurses run the electronic bowel report for their assigned residents at some point during their shift. The DON stated their threshold for concern is three days, at that point the nurse should have checked the MAR for medications to be given, administer the medications, completed a bowel assessment, and notified medical, the nurse supervisor and the next shift. 10 NYCRR 415.12

Based on observations, interviews, and record reviews during the COVID-19 Focus Infection Control Survey completed on 11/5/20, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of COVID-19, other communicable diseases, and infections. Specifically, the facility did not follow the cohorting requirements documented in the Dear Administrator Letter (DAL), dated April 29, 2020, for Residents #1 and #2. This is evidenced by the following: Review of the Center for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidelines, dated 4/2/20, included that long-term care facilities should separate residents who have COVID-19 from residents who do not, or have unknown status. The Executive Order 202.11, dated March 27, 2020, documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The New York State Department of Health DAL, dated April 29, 2020, documents the following: As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-19 positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful(ly) separate out patients in individual facilities. Review of the revised 9/17/20 facility policy, COVID-19 Exposure Plan, for suspected or confirmed cases of COVID-19 included for semi-private rooms, to keep the privacy curtain closed, and the residents separated as much as possible. Within 24 hours re-locate the resident with COVID-19 to a private room in a low-traffic area if available. Residents with confirmed COVID-19 may be cohorted with other residents with confirmed COVID-19. Avoid cohorting residents with confirmed COVID-19 with residents who are presumed COVID-19 or previously recovered from COVID-19. Resident #1 review of a lab report for COVID-19, dated 10/26/20, revealed the resident was positive for COVID-19. Resident #2 review of a lab report for COVID-19, dated 10/28/20, revealed the resident was negative for COVID-19. In an observation on 11/5/20 at approximately 12:25 p.m., Resident #1 and Resident #2, who were roommates, were sitting in chairs eating lunch in their shared semi-private room. Signage for the semi-private room included instructions for contact and droplet precautions, to keep the door closed at all times, to wear gloves, gowns, and goggles or face shield and to remove before exiting the room. The sign included that a N95 respirator was required, to apply prior to entering and remove after exiting, and to use alcohol-based hand rub before and after resident contact. In an interview on 11/5/20 at 10:00 a.m. and again at 3:16 p.m., the Acting Administrator and Infection Preventionist stated that Resident #1 and Resident #2 are cohorting. She said Resident #1 was re-tested several times and was negative. She said it was felt by the medical team that the test on 10/26/20 was a false positive, and therefore, the facility did not separate the two residents. She said that they were following the policy to keep the curtain closed and the residents separated as much as possible. She said, I thought that it was ok to cohort the residents because the roommate had already been exposed when the positive COVID-19 test result was returned. When interviewed on 11/5/20 at 3:53 p.m., the Medical Director stated that it was not his recommendation to cohort Resident #1 and Resident #2. He said his workflow guidance included to mask the residents if possible, close the privacy curtain, and within 24 hours to move the COVID-19 positive resident to a private room in a low traffic area if possible. The Medical Director said he was not aware that the residents were cohorting. He said that Resident #1 had subsequent negative tests and that it was most likely a false positive, so he was not concerned. He said if the facility was able to move the resident or roommate, they should have based on the positive test result for COVID-19. He said somehow that was missed in the communications. (10 NYCRR 415.19(b)(1); 10 NYCRR 400.2)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 3 of 31 residents reviewed for care planning, the facility did not develop or implement a plan of care for each resident that included measurable objectives and interventions to address the resident's medical, nursing, mental and psychosocial needs, or implement the plan of care. Specifically, Resident #60 did not have Dycem (rubber mat) in their wheelchair per plan of care, Resident #71 did not have a care plan developed for the use of an indwelling Foley catheter, and Resident #28 was not using and did not like the denture adhesive and it was not reported to the nurse per plan of care. This was evidenced by the following: 1. Resident #60 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/8/19, included that the resident had severely impaired cognition, no falls in the previous six weeks, and required extensive assist of staff for transfers. Review of an Occurrences Report, dated 10/24/19, revealed that the resident was found on the floor in front of their wheelchair, and it was determined that the resident slid out of the chair and was not injured. A Registered Nurse (RN) progress note, dated 10/28/19, revealed that the resident's family member called to voice concerns related to the resident always sliding out of the wheelchair. The family member requested something to help prevent the sliding and Dycem was offered. The current Certified Nursing Assistant (CNA) Assignment Summary, dated 10/28/19, revealed that the resident had a history of [REDACTED]. Apply Dycem to the chair pad to prevent sliding, monitor the resident frequently, and reposition as needed. Review of an Occurrences Report, dated 10/30/19, revealed that the resident was found on the floor in their room lying on the foot pedals of the wheelchair. The report did not include if Dycem (newly added to the care plan) was in use or not. The resident was unable to voice what had happened and was yelling in pain. The resident was admitted to the hospital with [REDACTED]. In an observation on 1/10/20 at 2:06 p.m., the resident was sitting slightly slouched in a wheelchair in the hallway. There was no Dycem in the chair. In an observation on 1/13/20 at 11:00 a.m. and again at 1:15 p.m., the resident was sitting in a wheelchair in the hallway. The resident's back was several inches away from the back of the chair. There was no Dycem in the chair. CNA #1 who was nearby checked and said there was no Dycem under the resident. During an interview on 1/13/20 at 2:05 p.m., when questioned about the Dycem, the resident's primary CNA #2, stated he did not know what Dycem was. After an explanation, CNA #2 said there was no Dycem in the resident's chair. CNA #1 said that there was some Dycem in the supply room and it was obtained at that time. When interviewed on 1/13/20 at 2:24 p.m., the RN stated that the incident on 10/30/19 should have included if the Dycem was in the wheelchair or not as it had just been added to the care plan to prevent the falls. She said the Dycem should be in place anytime the resident sits in the chair. 2. Resident #71 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/2/19, revealed the resident was cognitively intact and had an indwelling urinary (Foley) catheter. The current physician orders [REDACTED]. Review of the Comprehensive Care Plan (CCP) revealed the resident had an indwelling Foley catheter placed on 1/5/19 for stress incontinence. There were no goals or interventions related to the use of the Foley catheter. During an observation on 1/14/20 at 9:18 a.m., the resident was sitting in a wheelchair. The catheter tubing was running out of the resident's pant leg, under the chair to a covered drainage bag. When interviewed at that time, the resident stated they had an indwelling Foley catheter. During an interview on 1/15/20 at 11:00 a.m., RN Manager #2 stated the resident had an indwelling Foley catheter due to a [MEDICAL CONDITION] bladder (a bladder dysfunction flaccid or spastic caused by neurologic damage). RN Manager #2 said that the CCP should include the use of an indwelling Foley catheter including measurable goals and approaches, but it did not. 3. Resident #28 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/19/19, revealed the resident had moderately impaired cognition, mouth or facial pain, and discomfort or difficulty chewing. A Dental Evaluation, dated 5/24/19, revealed that the resident's dentures were loose and there was little mandibular alveolar ridge remaining with poor retention. Relining the dentures would not improve the retention. The resident was encouraged to use Fixodent. The CNA Assignment Summary, dated 1/13/20, revealed that the resident wears dentures and mouth care was provided twice a day by the resident or staff. Notify the nurse of dental complaints and issues and apply Fixodent (denture adhesive) per resident's choice. During an interview on 1/10/20 at 10:24 a.m. and on 1/13/20 at 8:43 a.m. and 9:24 a.m., the resident said their upper and lower dentures do not fit tight, they are loose. The resident said the bottom denture was worse than the top and that they did not like the denture adhesive paste because it was too goopy. The resident said they have told all of the CNAs that they do not like the denture adhesive. Interviews conducted on 1/13/20 included the following: a. At 9:13 a.m., CNA #3 and CNA #4 both said the resident has told them that they do not like the Fixodent. CNA #3 said the adhesive sticks and it was hard to pull the resident's dentures out for cleaning. b. At 10:57 a.m. and 11:40 a.m., Licensed Practical Nurse (LPN) #1 and LPN #2 both said that no one has told them that the resident dislikes the denture adhesive. LPN #2 said there were alternatives that could have been tried, like dental powder or paper inserts. When interviewed on 1/14/20 at 9:23 a.m., RN Manager #2 said that she was unaware of the resident's complaint. She said she expects the staff to advise her of such concerns so that something else can be tried such as dental powder. (10 NYCRR 415.11(c)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #36 and #52) of two residents reviewed for tube feedings, the facility did not provide appropriate treatment and services to prevent potential complications. Specifically, daily tube feedings and water flushes were not consistently documented or monitored to ensure physician orders [REDACTED]. This is evidenced by the following: 1. Resident #36 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/25/19, included that the resident was cognitively intact and received 51 percent or greater of total calories via the feeding tube. Review of the Comprehensive Care Plan revealed that the goal for the resident was to maintain adequate nutrition via a feeding tube. Interventions included, but were not limited to, checking the tube for placement, patency and residuals prior to the feeding and to provide the tube feeding per physician orders. The current physician orders [REDACTED]. (MONTH) use Fibersource HN until Diabetisource was available. The tube feeding will remain off from 8:00 a.m. to 10:00 a.m. for a gut rest. Nursing to verify tube placement and check for residuals (amount of feeding the resident stomach not yet digested to ensure the feeding was being tolerated) before each feeding every shift. In an observation on 1/9/20 at 11:36 a.m., the resident was sitting in the hallway and the tube feeding pump was turned off. In an observation on 1/9/20 at 1:54 p.m., the resident was in bed, the tube feeding pump was on, and there was a beeping sound. The tube feeding pump display had a message which read, Hold, and the feeding was not infusing. The pump continued to beep throughout an approximately 30-minute interview with the resident until the surveyor notified the nurse. In observations on 1/13/20 from approximately 8:10 a.m. through 1:35 p.m., the resident was observed numerous times in the hall and in the dining room with the tube feeding pump infusing at 75 cc per hour. At no time was the pump observed off for the daily gut rest. At 1:35 p.m., Licensed Practical Nurse (LPN) #2 was observed hanging a new bag of Fibersource HN with 1,000 ccs of feeding. LPN #2 did not check residuals or tube placement prior to hanging the bag. The pump was cleared of 1,750 ccs and started at 75 ccs per hour. When interviewed at that time, LPN #2 stated that she writes on the 24-hour report sheet that she hung a new bag but does not document anywhere else the amount of feeding. She said that she did not know if the amount cleared on the pump was accurate or not. LPN #2 said that the resident does not get a gut rest. Review of the electronic medical record did not reveal any documented evidence that the total amounts of feeding infused were documented or being monitored for completion or accuracy. The Treatment Administration Record included that Diabetisource AC and Fibersource HN were both being infused. Interviews conducted on 1/14/20 included the following: a. At 9:42 a.m. after reviewing the orders, LPN #2 stated that the resident should have had a gut rest and that she only checks tube placement prior to medications but not when hanging a new bag of feeding. When asked about residuals, LPN #2 stated that she does not check for residuals. b. At 11:55 a.m., the Registered Dietician (RD) stated that fluids are documented in the computer by the nurses or the CNAs. When reviewed at that time, the intake amounts documented in the computer for the previous 30 days revealed that the resident drank 200 ccs on 12/27/19 and 1,000 ccs on 1/5/20. There were no tube feeding amounts recorded in the resident's health record. The RD said that the resident should have a two-hour rest period. She said that the Diabetisource AC was on backorder and that if they are still using the Fibersource HN instead of the Diabetisource AC, it should be documented correctly. c. At 1:25 p.m., CNA #2 stated that they do not document anything related to the tube feedings. d. At 2:24 p.m., Registered Nurse (RN) #1 stated the they have never recorded the total amounts per shift or per day. She said the resident has unstable heart failure and was recently treated for [REDACTED]. RN #1 stated that she would expect placement and residuals checks to be completed per the physician orders. 2. Resident #52 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/23/19, revealed the resident had modified independence in cognitive skills and received 51 percent or more of calories and 501 cc per day through a tube feeding. Review of the current physician orders [REDACTED]. Nursing to record intake of formula at the end of every shift, change feeding bag and tubing set every 24 hours and check [DEVICE] placement every shift. Nursing to provide resident with free water flushes to self-administer with a goal volume of 1,080 cc per day, 180 cc twice per shift. Educate resident on goal volume for both the tube feeding and water flushes. Review of the Comprehensive Care Plan revealed that the resident chooses to self- administer their tube feeding, does not meet goal volumes at times, and drinks from the feeding tube. The goal for the resident was to maintain adequate nutrition via a feeding tube. Interventions included, but were not limited to, providing the tube feeding and water flushes per physician orders, checking tube feeding for placement, patency and residual per physician order, and nothing by mouth. Educate the resident on the importance of meeting their goal for both tube feedings and water flushes, and not drinking from the tube feeding tube. There was no documented evidence that the total amounts of tube feeding and water flushes infused were documented or being monitored for completion or accuracy. There was no documentation that the resident was re-educated when drinking from the tube feeding. RN #1 documented on 1/6/19 that the resident was educated on tube feeding and water flush goal volumes. There was no additional documentation on education of goal volumes. In an observation on 1/9/20 at 1:45 p.m., the tube feeding pump was beeping, flashing hold. There was a 1,000 cc bag of [MEDICATION NAME] 2.0 hung, dated 1/8/20 (10:30 p.m.) and 300 cc remained. The tubing was attached to the bag and dripping tube feeding onto the floor. The pump continued to beep for 30 minutes with no staff response. In an observation on 1/10/20 at 2:00 p.m., a 1,000 cc bag of [MEDICATION NAME] 2.0 was hung, dated 1/9/20 (9:30 p.m.). The pump was off with 700 cc remaining. There was tube feeding spilled onto the floor and the pump was turned sideways on the pole. When interviewed on 1/13/20 at 12:25 p.m. and 2:05 p.m., LPN #1 said the night nurses were responsible for totaling the 24 hours intake of tube feeding and water flushes prior to staff documenting in the electronic medical record. LPN #1 said if there was no order for strict monitoring of a tube feeding, such as Intake and Output, then 24-hour monitoring was not done. She said that the intakes were evaluated quarterly by dietary for consistency with the physician order [REDACTED]. Observations and interviews conducted on 1/14/20 included the following: a. At 10:44 a.m. and 11:05 a.m., LPN #2 said the resident refuses tube placement checks most of the time, and the resident refused that day. LPN #2 said that the nurses put water in a small container and leave it for the resident to administer. LPN #2 said she left 240 cc of water in the resident's room. LPN #2 said when the resident wants a new bag of tube feeding, they will come out of their room and get a new bag from a nurse, whether their tube feeding bag was empty or not. b. At 10:57 a.m., Certified Nursing Assistant (CNA) #1 said when he provides oral care, he can tell when the resident has taken tube feeding by mouth because there was tube feeding liquid on their teeth and in their oral cavity. CNA #1 said he reports that to the nurses. When interviewed on 1/14/20 at 11:52 a.m., RN #1 said the resident self-administers their own tube feeding. She said the resident connects their own tube feeding and has been known to drink out of the tube feeding bag. She said when the resident takes fluids by mouth, staff re-educate them. She said the night nurse used to total the 24-hour intakes of both the tube feeding and water but since the facility changed to a new electronic medical record that has not been done. She said the resident uses one bag a day which is 1,000 cc (ordered 1,100 cc day). When questioned, RN #1 said that was less than what was ordered, During an interview on 1/14/20 at 1:40 p.m. and 2:22 p.m., the RN Manager said she could not find any documentation in the medical record to show that anyone was monitoring the 24-hour total volumes of tube feeding and water flushes. The RN Manager said that she had reviewed the medical record and found the last time nursing documented that the resident was evaluated for the administration of the tube feeding and flush was (MONTH) (YEAR). She said it should probably be documented on the Comprehensive Care Plan how often to re-evaluate the resident for self-administration of the tube feeding and water flushes. Observations and interviews conducted on 1/15/20 included the following: a. At 9:59 a.m., LPN #2 and the surveyor went into the resident's room. The tube feeding pump was beeping, and the bag of tube feeding was not in sight. LPN #2 said the resident was sitting on the bag. She removed an empty folded bag, dated 1/14/20 (3:20 p.m.) from the resident's wheelchair. The resident wrote, Yes, I fed myself through the tube. b. At 1:06 p.m., the physician said he has not made any changes to the resident's orders because he expects the nurses to still try to check the resident's tube placement, cleanse the tube site, and prime the tubing. (10 NYCRR 415.12(g)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of four residents reviewed for respiratory care and oxygen, the facility did not provide proper care and treatment in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choice. Specifically, Resident #170 had incomplete oxygen orders and the oxygen equipment was not maintained per physician orders, and Resident #71 did not have an oxygen care plan and oxygen equipment was not maintained per physician's orders [REDACTED]. 1. Resident #170 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/14/19, revealed that the resident had severely impaired cognition and required oxygen therapy. The current physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) included the resident will tolerate the use of oxygen supplement via nasal canula, and their oxygen saturations will be at or above 92 percent at all times thru the next review. The Certified Nursing Assistant (CNA) Assignment Summary included oxygen at 2 liters at bedtime and as needed during the day. Review of the TARs for (MONTH) 2019 and (MONTH) 2020 revealed that the oxygen tubing and humidifier bottle were signed off as changed and the filter was signed off as cleaned on 12/17/19. Several observations of the resident's oxygen concentrator and tubing during the day on 1/9/20, 1/13/20, 1/14/20 and 1/15/20 revealed that the top and front of the oxygen concentrator was covered in dust and there were liquid spills. The oxygen tubing had a piece of tape that was dated, 12/20. When interviewed on 1/14/20 at 11:49 a.m. and on 1/15/20 at 11:19 a.m., the Registered Nurse (RN) Manager said that the oxygen tubing and humidifier bottle should be changed every two weeks. She said the resident's physician orders [REDACTED]. The RN Manager reviewed the (MONTH) 2020 TAR and stated that unless the resident's oxygen saturations were checked on a regular basis, staff would not know when titration of the oxygen was needed. In an observation on 1/15/19 at 11:26 a.m., the RN Manager and surveyor looked at the resident's oxygen concentrator and tubing. The RN Manager stated that the concentrator was filthy and needed cleaning. 2. Resident #71 has [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/9/19, revealed the resident was cognitively intact and received oxygen therapy. The physician orders [REDACTED]. The CCP and CNA Assignment Summary did not address the use of oxygen. There was no documentation that the oxygen tubing, humidifier bottle or filter had been cleaned or changed. During an observation on 1/13/20 at 2:10 p.m., the resident was sitting in their room and was receiving oxygen from a concentrator at three liters per minute via a nasal cannula. The humidification bottle was dated 8/7/19, and the oxygen tubing and cannula were undated. When interviewed on 1/14/20 at 12:15 p.m., the RN said that the oxygen tubing and humidification bottles are changed monthly by the night shift. She said that should be documented on the TAR. She stated that all nurses were responsible for checking the dates on the oxygen equipment. During an interview on 1/15/20 at 11:00 a.m., RN Manager #2 stated the resident used oxygen for chronic [MEDICAL CONDITION]. She stated the CCP and CNA Assignment Summary should include the use of oxygen, but it did not. She stated the oxygen tubing and humidification bottle should be changed every two weeks and as needed and documented on the TAR. She said the TAR should include changing the oxygen tubing and humidifier bottle, but it did not. RN Manager #2 stated the team leaders were responsible for checking the oxygen equipment to ensure the equipment was dated and cleaned. (10 NYCRR 415.12(k)(6))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of seven residents reviewed for influenza and pneumococcal immunizations, the facility did not ensure that each resident received the influenza immunization or did not receive the influenza immunization due to medical contraindications. Specifically, Resident #131 had a history of [REDACTED]. The nursing staff did not identify the adverse reaction or notify a medical provider prior to administering the immunization. This is evidenced by the following: Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/4/19, revealed that the influenza (flu) immunization was not administered due to a medical contraindication. The MDS Assessment, dated 11/22/19, revealed the resident had severely impaired cognition and received the flu vaccine 11/6/19. The current Vaccine Record Sheet revealed the resident had an allergy to the flu vaccine in 2011 to 2012. The Electronic Medical Record (EMR), in use at the time the flu vaccine was administered, revealed the resident had an allergy to the flu vaccine. A questionnaire for vaccine consent, signed by the Health Care Proxy (HCP) and dated 1/9/19, revealed the HCP did not wish for the resident to receive the flu vaccine that year. A Resident Flu Vaccine Consent for 2019 to 2020, dated 9/19/19, was signed by the HCP and directed to give the flu vaccine. A progress note, dated 11/6/19, revealed the resident was given the flu vaccine before dinner and at approximately 7:30 p.m., started to wheeze, cough, and had some emesis. At approximately 11:00 p.m., the resident was observed with vomiting, slightly swollen lips, a face rash, had drainage coming from their eyes and nose, and was transferred to the hospital. When interviewed on 1/9/20 between 1:22 p.m. and 1:44 p.m., the HCP said the resident was given a flu vaccine and had a reaction. He said nursing staff called him to report that the resident had vomited, had swelling in the face, and a rash. He said the staff reported they were not sure if the resident was having a reaction to the flu vaccine or had a urinary tract infection. He said the resident was sent to the hospital. The HCP said those were the same symptoms she had exhibited previously after receiving the flu vaccine. He said the resident had not been given a flu vaccine since that episode (2011 to 2012). He said he did not really remember receiving any information or signing anything to give the vaccination. Interviews conducted on 1/13/20 included the following: a. At 10:45 a.m., the Licensed Practical Nurse (LPN) said that the flu vaccine was identified on admission as an allergy. She said she did not know why it was given. b. At 1:26 p.m., the Nurse Practitioner said that the discrepancy between the flu vaccine allergy and the signed consent should have been identified, evaluated, and clarified by a medical provider prior to the administration of the flu vaccine. During an interview on 1/15/20 at 9:47 a.m., the Registered Nurse Manager said the nurse should have identified the allergy and contacted a physician or Nurse Practitioner for clarification. She said that although the flu vaccine was entered in the electronic medical record as a drug allergy on admission it was entered incorrectly so it did not flag as an allergy. (10 NYCRR 415.19(a)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 24 (Residents #11, #13, #21, #22, #31, #38, #60, #76, #84, #85, #100, #108, #115, #120, #131, #134, #146, #158, #159, #164, #167, #170, #173 and #422) of 24 residents reviewed for Baseline Care Plan, the facility did not develop a Baseline Care Plan that included the minimum required healthcare information necessary to properly care for a resident, did not have documented evidence that the Baseline Care Plan was completed within the required timeframe, or did not have documented evidence that the resident or representative was provided a written summary of the Baseline Care Plan. This is evidenced by, but not limited to, the following: The facility policy and procedure, Resident Comprehensive Care Plan and Committee, revised (MONTH) 2020, revealed that a Baseline Care Plan would be completed within 48 hours of admission. The Welcome Poster, which includes Baseline Care Plan information, will be reviewed with the resident or family member by the Transitional Care Coordinator or Social Worker within 48 hours of admission. All residents will have an interim care plan developed on admission to ensure that the residents' immediate care needs are met. 1. Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/30/19, revealed that the resident had severely impaired cognition. Review of the Baseline Care Plan provided by the facility did not include physician orders [REDACTED]. A progress note, dated 10/19/18, revealed a copy of the Welcome Poster was left in the resident's room. The Welcome Poster provided by the facility did not include a summary of the resident's medications. 2. Resident #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/23/19, revealed that the resident was cognitively intact. A Welcome Poster, dated 2/27/19, did not include a summary of the resident's medications or physician orders, and there was no documented evidence in the record that a written summary of the Baseline Care Plan was provided to the resident or representative. 3. Resident #134 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/17/19, revealed the resident had severely impaired cognition. Review of the Baseline Care Plan provided by the facility did not include physician orders [REDACTED]. An undated Welcome Poster provided by the facility did not include a summary of the resident's medications. Interviews conducted on 1/13/20 included the following: a. At 1:13 p.m., the Registered Nurse Manager stated the Baseline Care Plan should be completed within the first 24 to 48 hours. She said it was reviewed with the resident or the family member at the first care plan meeting. She said a list of medications was reviewed upon admission and at the first care plan meeting. She could not say that a copy of the Baseline Care Plan and medications were offered to the resident or family member at the care plan meeting. b. At 1:21 p.m., the Social Worker stated that Baseline Care Plans are started based on the information received from the hospital and input from the family if they are available. She said the Baseline Care Plan should be done within 48 hours and reviewed with the resident and family member at the initial care plan meeting. She said the care plan meeting was held within the first seven days of admission. When interviewed on 1/14/20 at 10:09 a.m., the Compliance Officer stated that the Welcome Poster was being used for the Baseline Care Plan and was given to the resident and family member upon admission. He said that he was not aware that the poster did not include the required information. When interviewed on 1/15/20 at 10:04 a.m., the Administrator stated that the facility has been working on the Baseline Care Plan since (YEAR) in preparation for the new regulations. He said the facility developed the Welcome Poster to be the brief summary of the Baseline Care Plan and it was presented to the resident or representative at the time of admission. After reviewing the Baseline Care Plan documentation for various residents, the Administrator said that all Baseline Care Plans were not consistently completed. He said as staff changed, the completion of the Baseline Care Plan went from the responsibility of Social Work to the nurse.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #86) of one resident reviewed for respiratory care, the facility did not provide proper respiratory treatments and/or care consistent with professional standards of practice. The issues involved an incomplete physician order [REDACTED]. Resident #86 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/1/18, revealed the resident had moderately impaired cognition and received oxygen therapy. The Comprehensive Care Plan, dated 8/14/18, revealed that the resident was at risk for hypoxic (lack of enough oxygen in tissues) episodes due to a history of pleural effusions (build-up of fluid between tissues that line the lungs and chest), and the need for oxygen supplement. The goal was to maintain oxygen saturation level at or over 92 percent, and for interventions the care plan directed to review the standing orders on the Treatment Administration Record (TAR) and Medication Administration Record. Physician orders, dated 7/26/18, included to obtain oxygen saturation levels every shift and if oxygen saturation levels were below 92 percent, apply oxygen via nasal cannula. There was no oxygen liter flow documented in the order. That order was scheduled for each shift. The oxygen was discontinued on 9/19/19\8 and reordered that same day, and included the previous order but was scheduled as needed versus every shift. A physician note, dated 8/16/18, revealed the resident's oxygen saturation levels were 96 percent on 2 liters of oxygen via nasal cannula. The (MONTH) (YEAR) TAR included to obtain oxygen saturation levels every shift and if the oxygen saturation level was below 92 percent, apply oxygen at liters via nasal cannula. There was no lifter flow documented. Staff signed off each shift through the morning of 9/19/18. The (MONTH) (YEAR) TAR, from 9/19/18 through 9/30/18, and the (MONTH) (YEAR) TAR included the same oxygen order but was scheduled as needed versus every shift and was not signed off as completed. Review of the Oxygen Saturation Levels Report, from 9/6/18 through 10/5/18, revealed that the levels were documented on four occasions on the day shift (9/10/18, 9/17/18, 9/24/18, and 10/1/18) and ranged between 94 percent and 99 percent. When observed intermittently on 10/2/18, 10/3/18, 10/5/18, and 10/9/18, the resident was receiving oxygen at 2 liters via nasal cannula continuously. During an interview on 10/5/18 at 1:43 p.m., a Licensed Practical Nurse (LPN) stated that if a resident uses oxygen, she would check oxygen saturation levels, monitor for shortness of breath, and monitor facial color and nail beds. The LPN said that monitoring oxygen saturation levels would require a physician order. She reviewed the resident's oxygen order, dated 9/19/18, and then stated the order was not transcribed correctly. The LPN said it was transcribed as needed and it should have been transcribed to check oxygen saturation level every shift routinely. When interviewed on 10/9/18 at 9:47 a.m., a Registered Nurse (RN) stated that the resident received oxygen continuously at 2 liters per minute. The RN that transcribed the physician order [REDACTED]. She stated that staff should observe the resident for shortness of breath, complaints of shortness of breath, and/or changes in the resident's color. She said that should all be included in the care plan. The RN reviewed the CCP and stated it did not include specific respiratory interventions. During an interview on 10/9/18 at 1:00 p.m., a Nurse Practitioner stated orders for oxygen should include the liter flow. She stated nurses should be checking and documenting oxygen saturation levels as ordered and monitoring the resident's respiratory status. (10 NYCRR 415.12(k)(6))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #237) of two residents reviewed for transmission based precautions, the facility did not implement a person-centered care plan to reflect the needs of each resident. The issue involved the lack of care planning for a resident on isolation precautions for an infection. This is evidenced by the following: Resident #237 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/2/18, revealed the resident was cognitively intact. Record review revealed the resident was readmitted to the hospital on [DATE] following a fall and [MEDICAL CONDITION]. The Social Work note, dated 9/5/18, revealed that she was contacted by a family member who reported that the resident tested positive for [MEDICAL CONDITION] ([MEDICAL CONDITION], bacteria that causes diaherria and inflammation of the colon) and will need a private room. The resident was readmitted to the facility on [DATE], and [MEDICAL CONDITION] was added to the resident's [DIAGNOSES REDACTED]. Physician orders [REDACTED]. The nursing admission note, dated 9/8/18, revealed the resident had loose stool but not [MEDICAL CONDITION]. A Nurse Practitioner note, dated 9/18/18, documented that the resident was found to have [MEDICAL CONDITION] on 9/5/18. The Comprehensive Care Plan (CCP), the Baseline Care Plan, and the Certified Nursing Assistant (CNA) Care Plan do not include any information regarding the resident having a [MEDICAL CONDITION] infection. During an observation on 10/4/18 at 9:21 a.m., the resident's door had a STOP before entering sign with instructions to report to the nurse before entering the room, contact precautions, gloves and gown required, remove before leaving room, and to use soap and water to wash hands before and after patient contact. A cart containing gloves, gowns and equipment was also in the hall by the door to the room. When interviewed at that time, the resident said she developed [MEDICAL CONDITION] in the hospital and was still having symptoms. When interviewed on 10/5/18 at 12:37 p.m., the charge Registered Nurse (RN) said the resident has [MEDICAL CONDITION] and is on isolation precautions. She said the RN Manager (RNM) completes the care plans. When interviewed on 10/5/18 at 12:53 p.m., the RNM said the resident's CCP should include the [MEDICAL CONDITION] infection, goals, and approaches. She said the CNA Care Plan should have a green star on it to show that the resident has an infection. After checking the CNA Care Plan, a green star was present. The RNM said the green star alerts the CNA that there is an infection, but not the type of infection or location. The RNM said that specific information regarding the infection should be on the CCP. When interviewed on 10/9/18 at 10:26 a.m., the RNM said two other RNs were learning to complete care plans and did not add the resident's [MEDICAL CONDITION] infection. She said the resident's [MEDICAL CONDITION] infection should have been added to the CCP. The facility policy for CCP, last revised (MONTH) (YEAR), includes the CCP committee will meet weekly and as needed to formulate a CCP for newly admitted residents. The CCP should have the needs and problems identified, including goals and approaches to reflect the relationship to the problem. (10 NYCRR 415.11(c)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. The issues include: a lack of data analysis for infections, proper infection control techniques for one (Resident #209) of two residents observed for incontinence care; a soiled transfer sling and oxygen concentrator (Resident #122) and a soiled toilet seat and bathroom wall bathroom (room [ROOM NUMBER]). This is evidenced by the following: 1. On 6/16/17 at 10:37 a.m., a review of the Infection Control Program with the Staff Educator Registered Nurse/Infection Control Designee revealed that line listings from December 2016 to May 2017 were not consistently completed to include control measures or resolution for infection tracking and did not include information on the use of antibiotics for urinary tract infections that were identified as 'mixed flora' or 'no growth.' The Staff Educator/Infection Control Designee stated that there were no policies or guidelines for completing a line listing. She said that she had a tracking system but had not completed any data analysis of infections since December 2016. She said that she was unable to provide any guidelines for the Infection Control Program. 2. Resident #209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) Assessment, dated 3/14/17, revealed the resident's cognition is severely impaired, and requires extensive assist of one staff for toileting. A Certified Nursing Assistant (CNA) Closet Care Plan, dated 6/16/17, directs limited assist of one staff for hygiene needs, that the resident wears a pull-up incontinent device and has a Foley catheter. Observations and interviews conducted on 6/15/17 included the following: a. At 4:07 p.m., the resident was incontinent of a large amount of stool. CNA #1 donned gloves and cleansed the rectal area first in a scrubbing motion, front to back and back to front. Without changing gloves or washing her hands the CNA then washed the resident's penis and Foley catheter tubing. When interviewed after the care, CNA #1 stated that the rule is to wash front to back and to wash the perineal area and then the rectum. She said she knows she should only use one stroke with the washcloth but she was trying to hurry. She said that she should have removed her gloves and washed her hands after cleaning the feces and before cleaning the penis and Foley. CNA #1 said that she was hurrying because the resident becomes impatient and gets angry. b. At 4:26 p.m., Licensed Practical Nurse (LPN) #1 said she expects staff to wash a resident from the front to the back and wash their hands when finished. She said it is not right to clean a dirty area like the rectum and then wash a cleaner area like the penis and Foley. Interviews conducted on 6/16/17 included the following: a. At 9:18 a.m., Registered Nurse Manager (RNM) #1 said she expects staff to clean a resident's penis and Foley first because of the possibility of contamination from the feces. She stated that staff should use a separate washcloth for each stroke. She said staff should change gloves and cleanse hands after cleaning the rectal area. b. At 10:37 a.m., the Staff Educator/Infection Control Nurse said if a resident with a Foley is incontinent of stool, staff may provide a shower to the resident. She said new linens should be used during care. She said staff should not wipe back to front, and should change their gloves several times during the process. Review of a facility policy, Peri-Care, dated May 2013, directs to provide perineal hygiene to prevent infection and skin breakdown for residents as indicated, (i.e. incontinent, catheterized, etc.) and includes to wash hands and put on clean gloves. Residents with a catheter: wash perineal area thoroughly, clean well around the entire insertion site. Always wipe catheter tubing from insertion site 4 inches toward bag (away from the body). Dispose of equipment and remove gloves and wash hands for infection control. Review of a facility policy, Handwashing/Hand Hygiene, dated June 2015, directs that adherence to handwashing and/or the use of alcohol based rubs, gloves and proper nail and hand care will be observed at all times. All employees will wash their hands with soap and water at any time they are visibly soiled and other specified occasions, (including) before performing any invasive procedure on a resident, before and after resident contact, and after handling items/surfaces potentially contaminated with blood or body fluids. 3. Observations and interviews conducted on 6/13/17 included the following: a. At 10:42 a.m., on the Orchard Way residential unit, a blue sling that had a foul odor and brown debris on it was left on top of a Medi-Lifter III mechanical lift in the hallway. b. At 3:01 p.m., the sling, with the brown smears, was still draped over the Med-Lifter III. CNA #2, who observed the sling at that time, said it was a hygiene sling and it needed to be cleaned. She said one of the residents had a fall that morning and staff could have used the sling to help the resident up. Interviews conducted on 6/16/17 included the following: a. At 9:20 a.m., Resident #119 said she had fallen on 6/13/17 while trying to use the bathroom and had been in a mess (incontinent). She said that staff had used the lift with the blue pad to get her up. b. At 9:47 a.m., RN #1 stated if a sling is soiled during use, staff should immediately rinse off visible soil, bag the sling and send it to laundry. She said this is an infection control and odor issue, and it was inappropriate to have left the sling on the lift in the hallway because anyone could have come into contact with it. c. At 10:37 a.m., the Staff Educator/Infection Control Nurse said slings are checked daily and before each use for cleanliness. She said staff should have bagged this sling right away and sent it to the laundry. 4. In observations on 6/14/17 at 9:19 a.m., and again at approximately 12:04 p.m., a filter on the back of a New Life Elite oxygen concentrator attached to Resident #122 and in use was observed to be heavily coated in white debris. Review of the Resident's Treatment Administration Records revealed that for the past three months the filter was signed off as changed every two weeks. Review of the owners' manual for the New Life Elite oxygen concentrators revealed that the air intake filters are to be cleaned before every operation, and to clean or wash the air intake gross particle filter with a warm solution of soap and water once per week. In an interview on 6/15/17 at approximately 1:15 p.m., LPN #2 said it is the duty of the 11:00 p.m. to 7:00 a.m. shift to clean the oxygen concentrator filters, and she thinks it is done once every two weeks. When interviewed on 6/16/17 at 10:37 a.m., the Staff Educator/Infection Control Nurse said oxygen concentrators are to be cleaned and filters changed by housekeeping staff or a nurse per manufacturer's recommendation. Review of the facility policy, Oxygen Administration, dated March 2017, includes that oxygen concentrator filters are to be removed every two weeks and washed with soapy water, rinsed, and dried. 5. In an observation on 6/13/17 at 2:17 p.m., in Resident room [ROOM NUMBER], brown debris was noted on the raised toilet seat and smeared on the back wall behind the toilet. When observed on 6/15/17 at 2:37 p.m., the brown debris and wall smear remained on the raised toilet seat and the wall. LPN #3 stated at that time that it appeared to be stool and that the bathroom should be cleaned daily. In an interview on 6/16/17 at 10:37 a.m., the Staff Educator/Infection Control Nurse said it is the responsibility of the staff who have provided care to clean a commode or bathroom after a resident has defecated. She said Housekeeping is to notify nursing staff if they find stool in a room or on equipment. Review of the facility policy, Standard and Transmission Based Techniques, effective date of January 2017, directs standard precaution are to be followed at all times with all residents. These include, but are not limited to, hand hygiene and the use of appropriate personal protection equipment. Also, equipment or items in the residential environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents, (e.g. wear gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another resident). (10 NYCRR 415.19(b)(4))

Based on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigations (#NY 086 and #NY 952) completed on 6/16/17, it was determined that for three of seven residents reviewed for abuse, and one of six residents reviewed for accidents, the facility did not thoroughly investigate injuries of unknown origin (Residents #153, #175 and #206) and did not report an incident to the New York State Department of Health (NYS DOH) involving a resident to resident altercation (Resident #144) in order to rule out abuse, neglect, or mistreatment. This is evidenced by, but is not limited to, the following: 1. Resident #206 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS)Assessment, dated 4/30/17, documented that the resident is cognitively intact, requires extensive assist of two staff members for transferring and toileting, does not ambulate and requires extensive assist of one staff member for locomotion on and off the unit, and no behaviors. Review of the current Certified Nursing Assistant (CNA) Assignment Summary revealed that the resident requires extensive assist of staff for transfers, but is independent with locomotion on the unit in a wheelchair. It also includes that the resident's hands are weak and numb making it difficult to use the call system, can be anxious, and to please check on the resident frequently. Review of the Nursing Progress Notes for the past month revealed that on 6/2/17 the nurse documented that the resident had a large bruise on the top of her left hand and several smaller ones on her right forearm and is resistive to care. There were no further notes related to physical behaviors, injuries or bruises. In an observation and interview on 6/13/17 at 2:08 p.m., and again on 6/15/17 at approximately 2:00 p.m., the resident was observed to have two bruises, approximately the size of a quarter, on the tops of both the right and left hands. When interviewed at that time, the resident stated that sometimes the staff members grab her by the hand. The resident said she tells them not to but they do not listen to her. She said the staff just pull and grab on her and they are rough. She later again stated, in front of a visitor, that staff are sometimes rough with her. Interviews conducted on 6/15/17 included the following: a. At 2:10 p.m., the CNA stated that she is the regular aide for this resident and that the resident has never mentioned to her that anyone is rough. The CNA said that she noticed the two bruises on the resident's hands earlier in the week and thought that she got them while self-propelling her wheelchair. She added that the facility has a stop and watch program which is a form they fill out to inform the nurses of any changes in a resident's skin. The CNA said she did not fill one out or let the nurses know about the resident's hand bruises. b. At 2:37 p.m., the Licensed Practical Nurse (LPN) stated that the resident mentioned to her that sometimes the staff yank on her arm when they move her. The LPN said that she was not aware of the bruises on the resident's hands. She said the CNA just told her that the resident has had those bruises for a while. In an interview on 6/16/17 at 11:31 a.m., the Registered Nurse Manager (RNM) said that she was just informed of the bruises on the resident's hands. The RNM said that she needs to do an investigation to determine how the resident got them. She said that the bruises looked old and that she saw the resident bump her hands on a table the week prior. She said she was not aware of the resident's statements about staff being rough. 2. Resident #153 has [DIAGNOSES REDACTED]. A MDS Assessment, dated 2/15/17, included that the resident is cognitively intact, requires extensive assist with bed mobility, transfers and toileting. Review of an Incident/Accident (I/A) Report, dated 1/27/17, revealed that nursing found the resident with a 4.5 centimeter (cm) x 3 cm bruise on the inner right upper arm during cares and that the resident was unaware of it. The I/A Report documented that the resident is on aspirin, bruises easily and that the bruise site is where the arm contacts the stand-lift transfer strap used by staff to transfer the resident. There was no evidence that interviews of staff were completed or that staff were observed during a transfer of the resident to ensure a safe transfer and proper sling size. Review of an I/A Report, dated 2/5/17, revealed that a CNA noted an ecchymotic (bruise) area below the left antecubital (lower forearm) while providing care. The resident was unaware of how it occurred. There was no evidence of a thorough investigation of the bruise to rule out abuse, neglect or mistreatment. When interviewed on 6/15/17 at 11:00 a.m., the Compliance Officer RN stated that she never received the I/A Reports to review. She said she is the one who completes the investigations. She said that staff should have been observed with the use of the stand lift and re-educated if necessary. When interviewed on 6/16/17 at 11:07 a.m., the Director of Nursing (DON) stated they use a Stop and Watch interactive program for bruises of unknown origin and that any employee can fill out the form and report it to any nurse. She said the procedure is that the LPN does an observation and the RN would have to do an assessment. She said staff should check to ensure that an I/A Report was already done and if not one should be started, noted in the 24-hour report and a note in the chart. The I/A Report should include interviews going back 72 hours if needed with the resident and staff, and if possible a conclusion to rule out abuse, neglect or mistreatment. She said right now, it is a fragmented system. When interviewed on 6/16/17 at 12:15 p.m., the Physical Therapist (PT) stated that the resident requires a stand lift for transfer. The PT said that the resident may or may not have received bruising from the sling. 3. Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A MDS Assessment, dated 4/11/17, documented that the resident's cognition is moderately impaired and no behaviors. Review of the I/A Report, dated 4/25/17, revealed that Resident #144 threw a cup of cold coffee at Resident #152, soaking her clothes. The residents were separated and no injuries were found. The facility concluded that because there were no injuries, it did not need to be reported to the New York State Department of Health (NYS DOH). When interviewed on 6/15/17 at 1:58 p.m., the RNM said that although she did not witness the incident, she felt that both residents were probably acting aggressively. She said Resident #152 can be verbally aggressive and Resident #144 has thrown objects at staff before. When interviewed on 6/16/17 at 10:09 a.m., the DON said that she was made aware of the incident but did not make the decision that it was not abuse. She said the Compliance Officer decided it was not abuse and therefore, it was not reported to the NYS DOH. She said the resident reacted in an aggressive manner and that if anyone throws something at a resident, it should be considered aggression. The DON said if the coffee had been hot, it would have caused an injury. She said that when there is resident to resident aggression, it should be reported to the NYS DOH. The DON said that this one was missed and it should have been reported. The facility policy, Incident and Accidents Reports, revised 10/15/90, directs to identify trends in incidents and recommend appropriate corrective, preventative and/or disciplinary action has been taken to protect persons from further harm and safeguard against the recurrence of similar or reportable incidents/accidents. (10 NYCRR 415.4(b)(2)&(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #136) of three residents reviewed for dental services, the facility did not code the Resident Assessment Instrument, including the Minimum Data Set (MDS) Assessment, correctly. The issue was incorrect coding and lack of care planning for dental. This is evidenced by the following: Resident #136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Dental Evaluation, dated 7/24/13, documented that the resident has a full upper denture, seven missing teeth, one fractured tooth and seven root tips on the lower arch. A Dental Evaluation, dated 2/15/17, documented obvious or likely cavities and broken natural teeth. The MDS Assessment, dated 4/14/17, revealed no dental issues. Review of the Comprehensive Care Plan (CCP), dated 3/29/11, revealed that the resident received a mechanically altered diet due to difficulty chewing. The CCP did not reflect any other dental issues. An observation on 6/13/17 at 1:47 p.m., revealed that the resident had several visible root tips on the lower front arch. Interviews conducted on 6/14/17 included the following: a. At 1:50 p.m., a Registered Nurse Manager (RNM), stated the Licensed Practical Nurses (LPNs) complete the dental section of the MDS Assessment. The RNM stated she developed the resident's CCP with the interdisciplinary team. The RNM stated that if the resident has root tips staff should monitor for signs of infection, pain and/or eating difficulties. She said the resident's dental issues should have been addressed on the CCP. b. At 1:59 p.m., the LPN who completed the MDS Assessment, stated that she reviews progress notes and dental evaluations. When interviewed on 6/15/17 at 9:00 a.m., the RNM stated a corrected MDS Assessment had been completed to accurately reflect the resident's dental status. She said the LPNs do not perform an oral exam when completing the dental section. Review of the facility policy, MDS Assessment Completion and MDS Accuracy Audit, dated 11/28/16, revealed that documentation of corrections or why the MDS is accurately coded will be documented in the electronic medical record. If the MDS is inaccurately coded, the NM or designee will correct the MDS. The MDS Manual, dated October 2016, defines broken natural teeth or tooth fragments as: a very large cavity, tooth broken off or decayed to gum line, or broken teeth (from a fall or trauma). The manual instructed to conduct an exam of the resident's lips and oral cavity with dentures or partials removed, if applicable. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth. (10 NYCRR 415.11(a)(2))

Based on record review and staff interviews, conducted during an Abbreviated Survey (complaint #NY 990) completed on 6/7/12, it was determined that for one of two residents reviewed for quality of care, the facility did not provide the necessary interventions to meet the resident's highest level of physical functioning and psychosocial well being. Specifically, Licensed Practical Nurses (LPNs) did not follow up with complaints of pain reported by Resident #1. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Review of the facility's pain management policy, dated October 2000, revealed that behaviors and/or symptoms should be evaluated regarding the presence of pain for residents who are cognitively impaired. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 4/27/12, revealed that the resident's cognitive skills for daily decision making are severely impaired. X-rays taken on 5/8/12 revealed that the resident had sustained an impacted [MEDICAL CONDITION] humerus with marked rotation of the head of the left humerus and suspect left mid to lower rib fractures. During an interview on 6/5/12 at 11:50 a.m., Certified Nursing Assistant (CNA) #1 stated that on 5/7/12, after the resident complained of pain, LPN #2 instructed the CNAs to put the resident back to bed. CNA #1 stated that she reported the resident's pain to LPN #2 on 5/7/12 and to LPN #1 on 5/8/12 and was not given instructions to change the method of transfer. CNA #1 stated that the resident continued to be transferred with a stand lift and continued to complain of arm pain. LPN #1's progress note revealed that on 5/7/12, during the 7:00 a.m. to 3:00 p.m. shift, Resident #1 complained of left shoulder pain at lunch time. Interviews on 6/6/12 revealed the following: a) At 11:58 a.m., LPN #1 stated that when Resident #1 is in pain, she weeps or says she hurts but does not specify the location of her pain. LPN #1 stated that on 5/7/12, CNA #1 notified her that Resident #1 was complaining of left shoulder pain during lunch. She advised CNA #1 that the resident had received routine pain medication ten minutes earlier. LPN #1 stated that she was standing approximately 15 to 20 feet away from the resident and did not look at the resident's shoulder. At 2:00 p.m. Resident #1 was sound asleep, so she did not bother her. LPN #1 added that she does not recall LPN #2 reporting Resident #1's complaints. b) At 11:45 p.m., LPN #2 stated that on 5/7/12, when feeding Resident #1 lunch, the resident was whiney, which is not typical. LPN #2 asked Resident #1 if she was in pain, and the resident rubbed her left shoulder and said it hurt. LPN #2 stated that Resident #1 already had her routine pain medication, so the resident was put to bed. LPN #2 stated that she looked at Resident #1's left shoulder at that time, and it was bruised, but she did not recall the size or color of the bruise and did not write a note. LPN #2 stated that she reported this to the charge nurse but does not recall who that was. LPN #2 stated that when the CNAs came to take Resident #1 to bed, she did not give them direction on how to transfer the resident to bed. c) At 11:15 a.m., CNA #2 stated that on 5/7/12 during lunchtime, LPN #2 said that Resident #1 was in quite a bit of pain and told the CNAs to put the resident to bed. CNA #2 stated he asked Resident #1 if she had pain, and the resident pointed to a couple of areas including her left arm above her elbow and on her left side. CNA #2 stated that LPN #2 did not tell him of any change in transfer status and that he did not see any nurses observe or examine the resident's arm. CNA #2 stated that the resident winced when the CNAs tried to remove the sling from under her left arm. CNA #2 stated he looked at where the resident pointed and noted a reddish indentation midway between her left shoulder and elbow, about 1/2 inch to 3/4 inch wide by 1 inch to 1 1/4 inch long. CNA #2 stated that he told CNA #1, the resident's primary CNA, what he observed but cannot remember if he told the nurse. d) At 11:00 a.m., the Registered Nurse (RN) Manager stated that when a resident complains of pain, the LPN is expected to look at the area and then report her observations to a RN. The RN Manager stated that an RN was not notified until 5/8/12 at 7:30 a.m. Interviews on 6/7/12 include the following: a) At 2:20 p.m., the Director of Nursing (DON) stated that when new pain is observed for residents with routine pain medications, the LPN is expected to look at the site, monitor and report observations to the RN. The RN is then expected to assess. The DON added that for residents with lower cognition, the nurses should evaluate nonverbal cues including rubbing the site and moaning. The DON stated that if a new bruise is noted, the LPN or RN should complete an incident report for injury of unknown origin. b) At 11:50 a.m., the Medical Director stated if the resident was indicating new pain, she should have been assessed, and if a fracture was known, the stand lift should not have been used. c) When interviewed by telephone at 1:30 p.m., the orthopedic physician's assistant stated that use of the stand lift with Resident #1's fractures would have resulted in increased pain for the resident and could move the fracture or make the fracture for the arm worse. (10 NYCRR 415.11(c)(3)(i))